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Navigating complexity with checklists (a book review)

Atul Gawande’s latest book, The Checklist Manifesto: How to Get Things Right is an incredible book that I highly recommend to anyone that works in a complex environment, especially if that involves working with multi-discipline teams. And most especially if this involves frequently working with people you have never worked with before.

I picked the book up not really knowing what I was in for. Talking about checklists, I thought maybe it would be a discussion of how to document and implement best practices, or something similar. Boy was I wrong.

At the surface, the book is the story of how Gawande, as part of a World Health Organization initiative to reduce surgical complication rates around the world, discovered the power of checklists to help avoid “avoidable failures.” Looked at more closely, it is a study of the importance of team building, team work, and communications between team members as they tackle the complex problems we all face today.

The first chapter, titled “The Problem of Extreme Complexity”, sets the stage. Later chapters build on this problem statement and uses examples from many diverse fields including aviation, construction,  and the operations of corporations and government. The common thread through each of these examples is the checklist – the lowly, simple checklist.

The challenges face by Gawande and the WHO team were (are) two fold: figuring out how to take what worked in these other industries and translating it into the needs of the surgical community; and getting past the culture of surgery and surgeons. The former was a relatively simple matter of trial and error, see what works and give it a try (in simulation first, where possible). The latter, on the other hand, remains a significant issue.

Part of the resistance is, according to Gawande, a misconception about what checklists are and the purpose they serve. This is a lesson he learned as he worked with engineers from Boeing in trying to understand what makes a good checklist:

It is common to misconceive how checklists function in complex lines of work. They are not comprehensive how-to guides, whether for building a skyscraper or getting a plan out of trouble. They are quick and simple tools aimed to buttress the skills of expert professionals. And by remaining swift and usable and resolutely modest, they are saving thousands upon thousands of lives.

As a systems engineer I recognize many of the issues, challenges, and solutions that Gawande discusses in the book. I was (am) quite appalled at how little of this systems type thinking seems to exist in the world of surgery and am quite hopeful that the idea of checklists catch on at all hospitals. If I ever have to go in for surgery, one of the first questions I ask the surgeon and his team is going to be, “Do you have a checklist prepared for this procedure?”

Perhaps the greatest insight about checklists in the book is that checklists – a lowly, simple, well crafted checklist – can take a group of individual experts and quickly turn them into an expert team.

All you have to do is use it.

Update: For more on the book, links to various media interviews, and some examples of effective checklists, visit Atul Gawande’s website.

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2010 03 24 Book Reviews
Complexity
Mastery
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The futility – and value – of planning

In his recent article Planning is very important…. It doesn’t work, Jack Vinson has this insight into planning:

If they hadn’t planned, there is no chance they would have been able to accomplish what they wanted to do.  At the same time, if they had decided that the plan was exactly what they were going to do, they would have never made it either.

This is a lesson I learned very early on in my military career, and something I wrote about back in March 2005 (has it really been that long?) while digesting the ideas in Malcolm Gladwell’s then-new book Blink.  The following is a slightly edited version of those original thoughts.

- – — — —–

Have been spending a lot of time “adjusting” plans lately. A colleague made the following comment today in one of our many (many many) sessions:

He who plans early, plans twice.

Which got me thinking about the apparent futility, and the obvious value, of planning.

The aphorism “No plan survives first contact with the enemy” is absolutely true. Proper preparation, though, can make that fact largely irrelevant. The very act of planning, and rehearsing that plan, involves preparation that enables you to effectively react to most any situation that may arise. In other words, proper planning allows you to IMPROVISE.

“What?” you say. “Improvise? That’s fine for comedy and music, but military operations? Business? I don’t think so. The whole purpose of planning is so you know what is going to happen, and when it is going to happen. Not to just wing it.”

In an Industrial Age setting, I may have agreed with that. But in the Information Age, I strongly disagree. If you tie yourself too tightly to a plan, and stick to it no matter what, you are doomed to fail.

As an example, consider a football (American) team – or any other team sport, for that matter. It is possible to develop a detailed game plan that dictates every play you will use, and when you will use them in the game. You could make a simple list of plays: On the first play, do this; On the second play, do that. etc. Or you could have a more detailed plan: If it is second and under 5 yards, and we’re in the red zone, we do this. etc. You could even take it a step further and include separate options that take into account the opposition’s activities. Of course, the more contigencies you identify, the bigger the play book you have to carry around and the longer it may take to figure out exactly what to do.

What actually happens is that the team develops a basic game plan ahead of time and rehearses the execution of that plan. By doing this, the focus of the team becomes achieving the goal of winning the game, and not just simply executing the plan.

I was inspired to write this post partly by a few key passages in Malcolm Gladwell’s new book Blink , in which he uses the obvious example of an improv comedy troupe (which in turn cites as one of their references a basketball team) to support the concept of “thin-slicing,” the ability to parse a given situation into the minimum information required to deal with that situation.

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2010 03 22 Creativity
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Parent as student

I have had a lot of teachers throughout my life. Some taught me because they were paid to, some because they were supposed to, and some because they wanted to. Many of the best teachers in my life, though, had no idea that they were teaching me. (Or, perhaps more accurately, that I was learning from them.)

At the top of this list of unintentional teachers are kids, especially my own.

When the relationship between parents and their kids is discussed, “parent as teacher” is a common interpretation. There is no doubt that parents need to teach their children. But if we only see ouselves as teachers, whether it is because we are supposed to or because we really want to, we are missing out on some of the greatest learning opportunities we will ever be given the chance to experience.

This is especially true if your kids are different from you, or different from what you expected them to be. For example, if you are a “jock” and your kid a “geek” ( or vice versa). Or your kid is disabled and you’re not.

If you are a parent, take the time to learn from your kids. You’ll be amazed at what they can teach you.

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2010 03 12 autism
learning
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There’s always something to learn

On the TV show NCIS the main character, Special Agent Gibbs, has two primary passions: catching bad guys and building boats. Not just any kind of boat, but hand made wooden sailboats. Which he builds in his basement. (A running gag on the show is the question of how he gets the boats out of the basement.)

In one episode, an old friend and mentor visits Gibbs for the first time in several years and sees a boat in progress in the basement:

“What’s this, number 3?”

“Four.”

“I thought you’d have enough practice by now.”

“There’s always something to learn.“

Truly words to live by, even if they do come from a fictional character.

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2010 03 12 Deliberate Practice
learning
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Parents should be leaders (not managers)

Autonomy  -  Mastery  -   Purpose

Three things that Malcolm Gladwell (Outliers) and Dan Pink (Drive) have written about in terms of meaningful work and a meaningful life aimed primarily at adults that are also important parts of growing up.

As infants and toddlers, the focus for kids is to learn, to master things like walking, language, and play. There is not a whole lot of autonomy, nor is there any long term purpose.

As kids grow through adolescence they start to accept, and demand, more and more autonomy. If they are lucky enough to discover a passion that demands all of their attention – sports, academics, music, writing – they will seek out mastery. Some will begin to see their purpose in life, and begin to move in that direction.

As teenagers and young adults our kids become completely autonomous – within bounds, of course – and are free to pursue their purpose and continued journey toward mastery.

For parents, it is all too easy – and tempting – to try to control, to MANAGE, our kids’ lives through each of these various stages. To decide what our kids should be interested in, what their purpose is. To make decisions for them, and not allow them the autonomy they crave. (“He’s only 10 years old, he can’t make a decision like that for himself.”)

Much more difficult – and, in my opinion, ultimately more rewarding – is for parents to be a LEADER for their kids. To observe and discover what our kids strengths are, what they are interested in, and encourage mastery in that. Even if it something we don’t understand or that we would never do. To always challenge our kids to reach just a little too far instead of always pulling them back from the edge. To accept the purpose they discover for their life, and encourage them to live that purpose even if it seems “stupid” to us.

Of course, being a leader is much harder work than being a manager. But a lot less frustrating and a lot more rewarding.

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2010 03 05 Life
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The opportunity cost of “easy”

In his book Mastery, George Leonard talks about the “war on mastery”. This could just as easily be called a “war on hard”. Watch TV for just a couple of minutes and you will be bombarded with ads or talk shows or news stories that show you how do something in just a couple (if that many) steps. You never see something that promises to be hard.

And yet, nearly anything worth doing – that results in growth or learning – is hard. The best you can really hope for from “easy” is to maintain what you’ve already got. At worse, you will lose something.

Does Google – or technology in general – make us stupid? No. But by being “easy”, it removes the need, and possibly the ability, to learn. Which some might say is the same thing.

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2010 03 04 Mastery Comments Off Permalink

Management : Efficiency :: Leadership :
??

When talking about management, what most people are thinking about is efficiency, maximizing output per unit of input. Many (most?) people talk about the need for leadership in addition to, or even instead of, management.

But what exactly do we get from leadership? What is its purpose?

The first word that comes to mind is “effectiveness”. But most measures of effectiveness are based on a desired end-state, which to me makes this just a different way of measuring efficiency.

Is leadership just another way to get people to do what you want them to do so you can accomplish your own goals? Or is it something different, something more?

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Some thoughts:

When you “manage” something / someone, the best you can hope for is what you ask for. When you “lead” someone, there is no way to know ahead of time what you will end up with.

Maybe the question is better addressed in the context of the Cynefin framework:

Management : Simple :: Leadership : Chaotic

(and possibly disorder), with a sliding mix of the two being appropriate in complicated or complex situations.

Of course, I’m not the first person to consider this question. There are many (many many) more thoughts on this question out there, as you can see in the Google search results for leadership vs. management.

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2010 03 02 Complexity
Innovation
Mastery
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Love the hard days

How often do you hear people say, “I sure hope today is an easy day”? Probably quite often. How often do you hear people say, “I sure hope today is a hard day”? Probably not quite as often.

Someone who knows the value of  the hard days is Cesar Millan, aka the Dog Whisperer. On a recently aired episode of his show, while observing the behavior of a new client and assessing the difficulty ahead (which in this case was significant), Cesar looked at the camera and smiled.

“I love days like this.”

He knew it was going to be a hard day, not only for him but for the dog and its owners. But he wouldn’t have it any other way, because he understands that it is only on the hard days that you can achieve great things.

So, love the hard days when they come, they are a gift and your chance to shine.

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2010 03 01 Life
Mastery
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What’s in a label? (take 2)

In my last posting, I wrote the following about the consolidation of Asperger’s Disorder and PDD-NOS into a single classification for Autism Spectrum Disorder:

My experience leads me to believe that many people don’t understand the concept of a spectrum unless they can clearly see the boundaries between the different layers of the spectrum.

This generated some interesting conversations that have helped me as I figure out what I think.

Of course, the problem I had with combining these separate diagnoses into a single one – that people would tend to see all autistics as “the same” – also exists with the more “specific” diagnoses. It’s just that now you’ve got several variations on the theme: all Asperger’s is the same, all PDD-NOS is the same, all Autism is the same.

Thinking about all this reminded me of the expression “If you’ve met one person with autism, you’ve met one person with autism.” We are making a lot of process in getting this message out, and identifying autism as a spectrum could help with this even more.

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2010 02 24 autism Comments (6) Permalink

What’s in a label? Autism, Asperger’s, and the DSM V

Several years ago, I wrote a two part article on my thoughts about whether autism should remain in the DSM. Here’s what I came up with:

For now, we need to keep autism in the DSM, because it serves as the way for autism parents to help their children get the services they need to succeed in the world.

The current draft of the DSM V, available for review and comment, still includes autism – now referred to as Autism Spectrum Disorder (instead of  Autistic Disorder). However, the DSM V proposal recommends that Asperger’s Disorder and Pervasive Development Disorder Not Otherwise Specified (PDD-NOS) “be subsumed into an existing disorder: Autistic Disorder (Autism Spectrum Disorder)“.

As you might imagine, there has been a lot of discussion about this. I’m not really sure what I think of this change yet, there are so many aspects to consider:

  • What is the impact to those already diagnosed with Asperger’s or PDD-NOS? In terms of available services? In terms of individual perceptions of self? Will they have to be rediagnosed, or will they be “grandfathered” in to an Autistic Spectrum Disorder?
  • What is the impact to future diagnoses? Will there be fewer children diagnosed autistic, or more? Will a child who would have been diagnosed with Asperger’s or PDD-NOS be diagnosed as autistic? How will this affect funding of special education programs?
  • Will parents accept a diagnoses of “autistic” for kids they believe are “too high functioning” to be autistic but whom they believe need the services that come with the diagnosis?
  • How will special education programs be impacted? Will they be able to avoid a “one-size-fits-all” approach to treating “autism” as if it is a singular thing, or will they remain flexible enough to develop education plans based on the needs of individuals?

And more, many more.

It is the last of my bullets above that most concerns me. Anyone who is involved in special education – as a parent, student, teacher, or administrator – knows that even now Individual Education Plans (IEP) are typically anything but individual. (There are, of course, exceptions, but you will find many many more horror stories than success stories about IEPs.)

I agree with Roy Richard Grinker when he writes that “the stigma of autism is fading”, though I’m not sure I agree with him that this is happening “fast”. I also agree that across the three current diagnoses there is a lot of commonality, both in terms of symptoms and “treatment”.  But there are differences, and I think that having the three separate diagnoses emphasizes the “spectrum” – or, as Grinker calls it, a “continuum”.

My experience leads me to believe that many people don’t understand the concept of a spectrum unless they can clearly see the boundaries between the different layers of the spectrum. Only when you see a rainbow of light coming out of a prism can you see that white light includes all of those colors, and that each of those colors has its own unique properties. We still need this prism effect with autism.

We are making progress in understanding, but we still have a long way to go. So for that reason, I’m leaning toward the opinion that Asperger’s and PDD-NOS should stay in the DSM. At least for now.

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2010 02 19 autism
Complexity
Education
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