We shouldn’t underestimate the power of the humble checklist

After reading Atul Gawande’s book The Checklist Manifesto I will never look at checklists the same way again. Not only are they deceptively simple ways of codifying knowledge in an organisation, they also provide a focus for keeping that knowledge up to date. Checklists – written guides that walk us through the main steps in a complex procedure – are so familiar we can easily overlook just how powerful they are. Checklists draw together experience and knowledge and make it available to others in an easily digestible format. If a checklist is created as a group exercise it also helps those involved focus on what is really important and share the fruits of their experience – a way of both codifying knowledge and connecting people. In complex high pressure environments, checklists can prevent us from overlooking routine matters that we would normally remember. They can also help us to avoid skipping important actions because we may mistakenly believe them to be non-critical. That’s why checklists are used in pre-flight preparations in every aircraft cockpit in the world.

We tend to think of checklists as only suitable for highly routinised work settings but experience shows that checklists work well even in complex working environments because they can help us maintain an effective balance between professional autonomy and organisational requirements. As Atul Gawande suggests “Under conditions of complexity, not only are checklists a help, they are required for success. There must always be room for judgement, but judgement aided – and even enhanced – by procedure.”

The Checklist Manifesto provides lots of useful hints for devising checklists and, importantly, keeping them up-to-date. An interesting distinction is made between READ-AND-DO checklist items (where you read the item and then carry out what is specified), and CHECK-ONCE-DONE (where you confirm you’ve carried out the specified action). Whatever way is used to construct a checklist, they work because they can help people to apply the knowledge and expertise gained in their organisation (and beyond) consistently well. And providing they are used and regularly updated in the light of new experience and knowledge, the better they become.



Knowledge Management is usually Information Management

Where is the Life we have lost in living?
Where is the wisdom we have lost in knowledge?
Where is the knowledge we have lost in information?

TS Eliot ‘The Rock’

Truly managing knowledge is a big challenge. So perhaps it is not surprising that many organisations which invest in knowledge management systems end up managing what they can, rather than what they intended to. This is why most knowledge management systems are actually information management systems. Does this matter?

There is a somewhat unfashionable idea in the field of knowledge management called the knowledge hierarchy. It may be unfashionable – some say it is too simplistic – but the knowledge hierarchy concept can be very helpful because it shows what needs to happen to raw data in order to make it really useful.

Data, information, knowledge, wisdom – these are the levels of the knowledge hierarchy. Data comprises facts, figures and observations. Information is data with added interpretation (categorisation, collation, comparison, and so on). When we internalise information and make connections with other things we know in order to help us answer our questions and make sense of the world we generate knowledge. And finally when we combine our knowledge with our experience and values so that we understand underlying principles and can apply these in different contexts we achieve wisdom.  The effort involved in moving from one level to the next become more demanding with each step we take up the knowledge hierarchy. This helps to explain why, when we aim to manage knowledge, more often we end up managing information.


So I believe the often-quoted words from poet TS Eliot’s ‘The Rock’ at the beginning of this post carry a very important message. If we try to convince ourselves – or genuinely believe – that we are managing knowledge when in fact we are managing information, we run the risk of devaluing the very nature of knowledge. Perhaps without intending to, we strip from our understanding of knowledge the deeper meaning and connections that provide its real value. And likewise if we believe we have developed wisdom when we have not spent the necessary time and effort to test and modify our knowledge in the light of practice – the very essence of wisdom – we may believe our knowledge to be applicable irrespective of context.

Managing information is important. Our organisations need the systems that enable us to access and use interpreted data. But it’s important to make sure that our ambitions to create knowledge management systems don’t lead us to overlook what gives knowledge its true value.


If you have to make a choice between codifying knowledge and connecting people, choose the latter


Some organisations invest heavily in knowledge management systems that aim to codify knowledge in the hope that colleagues can readily find answers to the challenges they face in their work. In my experience this can run the risk of creating expensive to set up and maintain database systems that provide answers to questions that no-one is asking. When resources are tight (and when is that not the case?) an organisation is likely to get a better return on its investment if it focuses on facilitating connections between colleagues, and less on trying to ‘capture’ knowledge – especially in written form. There are a number of reasons why an investment in connecting people gives good returns. Firstly, it is through dialogue that the nuanced exchange necessary to address the challenge of context is more likely to occur. Secondly, connecting people doesn’t just help one person to find an answer to their question it encourages the emergence of ideas that may be new to both colleagues. Thirdly, engaging in dialogue builds relationships that strengthen the organisation as a whole and help to create a culture of openness, exchange and mutual support.

There is, of course, value in codifying knowledge and making it available in a recorded (written, audio, video) form that can be accessed widely.  But in reality codifying knowledge is very difficult, so what tends to get recorded and managed is not knowledge but information. Codifying information is important – especially if it provides a springboard to making connections. For example, colleagues need to know who to look to for the kind of expertise they seek, and their search can be accelerated by creating something as simple as a staff directory – or what is often called an ‘organisational yellow pages’. But information has limitations. Information doesn’t carry with it the richness of analysis that knowledge implies. A staff directory can point us in the right direction, but it is the conversations we have, the often unique questions we ask, the considered answers we receive, and the experiences we share through person-to-person connections that provide the most valuable return on investment when it comes to learning in organisations.

The illustration in this post is by Tamsin Haggis. You can find more of her wonderful work at http://tamsinhaggis.blogspot.co.uk

What I have learned about learning in organisations

This year, 2015, Framework (the consultancy collective I work in) celebrates its 30th birthday. As well as being a time for celebration, an anniversary is also a good time for reflection. I have been a member of Framework for 15 of its 30 years and during that time I have worked with dozens of organisations. Many of those organisations have asked me to work with them on issues related to organisational learning and knowledge management.

Last week I was asked by Save the Children UK to give a brief presentation to around 70 of their advisers on the subject of ‘Becoming a Learning Department’. The time was short so it was difficult to know what to cover. Preparing the talk really made me think about what I could say that would be of practical use and wasn’t simply a few sweeping generalisations. To try to make it relevant I focused part of my presentation on how learning relates to Save the Children’s theory of change. I also introduced the ideas of planned and emergent learning and motive, means and opportunity from my INTRAC paper Organisational Learning in NGOs: Creating the Motive, Means and Opportunity.

After the morning’s event with Save the Children I walked along Euston Road to visit one of my favourite places in London – the Wellcome Collection. It has a great cafe and bookshop and over coffee I was thinking about my experience earlier that day. It is some time since I wrote the MMO paper, and the discussions following my presentation prompted me to reflect on some of the nuggets I have learned over the past few years about learning in organisations. In his book, Better: A surgeon’s notes on performance, Atul Gawande writes about how he makes five suggestions to his medical students. The fourth suggestion is “Write something … You should not underestimate the power of the act of writing itself …Even the angriest rant forces the writer to achieve a degree of thoughtfulness.” Whilst I was browsing in the Wellcome bookshop after my coffee, I came across Matthew Frederick’s 101 Things I Learned at Architecture School. At an early age I hoped one day to become an architect and I love books that encourage visual thinking so I quickly became absorbed. I could see how the format – a graphic and a few sentences or paragraphs of accompanying text – was liberating for the writer – no need to develop a well-argued narrative structure, just get the ideas out! I decided right then to try writing my own version – exploring learning in organisations.

So I have set myself the challenge to write about things I have learned concerning the reality of learning in organisations. Most will be ideas that have emerged from my experience of working with thoughtful and dynamic individuals in the organisations with which I have consulted. Others may be new perspectives on topics I have written about before, that seem to have stood the test of time. Some I hope to be able to illustrate – using the format of the 101 Things series. All will focus on the demands and realities of organisational learning in the real world … and there may even be the occasional rant. I’m about to start writing the first one now.

The illustration in this post is by Tamsin Haggis. You can find more of her wonderful work at http://tamsinhaggis.blogspot.co.uk

Surgery, Checklists and the BBC Reith Lectures

I love BBC radio and one of the highlights of their great programming is the BBC Reith Lectures series. Around November-December each year, the BBC commissions an eminent expert to give four lectures on her or his subject. This year the lecturer is Atul Gawande. Gawande is a surgeon, a staff writer at the New Yorker magazine, a researcher, and author of a number of prize-winning books including his most recent, Being Mortal: Illness, Medicine and What Matters in the End. I listened with fascination to his first lecture – he’s a quietly captivating speaker – and despite his very different field of interest I quickly thought “this guy speaks my language”. Gawande’s first lecture addressed the issue of how we learn, or more often do not learn, from experience. Indeed, he dared to use the ‘M’ word in his lecture title and this surprised me – I didn’t expect a surgeon to admit to making any mistakes. The more I listened, the more interested I became in his perspective on the fallibility of medical practitioners and his frequent references to complexity as an important part of the explanation for their mistakes. In his second lecture, Gawande describes systems failures in the health services and identified these as a further contributing factor in medicine’s inability to deal with the complexity that both enables and constrains its practitioners. I was hooked. I placed a library reservation for Gawande’s recent book ‘Being Mortal’ and for his earlier prize-winning ‘Complications: A Surgeon’s Notes on an Imperfect Science’. Being too impatient to wait for those to arrive, I also bought his intriguingly titled ‘The Checklist Manifesto: How to Get Things Right’ and found myself reading it in one sitting. The Checklist Manifesto is full of the well-written anecdotes for which Gawande is rightly praised. In it, he brings his world of the operating theatre vividly to life. He also draws in experiences of other professionals – from the aviation industry and the world of huge construction projects – and deftly draws parallels between them and his own realm. Despite this, the Checklist Manifesto is a curious book. For starters, how is it possible to write a whole book simply advocating the use of checklists? Writing a checklist is not exactly rocket science or brain surgery, is it? Except, we quickly learn that rocket science (or its kid brother, the aviation industry) does rely on checklists. And worryingly we find out that brain surgery (and simpler surgical procedures) that you might expect to be awash with checklists to protect patients and ensure nothing gets forgotten, doesn’t seem to have any. Yikes – how is that possible? In answering this and other questions, Gawande shows how the creation and adoption of a simple surgical checklist for the World Health Organisation had to confront issues of ego and teamwork, power and culture, organisational hierarchies, and the unintended consequences that are so often the unfortunate outcomes of well-meaning systems. Gawande’s heart is definitely in the right place – there is more than enough evidence to show that checklists really save lives and reduce infection even in the high-tech operating theatres of the United States. However this is a book aimed not only at clinicians but other professionals too. I was left with a concern that because his own field of medicine does not seem to codify its experience into tools such as checklists, Gawande assumes that very few other areas of human endeavour do so either – except for the aviation and construction industries that are such a source of inspiration to him. My experience suggests that this is an unreasonable assumption and one that risks undermining the broader applicability of his message. So who is Gawande hoping will sign up to his manifesto? Should development practitioners be queuing up to add their names? Well maybe – but aren’t we already pretty good at codifying what we do? And have most of us not embraced procedures such as after action review to learn from successes and unintended outcomes? Well even if we have, there is always room for improvement. The process of preparing a checklist may well be a really good way of recording the results of an after action review in a way that improves our ability to do things better in the future.

Reflecting on development practice got me thinking about my own profession – consulting. I can see that there are some consulting procedures I use that would benefit from simple written (not just mental) checklists to ensure that key points are covered whilst freeing up time and ‘headspace’ to concentrate on the tricky stuff.

One final reflection. Earlier this year I had reason to be in an operating theatre. My left retina detached when I was working in Armenia and I returned to Scotland to have emergency surgery carried out by the surgeon who had fixed my other eye a year before. The surgical team carried out the vitrectomy and laser photocoagulation procedure in less than an hour and I’m happy to say that there were no complications. If I have cause to be wheeled into my local hospital operating theatre again knowing what I have now learned about how easy it is for simple things to be overlooked even by experienced clinicians, I am glad to know that Scotland is one of the first countries to ensure that all of its surgical teams have adopted Gawande’s checklist.

Idea Magnetism and Open Source


Last weekend I visited an exhibition of 3D printing at the Science Museum in London.  It is nothing short of magical to see a 3-dimensional object being created before your eyes by a 3D printer attached to a computer. Chris Anderson – author of the recent business bestseller ‘Makers: The New Industrial Revolution’ describes how what we have learned about the digital world is now being applied to the physical world. The pace of innovation in this field is astonishing and it is not just confined to the technology. New business models based on open source sharing are turning conventional business thinking on its head. Intellectual property rights may become a thing of the past according to Anderson and he illustrates this using his experience of setting up a small company manufacturing “aerial robotics” – miniature helicopter ‘drones’. All of his company’s software and hardware specifications are shared freely with others. Far from leading to competitive suicide, this openness created a community of enthusiasts whose innovative contributions (mostly given free of charge) have led to the development of yet more groundbreaking developments.

One of the many challenging insights contained in Anderson’s entertaining and informative book is his discussion of Joy’s Law – “No matter who you are, most of the smartest people work for someone else”! The implication of this is the importance of tapping into what the economist Friedrich Hayek called “distributed knowledge”. Anderson describes how the internet allows us to find and tap into the best people no matter where or who they are. Indeed, the essence of open-innovation communities is that those people find you if you are willing to share what you are doing and they are interested in what you are sharing. His own company, DIY Drones, is an excellent example of this ‘idea magnetism’.

This is not particularly earth-shattering to those of us working in the field of development. We have been creating knowledge-sharing communities for decades – though with varying degrees of success. What was new to me is that the business world is beginning to act this way too. Just imagine for a moment  what would be possible if collaboration were to displace competition as the new business mindset.

Putting aside such flights of imagination, one message comes across clearly from Anderson’s book – the generous sharing of ideas can lead to unimagined results.

What can OD practitioners learn from TV thriller box sets?

I am a big fan of TV thriller series such as ‘The Killing’, ‘Arne Dahl’, ‘Life’ and ‘Homeland’. Maybe you are too. If so, have you noticed how often charts – comprising photos (usually suspects and victims), maps, Post-It notes and the connections between them – feature on the office walls of the investigators? You can see a couple of examples in the background of these photos.

Homeland Life

I assumed these wall-charts were a device used by the makers of the TV series to provide an interesting backdrop and aide memoire for us viewers who are often trying to keep track of multiple characters. However, it turns out that the use of wall charts is standard criminal investigation practice these days – and with good reason.

Trying to keep track of multiple pieces of data and then build an understanding of the relationships between them is challenging for most of us. When we are working in a team where each person has access to different pieces of the data it can be almost impossible to see the bigger picture using more conventional means of communication. Talking together and reading each others’ notes and reports are, of course, useful but what can really help is a visual representation of all the information. Hence the wall charts. These enable teams of investigators who are often trying to unravel complex crimes, build a shared understanding of the complicated web of relationships between the suspects, victims and other key players. The wall charts also act as a constant but subtle reminder of the investigation as a type of systems analysis, and can trigger insights into interconnections in a uniquely visual way.

It occurs to me that when we are conducting reviews and evaluations we are in a somewhat similar situation to the police investigators in ‘Arne Dahl’ and ‘Life’ or the spooks in ‘Homeland’. We usually work individually or in small teams and have to build a rapid understanding of the complex relationships within and between projects and programs. And yet, although I consider myself a visual thinker, until recently I have never thought to use the kind of wall chart that seems to be standard practice in criminal investigations.

So what might be the organisational development equivalent of a criminal investigation wall-chart? The most similar tool I can think of is the ‘rich picture’. The term ‘rich picture’ is borrowed from ‘soft systems methodology’ and simply means a drawing (often cartoon-type) or other visual representation showing the main actors in a situation and the relationships between them. I have used rich pictures in my organisational development work to help clients explore organisational problems and opportunities for development. Drawing a picture can feel uncomfortable at first for people who are more used to poring over lengthy reports or spreadsheets. But by encouraging us to make more use of the right-hand side of our brain which is responsible for creativity, intuition and synthesis, drawing can facilitate a deeper understanding of complex organisational issues.

Inspired by the investigators in my favourite TV series, I intend to adapt their wall charts and try them in other settings such as learning reviews and program evaluations. Step aside Sarah Lund!