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Ch 2 - The Checklist

- People can lull themselves into skipping steps even when they remember complex
processes, after all, certain steps don't always matter
- Checklists seem to provide protection against such failures
- They remind us of the minimum necessary steps and make them explicit.
- They not only offer the possibility of verification but also instill a kind of discipline of higher
- Checklists are often erroneously viewed as useful only for less experienced or less skilled staff
(i.e. nurses vs. doctors)..."Charts and checklists, that's nursing stuff - boring stuff. They are
nothing that we doctors, with our extra years of training and specialization, would ever need or
- Some physicians were offended by the suggestion that they needed checklists...others had doubts
about the evidence supporting their use
- Checklists establish a higher level of baseline performance
Ch 3 - The End of the Master Builder
- A key step is to identify which kinds of situations checklists can help with and which ones they
- Three different kind of problems in the world: simple, complicated, and complex
- Simple problems are ones like baking a cake from a mix...there is a recipe, sometimes a few
basic techniques to learn, but once these are mastered,
following the recipe brings a high likelihood of success
- Complicated problems are ones like sending a rocket to the moon...they can sometimes be
broken down into a series of simple problems, but there is no straightforward recipe. Success
frequently requires multiple people, often multiple teams, and specialized expertise. Unanticipated
difficulties are frequent, and timing and coordination are serious concerns.
- Complex problems are ones like raising a child. Once you learn how to send a rocket to the
moon, you can repeat the process with other rockets and perfect it. One rocket is like another
rocket. But not so with raising a child, because every child is unique.
- Complex problems - outcomes remain highly uncertain.
- With complex problems, the question of when to follow one's judgment and when to follow
protocol is central to doing the job well. You want people to make sure to get the stupid stuff
right. Yet you also want to leave room for craft and judgment and the ability to respond to
unexpected difficulties that arise along the way.
- The way project managers dealt with the unexpected and the uncertain was by making sure the
experts spoke to one another - on date X regarding Y process. The experts could make their
individual judgments, but they had to do so as part of a team that took one another's concerns into
account, discussed unplanned developments, and agreed on the way forward.
- The major advance in the science of construction over the last few decades has been the
perfection of tracking and communication.
Ch 6 - The Checklist Factory
- Bad checklists are vague and imprecise...they are too long; they are hard to use; they are
impractical...they are made by desk jockeys with no awareness of the situations in which they are
to be deployed. They treat the people using the tools as dumb and try to spell out every single
step. They turn people's brains off rather than turn them on.
- Good checklists, on the other hand, are precise. They are efficient, to the point, and easy to use
even in the most difficult situations. They do not try to spell out everything - a checklist cannot fly a
plane. Instead, they provide reminders of only the most critical and important steps - the ones that
even highly skilled professionals using them could miss.
- Pilots turn to checklists for two reasons. First, they are trained to do so. They learn from the
beginning of flight school that their memory and judgment are unreliable and that lives depend on
their recognizing that fact. Second, the checklists have proved their worth - they work.
- You must define a clear pause point at which the checklist is supposed to be used (unless the
moment is obvious, like when a warning light goes on or an engine fails).
- You must decide whether you want a DO-CONFIRM checklist or a READ-DO checklist
- DO-CONFIRM - team members perform their jobs from memory and experience, often
separately. But then they stop. They pause to run the checklist and confirm that everything that
was supposed to be done was done.
- READ-DO - people carry out the tasks as they check them off - it's more like a recipe.
- Checklist cannot be lengthy...rule of thumb some use is to keep it to between 5-9 items, which is
the limit of working memory...don't have to be religious on this point (in some situations you only
have 20 seconds, in others, you may have several minutes)
- After about 60-90 seconds at a given pause point, the checklist often becomes a distraction from
other things...people start "shortcutting." Steps get missed.
- You want to keep the list short by focusing on what is called "the killer items" - the steps that are
most dangerous to skip and sometimes overlooked nonetheless. Data establishing which steps are
most critical and how frequently people miss them is very helpful.
- Wording should be simple and exact, and use the familiar language of the profession
- Even the look of the checklist matters...should fit on one page, should be free of clutter and
unnecessary colors...should use both uppercase and lowercase text for ease of reading (use sans
serif type of font like Helvetica).
- Checklist has to be tested in the real world, which is inevitably more complicated than expected.
- Checklist should ideally contain only critical steps that are commonly skipped...not necessarily all
critical steps
- These are not comprehensive "how to" guides...they are quick and simple tools aimed to buttress
the skills of expert professionals.
Ch 8 - The Hero in the Age of Checklists
- In medicine, the checklist has arrived in operating rooms mostly from the outside in and from the
top down. It has come from finger-wagging health officials, who are regarded by surgeons as
more or less the enemy, or from jug-eared hospital safety officers, who are about as beloved as
the playground safety patrol. Sometimes it is the chief of surgery who brings it in, which means
we complain under our breath rather than raise a holy tirade. But it is regarded as an irritation, as
interference on our terrain. This is my patient. This is my operating room. And the way I carry
out an operation is my business and my responsibility.
- Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline
- We could even develop checklists for non-routine situations (i.e. when a stock "blows up" or
significant news announcement)
- As knowledge of how to control the risks of flying accumulated - as checklists and flight
simulators became more prevalent and sophisticated - the danger diminished, values of safety and
conscientiousness prevailed, and the rock star status of the test pilots was gone.
- It's ludicrous to suppose that checklists are going to do away with the need for courage, wits, and
- Pabrai - no matter how objective he tried to be about a potentially exciting investment, he found
his brain working against him, latching onto evidence that confirmed his initial hunch and
dismissing the signs of a downside. "You get seduced and start cutting corners."
- Pabrai noticed that even Buffett made certain repeated mistakes. "That's when I knew he wasn't
really using a checklist."
- Pabrai - when analyzing a company, stop and confirm that you've asked yourself whether the
revenues might be overstated or understated due to boom or bust conditions.
- "It's easy to hide in a [financial] statement; it's hard to hide between statements"
- "When surgeons are forced to wash their hands or talk to everyone on the team before surgery
[due to the checklist], they improve their outcomes with no increase in skill"
- The checklist gives investment teams an additional and unexpected benefit over competitors:
efficiency. Using the checklist increases up-front work time, but you are able to evaluate far more
investment ideas over time. By cutting down the time needed to determine whether an investment
was worthwhile, it reduced the behavioral bias to become "overinvested" in your research effort.
- In venture capital investing, those taking a checklist-driven approach had only a 10% likelihood of
having to fire senior management for incompetence or concluding that their original evaluation was
inaccurate. The others had at least a 50% likelihood.
- The fear people have about the idea of adherence to protocol is rigidity. They imagine mindless
automatons, heads down in a checklist, incapable of looking out their windshield and coping with
the real world in front of them. But what you find, when a checklist is well made, is exactly the
opposite. The checklist gets the dumb stuff out of the way, the routines your brain shouldn't have
to occupy itself with, and lets it rise above to focus on the hard stuff.
- The crew of US Airways Flight 1549 showed an ability to adhere to vital procedures when it
mattered most, to remain calm under pressure, to recognize where one needed to improvise and
where one needed not to improvise. They understood how to function in a complex and dire
situation. The recognized that it required teamwork and preparation and that it required them long
before the situation became complex and dire.
- All learned occupations have a definition of professionalism...all have at least three common
elements: 1) expectation of selflessness; 2) expectation of skill - that we will aim for excellence in
our knowledge and expertise; 3) expectation of trustworthiness - we will be responsible in our
personal behavior. Aviators have a fourth expectation: discipline - in following prudent procedure
and in functioning with others...this concept exists almost entirely outside the lexicon of most
professions. In medicine, they hold up "autonomy" as a professional lodestar, a principle that
stands in direct opposition to discipline.
- We are not built for discipline...we are built for novelty and excitement, not for careful attention
to detail. Discipline is something we have to work at.
- Checklists must not become ossified mandates that hinder rather than help. even the simplest
requires frequent revisitation and ongoing refinement.
- Airline manufacturers put publications dates on all their checklists - they are expected to change
with time. A checklist is only an aid. If it doesn't aid, it's not right.
- Technology can increase our capabilities, but there is much it cannot do: deal with the
unpredictable, manage uncertainty.
- We're obsessed in medicine with having great components - the best drugs, the best devices, the
best specialists - but pay little attention to how to make them fit together well. This approach is
wrong...anyone who understands systems will know immediately that optimizing parts is not a
good route to system excellence. He gives the example of a famous thought experiment of trying
to build the world's greatest car by assembling the world's greatest car parts.