The knowledge in medicine, and many other professions, is exploding and consequently creating enormous complexity that lead to many preventable errors. Humans beings are fallible: they overestimate their memory, take shortcuts, and occasionally miss key steps. Gawande proposes that a simple and underestimated, but profound and effective tool—the humble checklist, can help professionals reduce disasters. Using compelling stories from diverse fields such as skyscraper construction, public health, aviation, and even gastronomy, the book makes a strong case for the use of good checklists, for low probability, high impact routine processes. I think the increasingly complex field of investments would benefit from the use of checklists in the screening process. It would seem to be a valuable edge since most managers, and professionals in general, are reluctant to use them for behavioral-biased reasons. Gawande provides a checklist on how to create a good checklist. Hence, I will be compiling a checklist (in addition to purpose and process documentation) for my own investments.
- The world has grown increasingly sophisticated and complex. In the last past century, the amount of knowledge has increased to the extent that is has outgrown our ability to manage it.
- Humans are not all powerful; some things are simply beyond our ability (‘necessary fallibility’). But for things within our capability, we fail because of:
- ignorance: the lack of knowledge
- ineptitude: the lack of proper or consistent application of knowledge
- Professionals are highly trained and highly skilled. They often fail not for lack of knowledge, but for ineptitude. The volume and complexity of knowledge has become unmanageable. ICUs on average perform 178 tasks on a patient. Even an (admirable) 1% error rate results in 2 errors. That’s why many professions traditionally don’t punish failure, but encourage experience and training.
- To manage extreme complexity, professions have become specialized. Medicine has become super-specialized. Yet routine mistakes still occur—and a small error can be fatal.
- Human memory and attention is fallible, especially for matters that are routine, under time pressure, and particularly dangerous for processes that are ‘all-or none’. That’s where checklists are powerful: for mundane, low probability, high risk tasks.
- In construction, master builders yielded to contemporary teams of specialist engineers, architects, craftsmen, and contractors, who all use large collections of plans and checklists.
- Checklists, while primitive, are surprisingly effective:
- task: they help memory recall, instill disciple, ensure minimal necessary steps, and raise the level of baseline performance. They ensure the stupid but critical tasks do not get overlooked or hastily skipped.
- communication: they also ‘activate’ discussion and teamwork behavior. In construction, ‘submittal’ checklists force teams to talk and uncover issues before moving on. A checking system. One man is fallible, but a team of men less so. Leverage the wisdom of the group instead of the individual.
- With highly complex and unpredictable problems, the solution often is pushing the decision-making from the center to the periphery (e.g. handling the Hurricane Katrina disaster). Allow those closest to the ground to make decisions, but monitor their progress and force them to communicate.
- To get people to use checklists may involve a change in cultural practices (e.g. nurse enforcement before surgery). Keep them simple, easy, and meaningful, and then create reminders to use it.
- Know people’s names. Studies have found that teams where members don’t know each other’s names don’t communicate or work as well together.
- In hospitals, checklists reduced errors, improved team morale, decreased staff turnover, decreased post-surgery complications, and ultimately saved lives.
- WHO safe surgery checklist pilot program decreased hospital surgical error rates by ~35%. Yet participants were not exactly sure how checklists helped. Mostly, it was an increase in communication and teamwork. Despite the evidence of high effectiveness, surgeon adoption is still underwhelming due to ego and star performer culture.
- In finance, checklists make the research process more thorough, and paradoxically, faster. Methodical, procedeuralized venture capitalists have been shown to outperform, yet adoption of checklists in finance have been slow. It goes against the established paradigm of the intuitive genius/ hero.
- Good checklists:
- Concise: ideally 5 to 9 items. Should take less than 2 minutes to go through. They should not be comprehensive how-to guides. Too long and they become a distraction and people start taking shortcuts. List only “killer” easily forgotten items—things that must be done.
- Clear: use unambiguous and understood language. No fancy fonts or colors. Defined ‘pause point’ when it is used.
- Collaborative: ensure team members communicate and work together.
- Complement: they should aid a user’s judgements, not replace it. Be invoked at critical ‘pause points’. If it’s not practical and helpful, then it needs to be changed.
- Practical: useful and designed by functional experts, not desk jockeys.
- Updated: constantly revisited and revised as real world and new situations dictate.
- Two types: ‘Do-Confirm’ and ‘Read-Do’.
- Checklists have met with adoption resistance because: 1) go against established cultures and norms (e.g. authority, ego), 2) go against human instinct for novelty/ fear of rigidity, 3) overconfidence in human memory, 4) impatience/ not fun; 5) require disciple, 5) are underestimated due to its utter simplicity.
- Unlike almost all other complex professions like medicine, law, education, and finance, aviation prizes discipline. Flying takes a strict investigative approach to failures, and thus has a focused avoidance of recurrent mistakes.
- The goal is not to tick a box. It is to enhance teamwork, discipline, and performance.
Finished: 22-Feb-2018. Rating: 7/10.