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June 8, 2012

The Checklist Manifesto

Filed under: Book Reviews — Brandon @ 12:35 pm
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The manager over several teams in our department required his direct reports to read this book. Not to let his teams have a leg up on our team, To help support the manager’s efforts, I decided to pick up a copy at the library and see what it was all about. It is a medical book (610.28 GAW) and not a business management, personal managment, or even a self-help book, which took me a little by surprise, but a skim of the blurb on the flap of the dust cover and an endorsement by Malcom Gladwell on the back made me confident that it was a worthy and revelant read.

About The Book
The Checklist Manifesto is a very easy read, containing mostly case studies, many of which are based on the author’s own observations and experiences. The primary message: use checklists because they are effective in reducing error in an increasingly-complicated world. The problem is that we humans tend to resist checklists for a number of reasons. Use them anyway. What have you got to lose? And, yes, that is a rhetorical question, especially considering that Gawande’s focus is on surgical safety and the reduction of incapacitating or fatal errors. I feel like one warning is in order: this is a medical book, so the weak-of-stomach may need to prepare themselves accordingly.

The Case Studies
The backdrop of the book is Gawande’s experience in developing a surgical checklist for the World Health Organization to be used around the world to reduce common errors in surgery. Along the way, he draws from a variety of sources to illustrate what checklists are and how the can be used. Being a medical book, there are medical-related cases, such as the opening story about a drowning victim in Austria miraculously saved by a swarm of superspecialists, and a clinical study of soap conducted in Southeast Asia. Several cases come from events in the history of aviation, such as the 1935 crash of the B-17 prototype, the successful emergency landing of U.S. Airways Flight 1549 in the Hudson River in 2009, and others. He discusses the differences in the ways which FEMA and Walmart responded to the impact of Hurricane Katrina. He even cites an example from the book Crazy From The Heat by Van Halen singer David Lee Roth. Much of the book is based on personal observations and his own research in the areas of construction, finance, and the culinary arts.

Key Points
Read the book, it is worth the time. The case studies really drive home the points. I’ve distilled a few key points here.

Complexity, Success & Failure

  • Success requires three things: the capacity to succeed, knowledge, and the application of that knowledge. Thus, failure arises from fate (my word), ignorance, or ineptitude.
  • Complexity in today’s world (especially in medicine) has led to increasingly-deep levels of specialization of skills.
  • Tasks may be simple, complicated (repeatable sets of simple tasks), or complex (unique, not repeatable).
  • Really complex tasks cannot always be reduced to simple checklists — expertise is required.
  • Procedural steps are often missed for one of several reasons, such as distraction, plain forgetfulness, false memory that results from repetition, etc.
  • The “stupid stuff” is most-often missed.
  • Using checklists requires discipline.
  • Getting it right means nobody has to be a hero.

Checklist Qualities

  • Good checklists can be described as precise, efficient, and practical; conversely, bad checklists are vague, long, or otherwise difficult to use.
  • Intuitively, this means that the physical properties of good checklists would include words that are simple and exact in meaning, including appropriate trade lingo, presented in as little and uncluttered a space as necessary.
  • READ-DO checklists are explicit lists of steps that are checked-off as they are completed, whereas DO-CONFIRM checklists contain only a minimum number of (critical) steps that constitute [what I call] success criteria, the completion of which can be confirmed at appropriate times.
  • Checklists may address “normal” situations [i.e. the “happy path” scenarios] or non-normal ones [i.e. exception-handling]
  • Reminders to run through checklists can be placed in appropriate places. [David Allen of GTD fame would agree with this sentiment.]
  • “Pause points” that occur naturally in a process can be leveraged as well.
  • It is tempting to use checklists as record-keeping devices to gather metrics; however, this formality adds resistence.
  • Checklists are communication tools, and it may be more effective for a team to use them verbally instead of checking items off with a pen or pencil.

Checklist Benefits

  • The real value in using checklists is in communication — getting people to talk before undertaking complex tasks.
  • Checklists lead to consistency and (hopefully) quality improvement over time, though they are probably not the right instrument to use to measure these things.


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