Atul Gawande's title may have been a gamble in respect of this book's success, because as he says on page 173 "We don't like checklists". Not (just) because they are not much fun, but because someone whose skill lies in performing complex or difficult tasks probably also regards them as beneath her. Standard operating procedure implies rigidity and mindlessness. But the value of checklists according to Mr Gawande, a general surgeon in a US hospital, is the opposite: to take the stuff of dumb routines out of the way of skilled minds so that they don't have to focus on this.
This is important because complexity has increased, and seems sure to continue to do so as if on a one way street. Know-how and expertise is cumulative. And getting stuff right increasingly relies on ever more intricate co-ordination of experts and procedures. In solving life's problems there are two categories of failure that get in the way: one is not knowing what to do (ignorance) and the other is doing it badly (ineptitude).
There is no immediate fix for lack of know-how--but it (knowledge) progressively accumulates over time, and we now have a lot of it. But human beings have not simultaneously got better at handling complex procedures. So the balance of our limitations has shifted over time such that ineptitude is the larger constraint on success today. Yet there is a ready fix for this, which is the checklist. And it isn't rocket science or brain surgery but it helps both--the case studies in operating rooms and on flight decks (OK not actually rockets) that are sprinkled through this book are inspiring and fascinating highlights.
In some fields (medicine according to the author), opposition to procedural discipline is cultural. A belief has taken root that in high-stakes complex situations the solution is expert, almost maverick audacity. In others (construction, aviation), the supremacy of an autonomous all-knowing virtuoso has already given way. No modern building lacks a construction schedule detailing line-by-line tasks. Airlines and aerospace manuacturers have issued hundreds of checklists a year for decades. This is because failure for the latter two carries a very high public cost (in the form of collapsed buildings or plane crashes). It also does in medicine--serious complication rates are 5-15%--and to bereaved relatives, fatality due to human error is hard to forgive. But to the general public, outrage is alleviated by the positive net good surgery does for humanity everywhere, giving failures something of a pass. This is merely framing though. Preventable catastrophe remains preventable.
In respect of failure, "perfect storm" is an often used excuse for the unexpected. But the unexpected is, well, to be expected, in the sense that it is a large and perennial category of error. And perfect storms are hardly necessary--when landing an aircraft, or putting a patient under, or even when buying the ingredients to bake a cake, frequently if you miss one thing then forget it; it's all or none. This leads to communication checklists as well as the critical to-do type. And good ones of these disperse power within teams, so that any member can raise a red flag (and not be silenced by the omniscient chief, nor be too reserved to speak up). They also confer responsibility and trust in respect of who should talk to whom if something unplanned happens. Even name and role introductions before a team gets busy are helpful. US Airways flight 1549 pitched into New York's Hudson River in 2009 soon after take off when both its engines shut off, and the crew of 5 saved everybody; they had not worked together before, but went by the book, including shaking hands and building trust before they set off, and discovered that falling out of the sky was not as bad as they thought.
The emergent thesis from Mr Gawande is that checklists can probably defend almost anyone in almost any field against failure. And this followed doubtful perseverance and re-iteration in his own discipline, culminating in strong success rates of failure reduction, that read impressively and were controlled for observer effects. There is limited exploration outside healing, building and flying, but some. A high end Boston restaurant is opened up to its reliance on, well, recipes, but other lists as well. A health project to reduce hygiene-related early death in Karachi slums found that free extra soap and guidelines for hand washing made a huge difference. Van Halen's trick of demanding a bowl of m&ms with no brown ones in a dressing room was a test of whether their gig organisers followed procedures closely enough.
There is also mention of a couple of successful portfolio managers using lists to avoid investment errors. This reviewer expeienced a bit more scepticism in her perception of applicability here, but that may be the same "not for me" aversion in her case that made the author initially doubtful. What points in favour of the checklist manifesto is an enticing promise--of an improvement in outcomes with no increase in skill. And when aversion to it is called what it is--walking away from saving lives, leaving money on the table--such slow uptake and unwillingness to try should surely be questioned.
This is important because complexity has increased, and seems sure to continue to do so as if on a one way street. Know-how and expertise is cumulative. And getting stuff right increasingly relies on ever more intricate co-ordination of experts and procedures. In solving life's problems there are two categories of failure that get in the way: one is not knowing what to do (ignorance) and the other is doing it badly (ineptitude).
There is no immediate fix for lack of know-how--but it (knowledge) progressively accumulates over time, and we now have a lot of it. But human beings have not simultaneously got better at handling complex procedures. So the balance of our limitations has shifted over time such that ineptitude is the larger constraint on success today. Yet there is a ready fix for this, which is the checklist. And it isn't rocket science or brain surgery but it helps both--the case studies in operating rooms and on flight decks (OK not actually rockets) that are sprinkled through this book are inspiring and fascinating highlights.
In some fields (medicine according to the author), opposition to procedural discipline is cultural. A belief has taken root that in high-stakes complex situations the solution is expert, almost maverick audacity. In others (construction, aviation), the supremacy of an autonomous all-knowing virtuoso has already given way. No modern building lacks a construction schedule detailing line-by-line tasks. Airlines and aerospace manuacturers have issued hundreds of checklists a year for decades. This is because failure for the latter two carries a very high public cost (in the form of collapsed buildings or plane crashes). It also does in medicine--serious complication rates are 5-15%--and to bereaved relatives, fatality due to human error is hard to forgive. But to the general public, outrage is alleviated by the positive net good surgery does for humanity everywhere, giving failures something of a pass. This is merely framing though. Preventable catastrophe remains preventable.
In respect of failure, "perfect storm" is an often used excuse for the unexpected. But the unexpected is, well, to be expected, in the sense that it is a large and perennial category of error. And perfect storms are hardly necessary--when landing an aircraft, or putting a patient under, or even when buying the ingredients to bake a cake, frequently if you miss one thing then forget it; it's all or none. This leads to communication checklists as well as the critical to-do type. And good ones of these disperse power within teams, so that any member can raise a red flag (and not be silenced by the omniscient chief, nor be too reserved to speak up). They also confer responsibility and trust in respect of who should talk to whom if something unplanned happens. Even name and role introductions before a team gets busy are helpful. US Airways flight 1549 pitched into New York's Hudson River in 2009 soon after take off when both its engines shut off, and the crew of 5 saved everybody; they had not worked together before, but went by the book, including shaking hands and building trust before they set off, and discovered that falling out of the sky was not as bad as they thought.
The emergent thesis from Mr Gawande is that checklists can probably defend almost anyone in almost any field against failure. And this followed doubtful perseverance and re-iteration in his own discipline, culminating in strong success rates of failure reduction, that read impressively and were controlled for observer effects. There is limited exploration outside healing, building and flying, but some. A high end Boston restaurant is opened up to its reliance on, well, recipes, but other lists as well. A health project to reduce hygiene-related early death in Karachi slums found that free extra soap and guidelines for hand washing made a huge difference. Van Halen's trick of demanding a bowl of m&ms with no brown ones in a dressing room was a test of whether their gig organisers followed procedures closely enough.
There is also mention of a couple of successful portfolio managers using lists to avoid investment errors. This reviewer expeienced a bit more scepticism in her perception of applicability here, but that may be the same "not for me" aversion in her case that made the author initially doubtful. What points in favour of the checklist manifesto is an enticing promise--of an improvement in outcomes with no increase in skill. And when aversion to it is called what it is--walking away from saving lives, leaving money on the table--such slow uptake and unwillingness to try should surely be questioned.
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