Up to Code DAVID DRISCOLL
A ‘Checklist Manifesto’ for Professionalism?
I WRITE THIS SHORTLY AFTER CHRISTMAS OF 2016. As always,
the season was marked by the challenge of finding presents for people
who already have every material thing they really need or want. For
such recipients, I often purchase things that everyone needs to replace
sooner or later, such as gloves or umbrellas. Less commonly, I buy them
a book that I think most anyone would find a worthwhile read.
One such book is The Checklist Manifesto: How to Get Things Right, by Atul
Gawande. First published in 2009, it became a New York Times bestseller and
continues to sell well today. In the book,
as in his 2007 article in The New Yorker
on the same subject, Gawande argues
that the probability of good outcomes
in the performance of professional work
of great technical complexity can often
be significantly improved by the use of
checklists to ensure that necessary steps
have been taken. A surgeon by trade, Gawande cites multiple examples from the
practice of medicine to illustrate how the
incidence of bad outcomes in his profession could be, and had been, reduced
markedly through the use of checklists.
Gawande’s examples include descrip-
tions of the resistance that has often
confronted the assertion that so elemen-
tary a tool could be of help in improving
the work of highly trained physicians.
There is probably universal agreement
that checklists are appropriate for mak-
ing sure that one has packed appropriate
gear for a camping trip, or that the func-
tioning of the safety equipment in an
automobile has been verified, but many
have difficulty believing that profes-
sionals with high levels of training and
experience would find checklists ben-
eficial in their work. Experts, after all,
are generally regarded as such because
of their ability to recognize the unique
and important characteristics of a given
situation and to adapt their actions to its
demands. A checklist, by contrast, is ef-
fectively a hard-and-fast set of rules. Its
use does not require a high level of pro-
fessional education or experience.
But as Gawande points out, the complexity of modern medical practice, and
of modern technology generally, has
created a void that in many cases can appropriately be filled by a checklist. In an
intensive care unit, for example, there
are simply too many aspects of patient
care that must be executed appropriately
to rely on anything less than systematic
checking to establish that they have been.
In the field of aeronautics, Gawande recounts how advancing aircraft design
required the introduction of checklists to
be used by pilots in takeoff, flight, landing, and taxiing. The more complex our
work becomes, it seems, the more we can
benefit from the use of checklists to ensure that everything necessary for a good
outcome has been completed.
Others (notably Jay Jaffe, in the
April/May 2014 edition of The Actuary)
have taken note of Gawande’s writings
and the potential for actuaries to use
checklists in their work to guard against
errors. The development of the kinds of
checklists Jaffe describes would generally have to reflect the tasks required to
prepare specific actuarial work products.
As a member of the Actuarial Board for
Counseling and Discipline, I particularly
want to encourage actuaries to think also
about the use of checklists to ensure that
their work complies with the standards
of professionalism embodied in the Code
of Professional Conduct and actuarial
standards of practice (ASOPs).
The impetus for this suggestion is
(as one might expect) recognition of the
growing complexity of doing all one must
do to remain “professional.” While many
aspects of the Code seem not to require
a checklist to ensure compliance (e.g.,
you probably do not need a checklist to
They say before his invention, it was all done with strings around fingers.