Notes collected while reading checklist manifesto

Checklist manifesto A. Gawande

- main exposure: wiki


The book is full of relatively convincing examples and stories in
hopitals and co (so no small sample size) of how checklists helped.

page 8
medical fallibility. We cannot control everything.

ineptitude: failure to apply knowledge correctly
ignorance: missing knowledge
in the last seven decades we went from generally ignorant to
inept. We have the knowledge but we ignore how to apply it properly.
This is caused by the increasing amount of possible solutions known,
without knowing which solution should be applied
Pier: like searching for the effective chess move.

page 12
failure is an occasion to learn and improve.

page 13
To tackle the amout of possible solutions, one may rely on checklists.
Pier: well, what is a checklist if not a decision tree, so a way
to cut through the solution space properly? Nice.

page 35
Although cases are different from one another, what can be more different
that people with deseases, one can capture the common points to all the
cases and one can capture the macro points of all the cases.
The details of the macro points may be different, but the overview is similar
enough for a checklist.

page 36
checklist helps against routine (that decrease attention, or self suggestion
that one can skip steps) and interruptions.
all or none processes: either you do all the steps, or the result amounts to nothing.
Checklist tends to remind the minimum necessary steps to achieve good performance
on a task that was done before.

page 40
People are reluctant to adopt checklist if they think they don't need them.

page 48, 49
Checklist are not a solution from everything.
Some researchers say that problems are simple, complicated and complex.
Simple: one has to follow a known solution to have a high likelihood of success.
        The solution can be repeated if the problem appears again.
        Example: cooking with a recipe.
   one has to work on the problem that is more , maybe breaking it down in simpler
   solutions to then find the global solution. The solution can be repeated and
   improved if the problem appears again.
   Example: landing something on the moon.
   solving one problem produces a solution that can be only partially applied
   to a new instance of the problem.
   Example: raising a child.

page 50
from engineering forcing solutions: relatively clear solutions that force the necessary
behavior. A checklist.

page 65
Without coordination autonomous teams working on the same projects more often than
not produce incompatible decisions and overlooked errors. Therefore one has to plan
(and make checklists) also for coordination.

page 68
With complex work that have to coordinate you need someone or something that checks
if the various submitted plans fits or there are clashes. Those clashes then need to
be resolved earlier than late. So also the resolution of the clashes is scheduled.
Therefore coordination and communication in complex problems is crucial.

page 79
Decentralizing decision making (but also responsibility) helps in case of complex,
unpredictable problems. What is required is still coordination.

One needs a balance between extremes. Control and freedom of action,
specialization and group brainstorming, etc.
Therefore proper checklists provide at least two important features.
They provide a tool to avoid skipping menial but needed steps.
They provide a tool to force people to talk and coordinate leaving them room
to manage impredictable situation the best they know.

According to the author checklists are needed in case of complexity, as
they provide ehnanched capabilities of judgment according to well tested

page 80 
A way to ensure that detailed checklists are followed through is to put some
sample check actions here and there, that apparently could be skipped while not
that important. Only on the checklist one can mark them as important.
Then ask the one that execute the checklist if they went through it.

page 82
Recipes for food. They are guidelines as they cannot cook the food for themselves
but one cook said "they are essential to keep the quality of produced food over time".
The same for a checklist, helping keeping high levels over time.

page 94
Analysis of problems should be done to identify (and test) improvements with high ROI.
For example distributing soap with simple rules in places that are poor and uneducated
improving their living conditions a lot compared to othr measures.

page 100
A checklist may be useful but has no effect if it is not really implemented.
So a cultural change has to happen to follow it.

page 107
Once again stressing how important is, in a team/organization where no one can do the entire
job (in time at least), that people or sub-groups talk with each other
to be synchronized on the work to do. To know what is going to happen (briefing), 
at least as an idea of it and having a minimum familiarity (names) when they work together
to encourage talking and information flow.

page 108
It is also important that people in a team that do the work feel (and are) involved
and that their view counts. Statistics seems to suggest that when people feel engaged,
the morale is higher and the results are better. (really why do we wait thousands of years
to discover this)

page 109
a checklist should fit the workflow. If it is too long (and the time is critical
or the attentionspan goes down) or too abstract or too detailed, it doesn't help.
Therefore the checklist should be tested and improved, it is always a work in progress.

page 114
Checklist should be sized according to the context. Too long, and people won't use them,
making their value nil.

page 120
One can have hundreds of checklist. The important part is that each is appropriately
sized, effective, ____tested____ and people know where to find it and when to use it.

Checklist should not list every possible operation. People have brains and should be trained.
They need to list what is to do as recall point for the person using it.

page 121
Training is crucial for checklist. People need to trust them, know that they exists,
where, and they should be trained on the steps following the checklist.

page 123
From aviation (that faces no trivial cases).
DO-CONFIRM checklists: people do their job, then they check it against the checklist to
see if some things is missing.

READ-DO: people do the job of each step in the checklist.

page 128
Important point in the checklist. People have brains and likely in a procedure they
never fail to do some actions, so those actions do not need to be in the checklist
(unless order of action is important). Only the critical actions that need to not
be forgotten and are not routine need to be there.

page 133
As competitive games shows. If one wants to have less failures, one has to analyze
failures of the past (as soon as they happens) and build experience from them.
And no one does it enough (I am the first).

Another problem is: even if one learned a lesson, to apply it and to see it applied
elsewhere may take a very long time. Because damn our habit to keep the status quo.

page 137
Testing the checklist over and over, if possble in a rehearsal, helps a lot to
make it practical and useful. Otherwise there will be no time to fix it and
confidence in it will drop and won't be used.

page 150
Incorporating a checklist is a cultural change, it takes time to adjust and people
need to be willing to do it.

page 154
One needs to measure perfromance before and after a change (checklist) to be sure that
the change helped. It is not that easy.

page 176
One crucial point is: each time is different, and one needs to go through the checklist.
It doesn't matter how many times one used it, it can always happen to forget something.
Each time go through the checklist with focus.

page 184-185
Society is obsessed to have the best components in a system. The best technologies,
the best employees and so on, but rarely there is the thought that they have to
interact together. Having the best parts doesn't mean having the best system
as a whole.
Example: to have the best car getting the best components of different existing cars.
Those components won't fit together and therefore would amount to a pile of
unusable objects.

What seems missing is, taking example of how useful checklists are built, is
a systematic study of failures that then results in corrections to try to
avoid those failures.

One tool to limit those failures, in some cases, is a checklist.
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