In week 6 of re-read of The Checklist Manifesto by Atul Gawande (use the link and buy a copy so you can read along) we read about Atul’s first try using a checklist to solve a big problem.  The Chapter is titled The First Try. Let’s just say it is a learning opportunity.

The chapter starts with an example of Dr. Gawande engaging with the World Health Organization (WHO) to help address safety because of the massive increase in the number of surgeries. The problem was not that surgeries were being done, surgery saves lives, but rather the number of complications that happened in conjunction with the surgeries. The rate of post-surgical complications was unacceptably high.

Due to all sort of reasonable and rational reasons, the WHO does nothing simply. I don’t think it would surprise anyone that large multi-functional, multi-national groups tend to generate large complicated solutions and reports. (Note, Jim Benson has great examples of how you can break that cycle – ask him. If you need contact information check the show notes for SPaMCAST 400). The problem with large, complicated solutions is that they are hard to read, hard to implement and often are not successful in the long run. To validate the author’s implied suggestion that most if not all of the guidelines from the WHO are large, I tried to Google the shortest WHO guideline and after a few moments gave up and acceded to the I did, however, learn that the typical children’s picture book is 32 pages. Gawande suggests that successful interventions have three essential requirements:

  1. simple,
  2. measurable, and
  3. transmissible (capable of passing between people).

Dr. Gwande describes an experiment giving out soap in a slum in Pakistan (included control groups – at least on the surface the experimental design sounds solid) as an example of the how successful changes embrace these three attributes. The results of the study found that introducing soap with guidelines of when to use it can substantially improve health outcomes. The great idea in the study is that simple behavioral changes can have dramatic impacts. The instructions that went with the soap identified six situations where people should use it. No finger wagging just a gift of soap and non-judgmental advice to guide usage. Simple works and can have a significant ripple effect.

Near the end of the chapter, Gwande returns to the operating theater for his examples. Medicine, just as in software-related fields, addresses the twin problems of complexity and complications through specialization and formation of teams of specialists. Just putting people together does not create teams. Gawande suggests (and my personal experience attests) that the biggest problem in teams is disengagement. The “it’s not my problem” effect. For example, a coder that states that it is not her problem that the requirements should change to deal with a chaotic business environment is missing the point that software development is a team endeavor. Highly effective teams develop tools triggers (the Brown M&M example we have used earlier is a trigger) so that everyone feels comfortable with holding each other accountable. Triggers and checklists provide a basis for giving team members permission to hold each other accountable (activation phenomena). Holding people accountable for using the process creates muscle memory and makes usage habitual.

The chapter ends by going back to the WHO example the author began at the top of the chapter. In the end, the WHO greenlighted a checklist approach for a pilot on reducing post-surgical complications. The checklist developed was comprehensive (think about the three requirements mentioned earlier), and hard to use. Dr. Gwande could not even use it when he was performing surgery. It was not working. The idea of simple had gotten lost in the details, and like many other process improvement opportunities crashed on the launch pad.

(readers note – this is a critical chapter because it describes why process improvements often fail. I suggest reading this chapter twice even if you don’t think you will use a checklist.)

Bought your copy?  If not, use the following link and support the Dr. Gawande and our blog and podcast:  The Checklist Manifesto

Previous Installments:

Week 5 – The Idea

Week 4 – The End Of The Master Builder

Week 3 – The Checklist

Week 2 – The Problem With Extreme Complexity

Week 1 – Approach and Introduction