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The Joys of Checklists

I just finished reading Atul Gawande’s newest book, The Checklist Manifesto: How to Get Things Right. Dr. Gawande is a great thinker and I had enjoyed reading his prior two books about the medical community: Better: A Surgeon’s Notes on Performance
and Complications: A Surgeon’s Notes on an Imperfect Science.  In this book, he talks about a simple way to reduce errors in the operating room, a checklist. He talks about how checklists can be developed and how they are used in aviation to reduce errors in the cockpit.

There were a couple of key takeaways for me from this book.  Gawande reports on the research of the science of complexity.  Professors Brenda Zimmerman of York University and Sholom Glouberman of the University of Toronto have developed a distinction between three types of problems in the world.  The first type is simple – like following a recipe to bake a cake.  You may have to learn some parts of it, but it should be repeatable if you follow the instructions.  The second type is complicated – think of sending a rocket to the moon.  In a complicated problem, you can usually break it down into many simple problems, but you will have multiple people or teams, multiple specialties and timing and communication become serious obstacles to be overcome.  The third type is complex – the example given here is raising a child.  Unlike sending a rocket to the moon, if you successfully raise a child, there is no guarantee that your second child will turn out the same.  Experience is helpful, but by no means sufficient. It is possible to successfully raise a child (no matter how you define that), you just can’t predict how it will happen.

In each of these types of problems, a checklist can be helpful.  In the simple case, a recipe is a simple checklist that ensures that all of the steps are completed in the correct order.  In the complex case, a checklist can be used to schedule the work that needs to get done, coordinate the interactions between the different teams and even regulate the communication between teams that is required to iron out issues that arise during the project.  Gawande spends some time in the book detailing a large building project and their use of checklists to ensure that all of the myriad details that must be accounted for during a skyscraper construction project are managed.

It is in the complicated cases that the uses of the checklist have really not been utilized.  For many years, the complicated cases have seemed to be too random to be managed through checklists.  In the surgery, complications are all too often a regular part of the job.  This antibiotic doesn’t work for this patient.  The patient suddenly develops an infection.  The laboratory does not deliver the right type of sample collection device.  But Gawande and a team at the World Health Organization worked on a trial project with 8 hospitals around the world to try checklists in the operating room.  Their goal was not to address all of the potential complications.  They created a list of 19 specific things to check before, during and after a surgery.  Things like, did you check the patient’s name bracelet, did you give pre-surgery antibiotics, if there is a chance for blood loss, did you request blood supplies be available.  In addition, the checklist required that the team all introduce themselves before surgery.  This bit was introduced to help the surgical team function like a team, when the complications arose.

The results from the trial were unbelievable.  Hospitals from the US, Canada, UK, Australia, India, the Phillipines, Jordan and Tanzania participated.  Overall, the rate of major complications for surgical patients in all eight hospitals fell by 36% after the introduction of the checklist, while deaths fell 47%.  Such a simple concept.  But it forced everyone to concentrate on the issues that they had control over, while preparing them to work as a team on the unforeseen complications that inevitably arise.

Now, usually I write about entrepreneurship, so why is this so important?

Well, Dr. Gawande took his message of the value of checklists to experts in other industries to see if there was a correlation.  One of the folks he talked to was Geoff Smart, who wrote a top selling book on hiring called Who: The A Method for Hiring. Smart did a project with Venture Capitalists where he evaluated the style that the VC used to make investment decisions. The VC’s that used a checklist approach had a 10% likelihood of replacing the senior management versus 50% for VC’s that didn’t use the checklist. They were also more financially successful. The checklist users had an 80% ROI versus 35% or less for the rest.

As you look to develop your businesses, it seems like a good idea to implement checklists throughout your businesses.  Even though your outcomes may not result in life and death, like Dr. Gawande, the benefits of using checklists to cull out the simple and mundane errors and focus on the complicating factors will strengthen your business.

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