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More than ticking boxes: The Checklist Manifesto, How to Get Things Right by Atul Gawande

12 Mar 2019

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Book review by Rezah Reid, Business Analyst

Popular medical and business author Atul Gawande’s 2009 treatise on the humble checklist has gained enormous groundswell. It became a New York Times Bestseller in 2010 and is as widely read today as it was ten years ago. Gawande is a practising general surgeon at Harvard’s Vanguard Clinic and a consultant to the World Health Organisation. As a healthcare advocate, he is primarily concerned with improving patient outcomes, and was inspired to write The Checklist Manifesto after discovering that a physician who miraculously saved a young child who had fallen into a frozen pond relied heavily on checklists.

As a long time IT project manager and business analyst, my stock in trade has included making lists, prioritising actions, and ensuring that they are completed in a synchronised and concerted manner. At first glance, I imagined that the author was preaching to the converted, but there’s much more to the manifesto than that. This book explores the value of creating simple checklists as guidelines that we interact with daily in order to course-correct in our increasingly complex professional environments. The checklist becomes a way to tame some of the frenetic pace and complexity we face daily as we go about our ever more specialised professions.

"Substantial parts of what software engineers, financial managers, firefighters, police officers, lawyers, and most certainly clinicians do are now too complex for them to carry out reliably from memory alone." 

Gawande argues that two innate human fallibilities necessitate careful checklisting: (1) imperfect memory and attention, particularly in high stress situations; and (2) the tendency to skip steps in complex processes, due to a cognitive blind spot based on learned experience (the step that wasn't necessary nine times out of ten could save a life or prevent a huge misstep on the tenth). 

"Good checklists … are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything—a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps—the ones that even the highly skilled professionals using them could miss. Good checklists are, above all, practical."

Gawande draws heavily on the work Dr Pronovost, a medical researcher responsible for implementing checklist systems in hospitals across the United States. The research and subsequent programmes have led to double-digit percentage drops in preventable intensive care infections in highly underfunded and understaffed hospitals - all through the use of simple (five- to nine-point) checklists.

"… The more familiar and widely dangerous issue is a kind of silent disengagement, the consequence of specialized technicians sticking narrowly to their domains. “That’s not my problem” is possibly the worst thing people can think, whether they are starting an operation, taxiing an airplane full of passengers down a runway, or building a thousand-foot-tall skyscraper."

Knowledge is not necessarily the deficit, but clear and concise communication may be. This is well demonstrated in a ‘submittal schedule’ (page 65) used to manage complex processes in the construction industry. This tool facilitates regular, planned, frank communication among the requisite experts during the important stages of a building project. Taking this structured approach has shown a great benefit in reducing wastage and critical error.

"Knowledge has both saved us and burdened us."

In the end, it boils down to the fact that we all know more and more about less and less (through super-specialisation) but this doesn't necessarily translate into better performance. The Checklist Manifesto offers a means to create better baseline performance through ensuring that the basics are handled – and its many case studies speak for themselves.

In every field this method has been applied, performance gains have translated into significant cost savings and error reduction. In the parlance of my field, there is no point chasing alpha in an all-or-nothing process when we have not systematised the requisite building blocks, whether in terms of valuation, risk management, mandates, regulatory issues, deal structuring or performance management processes. 

"People need room to act and adapt. Yet they cannot succeed as isolated individuals, either—that is anarchy. Instead, they require a seemingly contradictory mix of freedom and expectation—expectation to coordinate, for example, and also to measure progress toward common goals."

The analogy Gawande uses is that of baking a cake: if one of the basic ingredients is missing, the outcome is potentially unpalatable. Referring back to our own sphere, merely identifying and analysing opportunities does little good if we fail to balance the present value against the costs associated with the investment. I highly recommend this book, if only for the incredible examples of the value that can result from using the right kind of simple, well-thought-through checklist.

Here's an example of a good checklist format.

Watch Atul's Ted Talk on the importance and value of a checklist. 

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