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The Checklist Manifesto

“The Checklist Manifesto” by Atul Gawande was an ironically random and inspiring read.

Originally recommended to me by a peer when attempting to coordinate on a better way to handle IT Service Escalations, “The Checklist Manifesto” had rave reviews and a length short enough that convinced me to pick it up.

Not only did the book satisfy, and inspire, but it forced me to come face to face with my own human nature.

The book itself is written by an experienced surgeon who begins by explaining the level of skill involved in surgery. Along the way you start to get a glimpse into the complexity of surgery in a modern hospital today.

The writer thrust me into the operating room over and over again, each time describing a unique surgery, the equipment being used, the complex obstacles of human biology that have to be overcome, and the variety and diversity of the teams performing the operations.

By the end of the first few chapters I had a great appreciation for the individuals working under these conditions and the incredible teamwork required to pull off even the most simplest of procedures. After multiple examples and stories I was absolutely amazed that we’re even capable of being successful a majority of the time.

However, that’s when Atul hit me with the reality of the situation. There are mistakes, tons of mistakes, enough to make one shudder honestly. The scariest part might be that all these mistakes are seemingly small and insignificant compared to the major tasks these surgeons have to perform. The majority of deaths due to surgery are related to basic steps that everyone in an operating room should be aware of, no matter what part of the globe or conditions they’re operating in.

Atul was forced to come to terms with this problem when the World Health Organization (WHO) reached out to enlist him to help them reduce the number of deaths caused by surgery worldwide. His tact was to take a page out of the aviators handbook… almost literally… Checklists.

Ironically I don’t even remember what inspired him to look into checklists, but once we were hooked we dove headfirst into how aviation adopted these long ago. Today they’re ingrained into the discipline.

Checklists are so standard in aviation that their computer systems are designed to present them to the pilots at the most opportune moment. Even in the face of death at thousands of feet in the sky, the most skilled pilots in the world resort to checklists before allowing their skill and intuition take over.

The best real world example I thought of to bring it home for myself was learning to drive dirt roads on the eastern plains of Colorado. When your vehicle hits a patch of ice or compact snow and you lose traction, your gut reaction is to pump the breaks. However, I was taught like most that this is exactly the last thing you want to do and I only had to experience it once to remember the lesson.

When you lose traction driving on ice or snow:

  1. Don’t touch the brakes.
  2. Point the wheel in the desired direction of travel.
  3. Slowly engage the throttle.

Not even realizing it, I depend on this checklist every time I run into this situation. It’s almost muscle memory today, but that doesn’t stop me from having to grapple with a gut reaction every time I feel the vehicle lose traction.

This gut reaction is a part of human nature it seems. In the book, one of the infamous aviation checklists begins with the first step: “Fly the Airplane”. It sounds so ridiculous out of context, but in an emergency situation that can come as a complete shock to the human experience, a simple reminder can go a very, very long way.

My favorite part of this book, the part that inspired me to remember I want to write these reviews, is the story of some of the biggest investors in the global stock market. While the most successful investors are incredibly skillful, Atul was aware of at least 3 of them who depend heavily on checklists to minimize the mistakes they make.

While trading in the hundreds of millions of dollars, mistakes can be as costly as the mistakes made in the operating room of a hospital or at thousands of feet in the sky. While not directly related to human death, I imagine the misappropriation of millions of dollars could easily create far more human suffering.

One trader referred to it as “cocaine brain” when they get excited about making a lot of money. It’s been measured by psychologists and the rush can and often clouds our ability to think rationally and follow a process. Especially if that process is not written down.

This is the key I took away; humans are just that, human. Whether its “rockstars” in the operating room, pilots with “just the right stuff”, or hedge fund managers on “cocaine brain”, none of us can see and think clearly 100% of the time. When the stakes are high, and egos prevent effective teamwork, we will make mistakes. It’s guaranteed.

As I write this I remember my military training, the drills, the pre-combat checks, and pre-combat inspections. The most dedicated, and professional soldiers I ever worked with depended on drills and trained with a level of discipline that I’d never seen before. I saw the opposite (cowboys) as well.

It’s clear to me now, that our human nature will always get the best of us, no matter how hard we work or how much talent we’ve been gifted.

Checklists, drills, and ultimately muscle memory built for situations and activities where we’re operating at our peak are essential for sustainable success.

The Irony: in an industry swarming with individuals and organizations trying to achieve 0.001% increase in performance, checklists are not being adopted en-masse. It was difficult to get “rockstar” surgeons to adopt checklists in modern hospitals, and everywhere else you look, there are only a few leaders who point to checklists & drills as the key to their success instead of luck, talent, or unique background.

While we still have to be inherently good at what we do, we can never forget we’re only human. However, that seems to be the real challenge here.

Discipline.

What an irony.