Checklists are for everyone

What do Johns Hopkins surgeons, anonymous big-time investors and World War II pilots have in common? This isn’t the set up for a terrible joke but a demonstration of how widespread an often-overlooked tool is – they all use checklists to avoid disaster.

For surgeons, disaster is a lethal infection caused by straying from proper precaution. For pilots, it’s crashing a plane that was deemed far too complicated to fly – the Boeing B-17. For investors, checklists avoid what is sometimes known as ‘cocaine brain’; the drive to make snap decisions on high-risk investments that often result in huge losses.

For more information on a similar process, see Warren Buffet’s Investment Checklist. It details the steps taken by the man known as the world’s greatest investor prior to parting with massive sums of money.

The Checklist Manifesto, written by writer/surgeon Atul Gawande, is proof that checklists really work (whether anyone wants to admit that or not). Check out the the Checklist Manifesto Review I wrote for more details.

In his words, if another solution that could be even a fraction as effective would be a new drug or piece of technology it would be backed by billions of dollars, sponsored by the state and be the only thing the worldwide medical journals talk about. A case he cites is the development of robots to perform tricky laparoscopic surgery. It was widely backed and implemented in many hospitals around the US to the great excitement of the medical community.

Positive results? Next to none.

Checklists, however, are deceptively simple. The Checklist Manifesto is the tale of how Gawande took an idea first popularized by pilots into the operating theater and then out into the hospitals of the world, with the help of the World Health Organization. Not only does the book document his own research, but implementations of similar strategies, from hugely complex construction projects to Walmart’s innovative yet highly organized approach when dealing with Hurricane Katrina.

Providing a solution to human error

One of the main problems with checklists is that some feel they are above them, unable to make silly mistakes in routine procedures and not subject to human error. Gawande references a 1970s essay by Samuel Gorovitz and Alasdair MacIntyre that boils down all situations to find the only two reasons for human dilemma:

“The first is ignorance – we may err because science has given us only a partial understanding of the world and how it works. There are skyscrapers we do not yet know how to build, snowstorms we cannot predict, heart attacks we still haven’t learned how to stop. The second type of failure the philosophers call ineptitude – because in these instances the knowledge exists, yet we fail to apply it correctly. This is the skyscraper that is built wrong and collapses, the snowstorm whose signs the meteorologist just plain missed, the stab wound from a weapon the doctors forgot to ask about.”

In practical terms, ignorance can be corrected by answering the question “what do I do?” and ineptitude with “how do I do it?”. Checklists can solve both of these issues. They are great teaching tools that can be used to convey information simply, such as our Podcast Publishing Checklist, as well as highly practical, no-frills documents such as the B-17 checklist, one of the most famous of all time.

An example that’s likely more useful to our world comes from one of the stand-out passages in the book where Gawande meets with three high-powered directors who meet to make venture capital investments in companies that have a slim chance to make a huge breakthrough. Since these investments are usually nothing short of gambling against terrible odds, this exclusive group of investors  implement one very simple tool – a checklist.

For them, this checklist is worth millions. That’s how much it has probably saved them by helping to avoid bad investments. This quote explains how Mohnish Pabrai, managing partner in Pabrai Investment Funds in Irvine, California, has taken the idea from medicine and aviation to use checklists in his work.

“Pabrai made a list of mistakes he’d seen—ones [Warren] Buffett and other investors had made as well as his own. It soon contained dozens of different mistakes, he said. Then, to help him guard against them, he devised a matching list of checks—about seventy in all.

One, for example, came from a Berkshire Hathaway mistake he’d studied involving the company’s purchase in early 2000 of Cort Furniture, a Virginia-based rental furniture business. Over the previous ten years, Cort’s business and profits had climbed impressively. Charles Munger, Buffett’s longtime investment partner, believed Cort was riding a fundamental shift in the American economy.

The business environment had become more and more volatile and companies therefore needed to grow and shrink more rapidly than ever before. As a result, they were increasingly apt to lease office space rather than buy it—and, Munger noticed, to lease the furniture, too. Cort was in a perfect position to benefit.

Everything else about the company was measuring up—it had solid financials, great management, and so on. So Munger bought. But buying was an error. He had missed the fact that the three previous years of earnings had been driven entirely by the dot-com boom of the late nineties. Cort was leasing furniture to hundreds of start-up companies that suddenly stopped paying their bills and evaporated when the boom collapsed.”

Are checklists for egomaniacs?

This cautionary tale shows what happens when a formal procedure isn’t in place when it really should be. The fact that the human brain is not so great can be proven by the amount of productivity tools, to-do lists, products like this, this and – when was the last time you forgot your baby in the car? – this.

These are tools for the simplest things! Brain surgery, alongside rocket science, has the anecdotal title as being among the most complex and difficult tasks in the history of the world.

What makes people think they don’t need tools for remembering the proper procedure? The thing is, people in these professions likely have genius-level IQs. This can result in what is known as intellectual arrogance, the features of which are:

• They have a “my way or the highway” attitude since only their views are supposedly the right way to think.
• They regard themselves as experts in a particular field or subject.
• They refuse to see the big picture or another viewpoint, especially of those they consider “ignorant”.
• They like explaining, theorizing and dictating; basically they like hearing the sound of their own voice.
• Their mood can become very nasty if their ideas and views are contradicted.
• They regard any question as an insult or a doubt on their intelligence.
• They are not above creating proof and arguments to defend their theories vehemently.
• They are very confident in their own knowledge and do not want to learn anything new.
• Sometimes they can come across as very wannabe and attention-seeking.
• They can get very smug and snobby, especially if they are actually right about something.
• They pretend to be very broad-minded but actually are very narrow-minded as they feel they know everything and in the right way.

(Source)

A man who fits the above description nicely.

Does this sound like the sort of person who would be open to the idea of being told what to do by a checklist?

That was the main problem Gawande ran into with the first large-scale implementation of checklists into hospitals worldwide. He notes how that the egotistical nature of surgeons plus the fact that checklists had to be read out by a subordinate created a large amount of friction among colleagues. He intended the checklists to promote teamwork in the same way we created our app to promote and streamline collaboration.

One of the first stages of the process was a friendly introduction to help everyone get on and work as efficiently as possible, knowing each others names and duties; you’d be surprised at the amount of surgeries performed by teams who have never met prior to the operation and leave the theater none the wiser as to each other’s names or positions. It was basically through the process of long trials and repeated exposure that Gawande managed to create success for his checklists.

After a while, people started to see results that were undeniable – checklists worked!

“More than 250 staff members—surgeons, anesthesiologists, nurses, and others—filled out an anonymous survey after three months of using the checklist. In the beginning, most had been skeptical. But by the end, 80 percent reported that the checklist was easy to use, did not take a long time to complete, and had improved the safety of care. And 78 percent actually observed the checklist to have prevented an error in the operating room. Nonetheless, some skepticism persisted.

After all, 20 percent did not find it easy to use, thought it took too long, and felt it had not improved the safety of care.Then we asked the staff one more question. “If you were having an operation,” we asked, “would you want the checklist to be used?”A full 93 percent said yes.”

The Checklist ‘Eureka!’ Moment

The penultimate chapter of the book ends on a powerful note, summing up the unlikely turn of events that led to widespread checklist usage in the aviation industry. Nothing sums up the point of the book more effectively:

“We are all plagued by failures—by missed subtleties, overlooked knowledge, and outright errors. For the most part, we have imagined that little can be done beyond working harder and harder to catch the problems and clean up after them. We are not in the habit of thinking the way the army pilots did as they looked upon their shiny new Model 299 bomber—a machine so complex no one was sure human beings could fly it.

They too could have decided just to “try harder” or to dismiss a crash as the failings of a “weak” pilot. Instead they chose to accept their fallibilities. They recognized the simplicity and power of using a checklist.”

If you enjoyed reading the Checklist Manifesto, take a look at our checklist software built on the book’s great ideas. If you haven’t read it yet, you can buy the book on Amazon here. If you have, let me know your thoughts in the comments. I’d love to hear your opinion!