Complexity checklists
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Use of checklists to cope with complexity, M. Mitchell Waldrop describes a vision of complexity via:
  • Rich interactions that allow a system to undergo spontaneous self-organization
  • Systems that are adaptive
  • More predictability than chaotic systems by bringing order and chaos into
  • Balance at the edge of chaos 
in medicine

Summary
Atul Gawande writes about the opportunity for a thirty per cent improvement in quality in medicine by organizing to deploy as agent based teams using shared schematic plans and distributed signalling or as he puts it the use of checklists

With vivid examples from a variety of situations including construction, air crew support and global health care Gawande illustrates the effects of complexity and how to organize to cope with it. 

Following the short review RSS is Rob's Strategy Studio additionally relates Gawande's arguments to its models of complex adaptive systems (CAS) positioning his discussion within the network of US is the United States of America.   health care, contrasting our view of complexity, comparing the forces shaping his various examples and reviewing facets of complex failures. 
The Checklist Manifesto
In Atul Gawande's book 'The Checklist Manifesto' he describes how medical knowledge has resulted in increased complexity in health care delivery.  He notes that a similar increase in complexity in piloting of aircraft was effectively managed by flattening the cockpit organization into a team based complex adaptive system (
This page introduces the complex adaptive system (CAS) theory frame.  The theory is positioned relative to the natural sciences.  It catalogs the laws and strategies which underpin the operation of systems that are based on the interaction of emergent agents. 
John Holland's framework for representing complexity is outlined.  Links to other key aspects of CAS theory discussed at the site are presented. 
CAS
)
Plans are interpreted and implemented by agents.  This page discusses the properties of agents in a complex adaptive system (CAS). 
It then presents examples of agents in different CAS.  The examples include a computer program where modeling and actions are performed by software agents.  These software agents are aggregates. 
The participation of agents in flows is introduced and some implications of this are outlined. 
agent
and organizing the processes as an integrated network including manufacture, training, operation, error recovery, and learning based around a shared
Plans emerge in complex adaptive systems (CAS) to provide the instructions that agents use to perform actions.  The component architecture and structure of the plans is reviewed. 
schematic structure
associated with specific cockpit situations by checklists. 

Gawande had been influenced by Samuel Gorovitz and Alasdair MacIntyre's essay on the nature of human fallibility where they pose a question 'why do we fail at what we set out to do in the world?'  The philosophers highlight three reasons:
  1. Necessary fallibility
  2. Ignorance - which Gawande notes, science has helped reduce.  But Gawande writes science has also contributed to and highlighted the complexity of what we set out to do.  It has increased our
  3. Ineptitude - In medicine Gawande argues large amounts of knowledge and complexity are the sources of the greatest difficulties and stresses.  He lists some troubling examples:
The problem of extreme complexity
Gawande laments that while
Walter Shewhart's iterative development process is found in many complex adaptive systems (CAS).  The mechanism is reviewed and its value in coping with random events is explained. 
Shewhart cycles
can help to increase competence the failures persist despite remarkable individual ability.  The know-how is unmanageable by specializing.  Avoidable failures are common and persistent.  He concludes that the volume and complexity, M. Mitchell Waldrop describes a vision of complexity via:
  • Rich interactions that allow a system to undergo spontaneous self-organization
  • Systems that are adaptive
  • More predictability than chaotic systems by bringing order and chaos into
  • Balance at the edge of chaos 
of what we know has exceeded our individual ability to deliver its benefits correctly, safely or reliably.  A different strategy is needed for overcoming failure.  He proposes checklists. 

Drowned patient checklist
Gawande introduces the case of saving a drowned infant which required scores of people, thousands of steps, while avoiding simple mistakes and coping with failures.  How had they been able to orchestrate the steps 'in the right sequence, with nothing dropped, leaving some room for improvisation, but not too much'? Gawande writes.  He outlines how the specific hospital was situated in an environment where drowning was unusually frequent.  The doctors had been able to look back at the details of each failed episode of care to identify the reason for failure.  They had responded by introducing a checklist that focused attention on critical aspects of the preparation and procedure.  Over time they adjusted the plan until it started to achieve success. 

In comparison with this 'vision' of success in health care provision Gawande reflects on how penicillin's deployment and broad success have hidden the growing complexity, M. Mitchell Waldrop describes a vision of complexity via:
  • Rich interactions that allow a system to undergo spontaneous self-organization
  • Systems that are adaptive
  • More predictability than chaotic systems by bringing order and chaos into
  • Balance at the edge of chaos 
problem. 

As we have identified greater than thirteen thousand ways a body can fail the health care providers have responded with more specialization.  Gawande describes the situation at Harvard Vanguard an outpatient clinic which strives to provide a full range of outpatient medical services.  It has expanded into 20 facilities with more than 600 doctors and 1000 other health professionals organized into 59 specialties.  Gawande notes that even with the specialization the general situation is for the doctors to see a complicated mixture of cases.  In a year a doctor will on average treat 250 different primary diseases and conditions.  And in the records a common condition was 'other'!  The rapid expansion of classified conditions has outpaced the electronic medical record coding infrastructure.  Also doctors do not have time to search for conditions that do not come rapidly to hand. 

In hospitals, intensive care units (ICU is intensive care unit.  It is now being realized that the procedures and environment of the ICU is highly stressful for the patients.  In particular sedation with benzodiazepines is suspected to enhance the risk of inducing PTSD.  Intubation and catheterization are also traumatic.  Sometimes seperated into MICU and SICU.  eICU skill centralization may bring down costs. 
) illustrate the difficulty health care providers' face.   Formerly fatal conditions: crushing, burning, bombing, burst aortas, ruptured colons, heart attack is an AMI. It can induce cardiac arrest.  Blocking the formation of clots with platelet aggregation inhibitors, can help with treating and avoiding AMI.  Risk factors include: taking NSAID pain killers (May 2017).  There is uncertainty about why AMI occur.  Alternative hypotheses include:
  • Plaques started to gather in the coronary arteries and grew until no blood flow was possible.  If this is true it makes sense to preventatively treat the buildup with angioplasty. 
  • Plaques form anywhere in the body due to atherosclerosis and then break up and get lodged in the coronary artery and start to clot.  If this is true it makes sense to preventatively limit the buildup of plaques with drugs like statins or PCSK9 inhibitors. 
s and raging infections can be effectively managed with treatment leveraging an ICU.  Lots of technology infrastructure is used to temporarily replace failing parts of a body. 

90,000 people are treated each day in ICUs in the US is the United States of America.  .  They average a stay of four days and have a 86% survival rate.  Much of medicine is now dependent on ICU support. 

178 individual actions are performed each day on each patient in the ICU.  All the actions pose some risk to the patient.  Bodies are not designed to stay immobile and breathing with a respirator.  Complications arise unless all the actions are successful.  A 1% error rate equates to two errors a day for each patient!  Gawande highlights line infections.  Such infections have been considered routine.  But they can extend the time in the ICU and overall recovery significantly.  That can result in patients becoming financially impacted or even devastated. 

Doctors' training has expanded over the last 100 years to cope with the escalating complexity and specialization.  It is now typical for a doctor to train for greater than 15 years.  This has increased training costs but does ensure practice at the specialty which allows the doctors the advantage of great experience.  However, the typical complex set of interactions undermines the specialization strategy.  Gawande argues that this helps explain the 150,000 deaths following surgery in the US each year.  But greater than half these deaths are avoidable!  So Gawande advocates a change of strategy. 
The Checklist
Test pilot's responded to complexity increases with a checklist.  These are salient summaries for specific points in time and procedure in a flight. 

Gawande noted that nurses had adopted a checklist like reminder 'vital signs'.  And they added a medicine timing chart and written care plans. 
Doctors however considered these checklists boring.  Until Johns Hopkins's critical care specialist Peter Pronovost developed a checklist for central line infections.  He got nurses to use the checklist to monitor how often doctors missed a step.  With that data he encouraged Johns Hopkins to authorize nurses to stop doctors if they saw doctors miss a step.  An 11% infection rate fell to zero. 

Johns Hopkins added further ICU is intensive care unit.  It is now being realized that the procedures and environment of the ICU is highly stressful for the patients.  In particular sedation with benzodiazepines is suspected to enhance the risk of inducing PTSD.  Intubation and catheterization are also traumatic.  Sometimes seperated into MICU and SICU.  eICU skill centralization may bring down costs. 
checklists.  These resulted in a 50% reduction in average patient stay in the ICU.  But Johns Hopkins is very well funded.  Can the methodology work in a poorly resourced ICU.  Gawande explains that in 2003 this was tested when Pronovost convinced Michigan State to adopt a central line checklist.  Pronovost asked hospitals to monitor central line infection rates.  He also asked insurers to reward participation in the checklist trial.  He made hospitals put an executive on the trial team.  Michigan saved $175 million and 15 hundred lives in eighteen months.  The executive focus had ensured road blocks were funded away. 

Gawande became even more interested in checklists for surgery when he discovered the essential contribution of a checklist process in the drowned child recovery described above and the building of a new OR suite at Brigham and Women's hospital where he is a surgeon. 
The end of the master builder
Gawande wondered with which problems checklists could help.  He reflected on Zimmerman and Glouberman's distinction of three different kinds of problems:
  1. Simple - can be solved by following a recipe. 
  2. Complicated - no straightforward recipe exists.  Success requires multiple people, often in multiple teams, and specialized expertise.  Timing and coordination are serious concerns.  
  3. Complex - for example raising a child.  No two are the same.  Success with one does not guarantee success with the next.  The outcome is uncertain.  To Gawande improving the ICU is intensive care unit.  It is now being realized that the procedures and environment of the ICU is highly stressful for the patients.  In particular sedation with benzodiazepines is suspected to enhance the risk of inducing PTSD.  Intubation and catheterization are also traumatic.  Sometimes seperated into MICU and SICU.  eICU skill centralization may bring down costs. 
    was such a complex problem.  The drowned child recovery had shown a checklist process could help here.  
How could it cope with specialization Gawande wondered?  He realized that the operations of the builders constructing Brigham and Women's new OR is operating room. 
were highly robust and yet very specialized.  He found that until a hundred years ago buildings were constructed by master builders, analogous to surgeons, who controlled the operation of the many trades putting up a building.  But for the last 100 years things had been too complex for a master builder to cope.  Instead a team uses a plan (list) to define the activity network that will result in the effective construction of the building. 

As they proceed with building unplanned problems occur.  The issues are identified and reviewed.  Specialists are identified that must participate in the review and agree on acceptable fixes.  Discussions are scheduled.   Feedback from the discussions is integrated into the plan.  The team with its adaptive plan and communications processes becomes a highly scalable and robust master builder. 
The idea
Gawande concludes there are two responses to risk:
  1. Centralize and take control.  But this strategy becomes overwhelmed by a network of communication errors. 
  2. Push down decisions to the effective agents, leverage checklists and encourage communication throughout the network.  A simple set of shared goals can enable effective adaptation in evolutionary biology is a trait that increased the number of surviving offspring in an organism's ancestral lineage.  In Deacon's conception of evolution an adaptation is the realization of a set of constraints on candidate mechanisms, and so long as these constraints are maintained, other features are arbitrary. 
    to even major failures within the network of agents.  It also provides the opportunity for the agents to be creative and it scales well.  Even to solving big complex problems.  And it is more robust in initially chaotic situations.  
Gawande views the checklists as essential in solving complex problems.  It supports judgment with procedure.  He illustrates the point by describing the operation of a prize winning restaurant. 

Gawande admires Jody Adam's restaurant
The restaurant includes:
The first try
Gawande explains how a World Health Organization (W.H.O. is World Health Organization a United Nations organization.  ) project focused his attention on the need to improve the quality of surgery as it was being applied on a hugely increased scale across the world.  More people now have operations worldwide each year than give birth!  A significant proportion of the operations were so unsafe as to make surgery a global public health is the proactive planning, coordination and execution of strategies to improve and safeguard the wellbeing of the public.  Its global situation is discussed in The Great Escape by Deaton.  Public health in the US is coordinated by the PHS federally but is mainly executed at the state and local levels.  Public health includes:
  • Awareness campaigns about health threatening activities including: Smoking, Over-eating, Alcohol consumption, Contamination with poisons, Joint damage from over-exercise;
  • Research, monitoring and control of disease agents, processes and vectors by agencies including the CDC. 
  • Monitoring of the public's health by institutes including the NIH.  
  • Development, deployment and maintenance of infrastructure including: sewers, water plants and pipes.  
  • Development, deployment and maintenance of vaccination strategies. 
  • Regulation and constraint of foods, drugs and devices by agencies including the FDA. 
hazard.  The death rates equated to those for
Sonia Shah reviews the millennia old (500,000 years) malarial arms race between Humanity, Anopheles mosquitoes and Plasmodium.  250 - 500 million people are infected each year with malaria and one million die. 
malaria
and tuberculosis. 

The team wondered how to fix the problem.  They reviewed a number of historic public health strategies but many of these were simple interventions that did not seem to equate with the complexities of surgery.  But one successful study had to deal with complexity, M. Mitchell Waldrop describes a vision of complexity via:
  • Rich interactions that allow a system to undergo spontaneous self-organization
  • Systems that are adaptive
  • More predictability than chaotic systems by bringing order and chaos into
  • Balance at the edge of chaos 
and leveraged a checklist.  It was promoting the use of soap in Karachi.  It resulted in 52% reduction in diarrhea can have many causes.  Contaminated water supplies can result in infection with:
  • Viruses: Cytomegalovirus, Hepatitis, Rotavirus, Norwalk; less commonly Ebola
  • Bacteria: Campylobacter, Clostridium difficile, Escherichia coli, Salmonella, Shigella
  • Parasites: Cryptosporidium, Giardia lamblia
, 48% reduction in pneumonia is an inflamed lung.  It can be caused by infection with viruses or bacteria, drugs and autoimmune diseases.  HAP, including VAP can be very troubling.  and a 35% reduction in impetigo.  Gawande's attention was raised by where the value had come from.  The study:
  • Reduced the barrier of cost of the soap. 
  • Increased the systematization of its use (via a checklist). 
  • Leveraged a great smelling, consumer brand soap. 
  • Provided a gift of soap which the subjects appreciated. 
The contribution of a checklist increased the team's interest.  They looked for general surgery checklists and discovered some candidates:
The team was concerned that some aspects of surgery would undermine the checklist strategy:
  • Surgical 'teams' are traditionally hierarchies.  Psychologists had found that the more junior members of the team were very aware of their place and can hide there (not their problem).  And typically the membership of the 'team' changes daily. 
  • Checklists that were being tried were obviously not right.  Skeptics could easily undermine their use.  Gawande designed and tested a global surgical checklist but when prototyping its use found it hopelessly ambiguous and so time consuming that it detracted from the focus on the operation. 
Gawande decided they needed to consult an expert that had been developing successful checklists and using them in rapid response teams.  Boeing had a specialized organization that designed, deployed and updated the checklists for air crew of its commercial aircraft. 
The checklist factory
Boeing's flight philosophy governs the way the cockpit crew flies the plane including:
  • Their routines, 
  • What should be left to computers or be performed manually,
  • How they should react when the unexpected occurs.  
Boeing studies thousands of crashes to understand human error. 

A checklist handbook covers a vast range of flight scenarios: normal and non-normal;

Checklists are designed in tandem with modifications to the plane responding to failures with the goal of providing the crew time and procedures to mitigate the risk.  They are compiled by checklist factory experts.  The checklists must be:
  • Precise,
  • Efficient,
  • To the point - If the list takes more than 90 seconds to review it will be distracting and flight crew will take short cuts.  So there are reminders of just the critical steps,
  • Easy to use in a crisis.  
There are two types: do-confirm and read-do.  The pilots' training includes consulting these checklists.  And pilots know that they work.  That is because the new checklists have already been iteratively tried 'live' and then fixed.  The factory can do this because flight simulators are available to allow them to introduce failures and monitor the crew/prototype checklist responses. 

Any new accident is investigated and the recommendations are then applied as a checklist.  They are deployed to flight handbooks of every commercial plane. 
The test
Atul Gawande's team tried to make the W.H.O. global surgical checklist useable.  Just as the air crew checklists are read by the 'pilot not flying' it was felt the surgeon should not be the reader.  They have too many distractions.  And giving another of the staff the role asserts there is a team and devolves responsibilities from the surgeon.  Therefore the circulating nurse calls the start. 
They argued that the checklist was not a record keeping activity but a team conversation and did not need to be written down.  They agreed that pause points should not be more than 60 seconds in duration.  But identifying non-vital items to remove was difficult to do. 

Trials were setup at eight hospitals worldwide.  There were four wealthy first-world hospitals and four hospitals from the under developed world.  The procedures were radically different in the two situations.  So were the organizational and budget constraints.  Each hospital had to agree to provide its current surgical error rates.  Local researchers gathered the data.  Problems were seen at all the hospitals.  These included: wound infections, major bleeding, heart attack is an AMI. It can induce cardiac arrest.  Blocking the formation of clots with platelet aggregation inhibitors, can help with treating and avoiding AMI.  Risk factors include: taking NSAID pain killers (May 2017).  There is uncertainty about why AMI occur.  Alternative hypotheses include:
  • Plaques started to gather in the coronary arteries and grew until no blood flow was possible.  If this is true it makes sense to preventatively treat the buildup with angioplasty. 
  • Plaques form anywhere in the body due to atherosclerosis and then break up and get lodged in the coronary artery and start to clot.  If this is true it makes sense to preventatively limit the buildup of plaques with drugs like statins or PCSK9 inhibitors. 
s and pneumonia is an inflamed lung.  It can be caused by infection with viruses or bacteria, drugs and autoimmune diseases.  HAP, including VAP can be very troubling. 

The trial tracked 4,000 surgical patients.  Four hundred developed major complications.  50% of these were infections.  Another 25% were technical failures that needed a second surgery to stop the bleeding or repair the problem.  56 patients died.  All eight hospitals had opportunities to improve.  None had a routine approach to assure teams identified and prepared for high blood loss.  None conducted a pre-op team briefing. 

The checklist deployment was managed through the hospitals' leaders.  They were seen to be promoting the checklist process.  They provided instruction supported by videos W.H.O. had setup.  The current error data was also made known.  Deployment of the checklist was staged into one operating room first so that it could be tested for local issues and updated with identified corrective actions.  It was also expected that the hospitals would have to update their processes to fit the use of checklists. 

Some surgical teams refused to use the checklists but the majority deployed them.  It was difficult.  People had to change habits to fit in with the checklist approach.  Different hospitals had additional challenges based on their local situation:
Applying the checklist highlighted issues with current procedures in a variety of the eight hospitals. 

The results included:
  • 47% reduction in deaths. 
  • 36% reduction in major complications including 1/3 reduction in first world hospitals.  
  • 50% reduction in infections. 
  • 25% reduction in returns to the operating room. 
The hero in the age of checklists
Checklists offered opportunities in many industries but resistance was significant. 

Gawande reviews significant benefits obtained by value investor investment funds.  Checklists made selection of target companies faster and better.  But even once this was known most investment fund managers rejected using them.  Gawande wondered why?  He notes research by psychologist Geoff Smart studying venture capitalists (VC is venture capital
).  The research looked at how the VCs rate entrepreneurs.  The approaches were classified as:
  • Arts critics - make instant judgments of the entrepreneur. 
  • Sponges - review all the available data and then make an instant judgment of the entrepreneur. 
  • Prosecutors - interrogated entrepreneurs via interviews. 
  • Terminators - invest in the best idea and then replace the failing entrepreneur. 
  • Airline captains - use a checklist approach to manage selection of an entrepreneur. 
Smart's results showed Airline captains were far more effective.  Their choices resulted in a 10% firing of the entrepreneur while all other approaches had to fire half their choices.  But even once the effectiveness data was known the approach ratios remained stable.  Most VCs adopt the approach of 'arts critics' and 'sponges'.  Only one in eight adopt the approach of 'airline captain'. 

Gawande believes discipline is needed to apply checklists and this is not attractive to most people.  When discipline is required people would prefer to use tools including computers to enforce discipline.  But automation struggles with uncertainty and unpredictability.  It is also often applied to the component that needs support rather than to fix the system. 

Of course Gawande provides a checklist for developing checklists (last updated 1/14/2010) is in three phases: development; drafting and validation as detailed by Atul Gawande in The Checklist Manifesto.  During:
  • Development he asks:
    • Do you have clear, concise objectives for the checklist?
    • Is each item:
      • A critical safety step and in great danger of being missed?
      • Not adequately checked by other mechanisms?
      • Actionable, with a specific response required for each item?
      • Designed to be read aloud as a verbal check?
      • One that can be affected by the use of a checklist?
    • Have you considered:
      • Adding items that will improve communication among team members?
      • Involving all members of the team in the checklist creation process?
  • Drafting he asks: 
    • Does the Checklist:
      • Utilize natural breaks in workflow (pause points)?
      • Use simple sentence structure and basic language?
      • Have a title that reflects its objectives?
      • Have a simple, uncluttered, and logical format?
      • Fit on one page?
      • Minimize the use of color?
    • Is the font:
      • Sans serif?
      • Upper and lower case text?
      • Large enough to be read easily?
      • Dark on a light background?
    • Are there fewer than 10 items per pause point?
    • Is the date of creation (or revision) clearly marked?
  • Validation he asks:
    • Have you:
      • Trialed the checklist with front line users (either in a real or simulated situation)?
      • Modified the checklist in response to repeated trials?
    • Does the checklist:
      • Fit the flow of work?
      • Detect errors at a time when they can still be corrected?
    • Can the checklist be completed in a reasonably brief period of time?
    • Have you made plans for future review and revision of the checklist?




The application of
This page introduces the complex adaptive system (CAS) theory frame.  The theory is positioned relative to the natural sciences.  It catalogs the laws and strategies which underpin the operation of systems that are based on the interaction of emergent agents. 
John Holland's framework for representing complexity is outlined.  Links to other key aspects of CAS theory discussed at the site are presented. 
CAS theory
represents the US is the United States of America.   health care network as a set of
This page discusses the mechanisms and effects of emergence underpinning any complex adaptive system (CAS).  Key research is reviewed. 
emergent
niches as categorized by
US healthcare is ripe for disruption.  Christensen, Grossman and Hwang argue that technologies are emerging which will support low cost business models that will undermine the current network.  Applying complex adaptive system (CAS) theory to these arguments suggests that the current power hierarchy can effectively resist these progressive forces. 
Christensen, Grossman and Hwang


Gawande highlights a variety of aspects which are typical of CAS including:
Atul Gawande's inspiring vision is highly informative and should be broadly understood.  While the challenges are significant it can only help for Gawande and other aligned leaders attempts to improve the health care process to be seen as significant options for change.  
































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This page looks at schematic structures and their uses.  It discusses a number of examples:
  • Schematic ideas are recombined in creativity. 
  • Similarly designers take ideas and rules about materials and components and combine them. 
  • Schematic Recipes help to standardize operations. 
  • Modular components are combined into strategies for use in business plans and business models. 

As a working example it presents part of the contents and schematic details from the Adaptive Web Framework (AWF)'s operational plan. 

Finally it includes a section presenting our formal representation of schematic goals. 
Each goal has a series of associated complex adaptive system (CAS) strategy strings. 
These goals plus strings are detailed for various chess and business examples. 
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