Algorithms, statistics, checklists and simple rules
The power of something as simple as a checklist is has been shown by Kahneman to have “saved hundreds of thousands of infants”. He gives the example of new born infants a few decades ago, where obstetricians had always known that an infant that is not breathing normally within a few minutes of birth is a high risk of brain damage or death. Physicians and midwives through the 1950’s typically used their varying levels of medical judgment to determine whether a baby was in distress. Different practitioners used their own experience and different signs and symptoms to determine the level and extent of this distress. Looking at these different symptoms meant that danger signs were often overlooked or missed and many newborn babies died. When Virginia Apgar, an American obstetrical anesthesiologist, was asked somewhat casually by a student how to make a systematic assessment of a newborn, Apgar responded “that’s easy” and jotted down five variables (heart rate, respiration, reflex, muscle tone and color) and three scores (0, 1 or 2 depending on the robustness of each variable). Apgar herself began to use this rating scale in her own work. She began applying this assessment about sixty seconds after birth of all infants she handled. A baby of eight or greater was likely to be in excellent condition. A baby with a score of four or less was in trouble and needed immediate attention. What is now called the “Apgar Test” is used in every delivery room every day and is credited for saving thousands of infant lives. Indeed, a report on CNN.com as recently as March 2014 (Hudson, 2014) indicated that about one in twenty five patients that seek treatment in US hospitals contracts an infection from the hospital, and that patients acquired some 721,800 infections in 2011. This statistic is however significantly better than previous years, about 44% from 2008 to 2012. This result came from “requiring hospitals to follow a simple checklist of best practices”. Simple checklists focused on complex situations work!
Resistance to assessment, prediction and tracking methods
Kahneman writes in detail of the level of resistance, even hostility, that he and other researchers have met with when presenting the results of his research on this topic. From medical professionals to psychologists and wine producers, these experts either rejected or ignored the results, and in some cases responded with derision. Perhaps this is predictable, because these results challenge the assessment and predictive capabilities of these same experts who have developed their skills over many years and have rightly developed high opinions of their capabilities.
Kahneman quotes Gawande who writes in his book “The Checklist Manifesto”:
We don’t like checklists. They can be painstaking. They’re not much fun. But I don’t think the issue (people resistance) here is mere laziness. There’s something deeper, more visceral going on when people walk away, not only from saving lives, but from making money. It somehow feels beneath us to use a checklist, it’s an embarrassment. It runs counter to deeply held beliefs about how the truly great among us – those heroes we aspire to be – handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not need protocols and checklists. Maybe our idea of heroism needs updating.
I agree with this sentiment. I have experienced this kind of response, verging on disdain when presenting various checklists related to change and transformation. Somehow a checklist, algorithm or computation trivializes their personal sense of the expertise, making them feel less expert. But, I believe a key element of introducing assessments and checklists is missed in Kahneman’s dialogue. These tools should be developed – as best as possible – together with the experts that will ultimately use them. This is a basic “behavioral change” principle, designed to overcome the “not invented here syndrome”. This principle has helped me introduce checklists into organizational change initiatives where many executives feel they “know it all”. Kahneman’s “close your eyes” rule is also valuable in these situations.
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