I just finished Dr. Atul Gawande’s latest book, The Checklist Manifesto: How to Get Things Right. I believe that this book is the single most important book of the year for ANY Lean leader, not just people working in healthcare. I’ll share more of my thoughts on the book in another post, but I wanted to address a recent review in the WSJ.
There’s room for intelligent disagreement on issues like this, but the conclusions drawn by the WSJ reviewer really makes me question his reading comprehension skills or his agenda.
The title of the review signals its negativity: “Problems with Protocols: Checklists, although valuable in some settings, are a menace in others.”
The reviewer, Philip K. Howard, an attorney, gives rightful credit to the lifesaving impact that checklists have in healthcare. But, it seems that Mr. Howard suffers from the same ailment that Dr. Gawande attributes to many physicians – that just because you’ve gone to school long enough you are therefore above checklists and, what we’d call in the Lean world, “standardized work.”
Dr. Gawande, in his book, states that checklists would have a positive impact in legal work (to prevent frequent legal errors in simple filings) and in investing and venture capital. It seems Mr. Howard is allowing emotion and defensiveness to get in the way of considering Dr. Gawande’s approach.
Mr. Howard tries to counter Dr. Gawande’s argument for checklists, where he cited how Wal-Mart (which allowed managers to be creative) outperformed FEMA (which relied on bureaucratic rules) in Hurricane Katrina relief by saying:
“But giving someone the authority to use her judgment means relying on individual creativity and improvisationâ€”the opposite of a checklist.”
This is exactly the OPPOSITE of the point that Dr. Gawande makes in the book, saying:
There must always be room for judgment, but judgment aidedâ€”and even enhancedâ€”by procedure.
Mr. Howard also writes:
“But bureaucracy is nothing but checklists. That’s part of what’s wrong with modern governmentâ€”officials go through the day with their heads in a rulebook, dutifully complying with whatever the lists require instead of thinking about what makes sense.”
Mr. Howard really has it mixed up. The bureaucracy of FEMA is NOT the result of checklists. Checklists, as Dr. Gawande writes, free up people from mundane decisions to 1) help prevent errors and 2) allow people to apply their critical thinking skills to important decisions. Dr. Gawande writes convincingly of how Captain “Sully” Sullenburger and First Officer Skiles both landed US Air Flight 1549 because they used checklists to handle the mechanics of the situation, freeing up Sully to remain calm and make the one important decision of WHERE to land the plane.
Mr. Howard rails against a real problem in modern education:
“Teachers, for example, are shackled to lists and protocols that prevent them from doing their jobs properly (e.g., disciplining students).”
This is not a “checklists” problem. Not letting teachers exercise professional judgment is a MANAGEMENT problem. If you institute checklists in a culture where you don’t let people think, I’m sure you’ll have a lot of problems. But this is FAR from the culture that Dr. Gawande advocates. How Mr. Howard missed that is beyond me.
Mr. Howard again tries to argue against checklists:
“But most people can think of only one thing at once: If they’re thinking about a checklist, they may not be focusing on solving the problem at hand.”
Again, this argument is clearly refuted by the US Airways case and Dr. Gawande’s O.R. mishap that nearly killed a patient (and would have, if not for the checklist). Checklists can, in the case of US Airways, provide structure for solving an unintended circumstance or they can, in the case of Dr. Gawande, provide a “pre-flight check” to ensure that there is enough blood on hand even if the surgeon didn’t anticipate cutting a patient’s artery. The US Airways crew didn’t anticipate a bird strike, but checklists benefitted them (and the passengers) and didn’t mean their creative brains were shut off. The cockpit checklist did NOT say “Step 7, land in the Hudson River.” That was pure creativity enabled by a checklist.
Mr. Howard tries to dispute this by saying:
“It was undoubtedly a good thing that every member of the crew had been drilled in various procedures. But the “miracle on the Hudson” happened because Capt. “Sully” Sullenberger focused on flying the plane, not a checklist on how to fly the plane.”
Mr. Howard misses the key point that so many missed – it wasn’t just Sully who landed the plane. It was a team effort where he and the First Officer (who was following a checklist to try to restart the engines) worked together to avoid catastrophe.
Mr. Howard tries to use the skilled hero model for Sully by quoting William Langewiesche:
“Across a lifetime of flying, Sullenberger had developed an intimacy with these machines that is difficult to convey. He did not sit in airplanes so much as put them on. He flew them in a profoundly integrated way, as an expression of himself.”
Sully himself, as stated clearly in Dr. Gawande’s book (again, something Mr. Howard missed), dismisses the notion that he was uniquely skilled or that his experience, heroism, or decades-old glider experience were important factors. From Dr. Gawande:
As Sullenberger kept saying over and over from the first of his interviews afterward, “I want to correct the record right now. This was a crew effort.” The outcome, he said, was the result of teamwork and adherence to procedure as much as of any individual skill he may have had.
Mr. Howard makes his world view clear in a final comment:
“Accomplishment is personal. That’s why giving people the freedom to take responsibility is so important.”
He clearly doesn’t understand the impact of systems, nor does he realize that we all (including lawyers) work in a system. He holds to the heroic notion that our success is completely due to our own individual exceptionalism.
Mr. Howard seemed to push his own agenda against being stifled by checklists or standardized work instead of simply reviewing Dr. Gawande’s book. Maybe Mr. Howard works for unenlightened managers who DO equate standardized work with not thinking. Or maybe he’s a Taylorist at heart, himself.
Lean thinkers, I believe, wouldn’t buy his argument. I rest my case.
Rather than assuming that checklists would be damaging, has Mr. Howard tried them in his own practice? Has he tried using them in an environment that still values and allows professional judgment and creativity?
I give credit to Dr. Gawande, and others around the world, who have been willing to try something new (checklists) – not turning aside data that shows that they work.
Thanks for reading! I’d love to hear your thoughts. Please scroll down to post a comment. Click here to receive posts via email.
Now Available – The updated, expanded, and revised 3rd Edition of Mark Graban’s Shingo Research Award-Winning Book Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement. You can buy the book today, including signed copies from the author.