Indira Rajaraman: A checklist of waste

The damage done through neglecting the structure of public systems affects macro outcomes

The multiple road bypass outside the All India Institute of Medical Sciences (AIIMS) in Delhi is grandly laid out, with a landscaped lawn decorated with metal art forms, the whole sweep floodlit by night. During the day, the sun takes over the task of illumination, but the floodlights sometimes remain on right through. Looking at this profligacy, you would never guess that India suffers from an acute power shortage. Is there an employee of the Municipal Corporation of Delhi (MCD) to whom the task is exclusively assigned, so that when he is on leave, the lights stay on during the day? Or is there an automatic switch, with no one assigned the task of checking whether it switches off at dawn the way it is supposed to?

Is the MCD not bothered about these lights because it does not pay its power bills anyway? Power distribution companies borrow to keep themselves afloat in the face of non-paying consumers. The 2010-11 edition of Trends and Progress of Banking in India, an annual publication of the Reserve Bank of India, shows that the exposure of the banking system to the infrastructure sector (read power sector) has grown very rapidly in the last two years. The health of the financial system is at risk.

India has a chronic water shortage. In most urban residential areas, continuous water supply on tap all day is a fond but distant memory. Ground level sumps function as private catchment buffers between the irregular supply, and the domestic need for a continuous supply. Residents form their expectations of the hours of water supply on the basis of what economists call an adaptive expectations model, expecting for tomorrow the pattern established in the most recent days and weeks. But all of a sudden there can be a flood of water, supplied well beyond the usual time, bubbling uncontrollably out of sumps, and forming lakes that can provide sustenance for at least one larval cycle of mosquitoes. Then there can be a drought for some days, when no water comes through at all, and people anxiously await water tankers to provide an emergency minimum for those empty sumps.

In a country that leads the road accident mortality league tables, we continue to have malfunctioning automated traffic lights. Traffic lights don't necessarily switch off when they fail; they remain permanently on the last colour. When motorists facing an unending red light decide to move on, they pose grave risks to those favoured with an unending green light.

At toll booths on highways, the sum asked for can be an awkward figure like Rs 21, where the toll collector carries no change. It takes only a single motorist without the exact sum, and refusing to forgo his change, to cause a car hold up stretching for a kilometre or more, adding pointlessly to the oil import bill, and thereby to the weakness of the rupee.

These instances are taken only from the kinds of public mismanagement confronted by the privileged citizens of India. When it comes to the underprivileged, their survival is more directly threatened. The most horrific are the recent cases in public hospitals, where lethal liquids were served to patients entrusted to their care.

As public systems, or any systems for that matter, have become larger and more complex – in the sense of multiple components all needing to be sequenced in a particular order for effective functioning of the whole – something as simple as a formal checklist may be all that is needed. Atul Gawande, a distinguished surgeon of Indian origin in the US, as renowned for his writing as his surgical skills, has a recent book (The Checklist Manifesto), in which he documents cases where the checklist as a formal prior procedure has saved lives in diverse settings ranging from surgical theatres to aircraft preparation for flights, or improved the speed of completion of buildings and public infrastructure.

The checklist cannot be easily accepted in his country of origin however. In our culture, excellence is measured by contempt for externally-imposed discipline. We rely on the unwritten rather the written, the informal rather than the formal. We are proud of our ability to improvise in the moment, the desperate dash by the orderly from the surgical theatre to the blood bank if an operation goes awry and lets loose a torrent of blood. And if the blood bank is temporarily shut because the keeper is out to tea — well, the orderly just continues his dash to the canteen. Everyone cooperates to find the man with the key, but the patient may need the blood no longer when it finally reaches him.

Checklists lower the risk from human failure and failings. They are a way by which routine safety nets in the form of contingency personnel can be brought into play for staff failing to report to duty. In India, more than elsewhere, effective service delivery requires contingencies in place for pervasive public failure. Traffic, VIP movements and a host of external shocks are more likely here than elsewhere to make for staff absences and delays.

Even large and formal systems neglect the need for contingency replacements. As a result, available staff are made to perform multiple tasks or to work excessively long hours without a break. Raja Parasuraman, a distinguished cognitive neuroscientist of Indian origin in the US, has a number of recent published papers on performance by military personnel tested through high-fidelity simulations of soldier tasks, showing that collateral damage in warfare results from avoidable multi-tasking at the front line. Likewise, when people are pushed to work for long hours without a break, like drivers of freight trucks, our highway mortality rates go up.

Complex systems require engineering to protect against risk from human failure. The damage done through inattention to the structure of public systems extends far beyond the delivered outcomes of those systems themselves.

The author is Honorary Visiting Professor, Indian Statistical Institute, Delhi