I just finished Dr. Atul Gawande's latest book, The Checklist Manifesto: How to Get Things Right. I believe that this book is the single most important book of the year for ANY Lean leader, not just people working in healthcare. I'll share more of my thoughts on the book in another post, but I wanted to address a recent review in the WSJ.
There's room for intelligent disagreement on issues like this, but the conclusions drawn by the WSJ reviewer really makes me question his reading comprehension skills or his agenda.
The title of the review signals its negativity:
“Problems with Protocols: Checklists, although valuable in some settings, are a menace in others.”
The reviewer, Philip K. Howard, an attorney, gives rightful credit to the lifesaving impact that checklists have in healthcare. But, it seems that Mr. Howard suffers from the same ailment that Dr. Gawande attributes to many physicians – that just because you've gone to school long enough you are therefore above checklists and, what we'd call in the Lean world, “standardized work.”
Dr. Gawande, in his book, states that checklists would have a positive impact in legal work (to prevent frequent legal errors in simple filings) and in investing and venture capital. It seems Mr. Howard is allowing emotion and defensiveness to get in the way of considering Dr. Gawande's approach.
Mr. Howard tries to counter Dr. Gawande's argument for checklists, where he cited how Wal-Mart (which allowed managers to be creative) outperformed FEMA (which relied on bureaucratic rules) in Hurricane Katrina relief by saying:
“But giving someone the authority to use her judgment means relying on individual creativity and improvisation – “the opposite of a checklist.”
This is exactly the OPPOSITE of the point that Dr. Gawande makes in the book, saying:
There must always be room for judgment, but judgment aided – and even enhanced – by procedure.
Mr. Howard also writes:
“But bureaucracy is nothing but checklists. That's part of what's wrong with modern government – officials go through the day with their heads in a rulebook, dutifully complying with whatever the lists require instead of thinking about what makes sense.”
Mr. Howard really has it mixed up. The bureaucracy of FEMA is NOT the result of checklists. Checklists, as Dr. Gawande writes, free up people from mundane decisions to 1) help prevent errors and 2) allow people to apply their critical thinking skills to important decisions. Dr. Gawande writes convincingly of how Captain “Sully” Sullenburger and First Officer Skiles both landed US Air Flight 1549 because they used checklists to handle the mechanics of the situation, freeing up Sully to remain calm and make the one important decision of WHERE to land the plane.
Mr. Howard rails against a real problem in modern education:
“Teachers, for example, are shackled to lists and protocols that prevent them from doing their jobs properly (e.g., disciplining students).”
This is not a “checklists” problem. Not letting teachers exercise professional judgment is a MANAGEMENT problem. If you institute checklists in a culture where you don't let people think, I'm sure you'll have a lot of problems. But this is FAR from the culture that Dr. Gawande advocates. How Mr. Howard missed that is beyond me.
Mr. Howard again tries to argue against checklists:
“But most people can think of only one thing at once: If they're thinking about a checklist, they may not be focusing on solving the problem at hand.”
Again, this argument is clearly refuted by the US Airways case and Dr. Gawande's O.R. mishap that nearly killed a patient (and would have, if not for the checklist). Checklists can, in the case of US Airways, provide structure for solving an unintended circumstance or they can, in the case of Dr. Gawande, provide a “pre-flight check” to ensure that there is enough blood on hand even if the surgeon didn't anticipate cutting a patient's artery. The US Airways crew didn't anticipate a bird strike, but checklists benefitted them (and the passengers) and didn't mean their creative brains were shut off. The cockpit checklist did NOT say “Step 7, land in the Hudson River.” That was pure creativity enabled by a checklist.
Mr. Howard tries to dispute this by saying:
“It was undoubtedly a good thing that every member of the crew had been drilled in various procedures. But the “miracle on the Hudson” happened because Capt. “Sully” Sullenberger focused on flying the plane, not a checklist on how to fly the plane.”
Mr. Howard misses the key point that so many missed – it wasn't just Sully who landed the plane. It was a team effort where he and the First Officer (who was following a checklist to try to restart the engines) worked together to avoid catastrophe.
Mr. Howard tries to use the skilled hero model for Sully by quoting William Langewiesche:
“Across a lifetime of flying, Sullenberger had developed an intimacy with these machines that is difficult to convey. He did not sit in airplanes so much as put them on. He flew them in a profoundly integrated way, as an expression of himself.”
Sully himself, as stated clearly in Dr. Gawande's book (again, something Mr. Howard missed), dismisses the notion that he was uniquely skilled or that his experience, heroism, or decades-old glider experience were important factors. From Dr. Gawande:
As Sullenberger kept saying over and over from the first of his interviews afterward, “I want to correct the record right now. This was a crew effort.” The outcome, he said, was the result of teamwork and adherence to procedure as much as of any individual skill he may have had.
Mr. Howard makes his world view clear in a final comment:
“Accomplishment is personal. That's why giving people the freedom to take responsibility is so important.”
He clearly doesn't understand the impact of systems, nor does he realize that we all (including lawyers) work in a system. He holds to the heroic notion that our success is completely due to our own individual exceptionalism.
Mr. Howard seemed to push his own agenda against being stifled by checklists or standardized work instead of simply reviewing Dr. Gawande's book. Maybe Mr. Howard works for unenlightened managers who DO equate standardized work with not thinking. Or maybe he's a Taylorist at heart, himself.
Lean thinkers, I believe, wouldn't buy his argument. I rest my case.
Rather than assuming that checklists would be damaging, has Mr. Howard tried them in his own practice? Has he tried using them in an environment that still values and allows professional judgment and creativity?
I give credit to Dr. Gawande, and others around the world, who have been willing to try something new (checklists) – not turning aside data that shows that they work.
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Our principles, or beliefs, are a product of our experiences. This reviewer clearly had experiences that drove his beliefs, and that filter or mental model was so think that he wasn’t going to see or hear the arguments in the book if they were directly injected. By why would he hang onto such beliefs so strongly?
Chances are, he had really bad experiences with checklists. The think is, the checklist itself doesn’t make things better or worse. It is the way in which the checklist is used that makes the difference. This still requires the right principles and behaviors (read as culture). Checklists aren’t any more a magic tool than 5S or kaizen events. They are a simple and powerful tool, but only when used in the right way.
I haven’t read the book yet, only because my inflow (I’ve had 5 authors send me books to review in January) is greater than my outflow of book reading, so I can’t comment on the book itself. But I plan to read the book. But readers should take away that they shouldn’t go ‘checklist crazy’ and just insist people have checklists. Develop checklists with a purpose. Develop a culture that utilizes them properly.
Jamie Flinchbaugh
http://www.jamieflinchbaugh.com
Yes, you’re right Jamie – and Dr. Gawande makes those points in the book. Checklists aren’t a cure all (the checklist won’t fly the plane for you), they need to have a purpose, they need to be simple, tested, and effective in use.
I wish the WSJ would have had a physician or surgeon review the book.
Mark;
We have seen this as a very powerful tool when used in the right situation. From order entry errors to determine Pareto analysis and many other situations. There are checklists on forklifts to provide safety guidelines for the protection and well being of our employees. Last year, a competing sign company had a 80′ Taco Bell pylon sign snap in half and fall upon a parked truck, which resulted in the death of an innocent person just sitting in the vehicle. What if (as we do) their engineering and fabrication personnel utilized a checklist to validate structural requirements for this type of signage? The sign snapped because someone bypassed the “standard.” It may have been viewed as innovative cost saving activity by those involved but the short cut past the standard resulted in a tragic ending. As noted by Jamie, checklists can be very powerful tool, when used appropriately.
Great post. I am amazed at what I miss when reading based on my mental state at the time, and my overall mental model. When I re-read books I am always amazed at the great things that I missed the first time around.
I had a class that talked a lot about mental models and systems thinking, and they mentioned a story about an article that was writen with the exact same number of arguments for and against a political issue. When the readers finished it, whether their own view was for or against the issue, they agreed 100% because their minds filtered out what they didn’t want to hear. I think this is a very common occurance to be aware of when teaching anything.
Mark,
This reminds me of a time 20 years ago when “experienced engineers” said “they do not need a checklist” to qualify a product design. After time they realized the checklist eliminated the mind clutter of routine requirements and their minds were freed up to apply creativity to their designs.
BTW applying this and many other Lean methods allowed the product development cycle to shorten from 3-5 years to 6-9 months.
“Set a Standard, Follow the Standard, Look for a Better Way”. I also read the book, and it places checklists within this scenario. It emphasizes that a checklist is part of continuous improvement, not a mindless bureaucratic exercise. I was very impressed with the book as well!
.-= Mike Sporer ´s last blog ..A Student of Human Moves =-.
A potential problem to watch out for with checklists is when the checking process doesn’t require you to actually “go look” at the items being checked. This can lead to a dangerous routinized non-conscious behavior if every time you go through the list, certain critical items are regularly checked off as being “okay.” Because of your habitual familiarity with the list, the process, and the responses, you can end up following a “script” and go through the list by rote. You find yourself not paying attention to the very discrepancies you are supposed to be checking for when non-routine conditions occur.
A real example: Right after taking off in Washington D.C. during below freezing temperatures on January 13, 1982, Air Florida Flight 90 crashed and fell into the Potomac River. The recovered cockpit recording of the flight includes a segment with the pilot and co-pilot going through a pre-flight checklist. One of the things they routinely checked was the “on/off” status of an anti-icing device that must be on during such freezing weather, so as to prevent the icing and consequent failure of certain critical engine gauges.
The co-pilot can be heard reading from the checklist, “anti-ice” with the pilot responding, “off.” Given the weather conditions, this should have resulted in immediate corrective action, but it didn’t; they just continued on down the checklist.
Now you can attack the pilot and co-pilot for joint inattentive behavior, or, using a Lean approach, you can question the process instead to see how it might have caused the behavior.
What was the standard? It was to read off the checklist in the cockpit. Why did neither the pilot nor the co-pilot react to the need to turn on the anti-icing device? The “anti-ice” check item and pilot’s “off” response to it was a combination that had likely occurred countless times when going through the checklist previously, without any need for action, since Florida (it was an Air Florida flight) is routinely warm. This was probably routinized in the pilot and co-pilot’s brain patterns as well. If either one had gone to the “Gemba” and looked out the airplane at the weather, instead of “reading reports” in their “office” (metaphorically speaking), they would have observed for themselves the obvious action to take. Instead, following the process, they just kept going down the checklist in an habituated tempo. Seventy-eight people died.
Checklists work for anyone that puts the effort into designing one for a purpose.
Pilots use their checklists constantly to ensure that everything is done right, so they can minimize the possibility of a problem.
Good food safety inspection requires checklists so that you do not accidentally miss something that kills a person.
Good lawyers use them for routine tasks to ensure everything gets done on time. I know one that is almost religious about them, he tells me it allows him to focus more on his clients instead of the process. Most law practise is repetitive procedures that need to be followed, the checklist makes sure evrything is done in the right order at the right time.
Even when I design a presentation I create a temp checklist to ensure I have all the parts in place.
Good webdesigners use them to ensure they do not miss parts that could cause poor results in the search engines.
Good doctors use them to prevent mistakes, and ensure that their patients get the best possible treatment. Because they do not have to concentrate on the routine stuff they can focus more energy, on looking for non-routine issues. Several I know couple it with their patient’s visit treatment record, so at a glance they can see everything they may need.
World class chefs insist on them, the little things can destory a class restaurant in a hurry. Additionally strict checklist use can prevent many false lawsuits.
After all a checklist is a form of a plan for routine things, the lawyer/writer probably never plans out anything either. Although good lawyers do.
The unfortunate thing is that people who do not care in the first place would design a checklist that way too. Having it in that situation would be useless.
Anyway why would a lawyer be writing for the WSJ, doesn’t he have real work to do.
Routine use of a checklist can allow us to eliminate (or reduce) attention spent on things we DON’T have to consider in the heat of an emergency so that artistry, intuition, talent, and heroism can come fully into play.
A rigorous and standardized definition of “normal” allows us to focus on the abnormal condition with the attention it deserves.
Isn’t there some kind of checklist for writing book reviews?
Step 1: Read the book…
While I believe there is great utility in checklists, I think Mr. Howard makes some valid points in his review (whether or not they reflect appropriately on Dr. Gawande’s book, which I have not read). This is not an either/or issue; there needs to be a balance. As a physician, I have observed that the checklist mentality is often promulgated beyond seeming reasonable balance, pushed by CMS, JCAHO and hospitals administrations. The danger lies I think when employees are judged not on their work, but on how well they fill out or adhere to the checklists, which is much easier for management to quantify. See Abraham Verghese’s writing on “the virtual patient”. I think checklists function better as a tool used from the bottom up, rather than imposed from the top down. On a related topic, also see Jerome Groopman’s essay in the NY Review of Books in February.
Thanks for the comment, T.F. and thanks for reading.
I understand the concern that there can be dysfunctions in the use of checklists. A lot of those dysfunctions sound like management dysfunctions that could occur with lean or other approaches. I agree balance is necessary, so I’m sure we’d agree that doesn’t mean that checklists are an easy cure-all, nor should they be thrown out with the dysfunction bathwater.
Dr. Gawande writes quite convincingly that checklists cannot be mandated from the top down, they should be developed by those who use them. I hope you’d give his book a chance and then influence your organization to do this the right way.
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