Checklist Manifesto by Atul Gawande... Review of the week

Today, I will start writing about some books, articles, and sources of information about Lean & also 6 Sigma. Since I´m close to 1000 visits to this blog, and I´m super excited, wanted to share with you my thoughts on The Checklist Manifesto by Atul Gawande.

I came across this book, because I was struggling to implement a control tool on a warehouse and needed to get some fuel about what others have accomplished or what other organizations have implemented with success. The Title, The Checklist Manifesto was for me, intriguing. As I have stated on other posts, my background is on the Manufacturing Side, so I remember that once I ran an experiment to try between different tools and demonstrate, with data, which one was the most effective to avoid mistakes. Checklist, was the last tool. Which in my studio meant that it was the least reliable tool of all. Because usually we all start with great enthusiasm using it, but eventually stop doing it, and obviously, doesn´t work anymore. In my studio, a better tool would be a poka yoke, or an error proofing. Andons, proved to be more effective than Checklists, so my curiosity grew. What can a surgeon teach me about how to control a process? I asked my self. Also thought that when there is stagnation in one´s mind, anything out of the box, could lead to pretty good ideas. So I gave it a shot.

Glad I did, the book was a revelation to me. Not because it was a bout checklists, but because it was well written, sometimes looks like I was reading a novel instead of a book about check lists and because If you read carefully, will find elements from Lean that, I don´t think were put there intentionally but In Dr. Atul Gawande may lie a lean thinker, and I´m not sure he is even aware of it.

The chapters will get you in a instant. From the description where a patient almost dies in a hospital because some extraordinary situation at the beginning of the book, to the story where Dr. Gawande almost kills a patient and how his Checklist helped him to save the patients life. There are also good episodes about flying complications and how aviation uses Checklists to control the uncontrollable, or to expect the unexpected. In one chapter Gawande, writes about how flying in poor weather conditions (extremely cold conditions) may lead to ice in the gasoline (or should I say turbosine). This small issue may lead to one potential catastrophe, as one of the engines would not receive enough fuel, and fail. How should captain and first officer  handle an issue like that? With a Checklist, Dr. Gawande should have answered. 

The book isn´t about Checklists. I believe the book talks about Standard Work and how Standard Work helps any industry, from aviation, to construction to health improving the way they work on a daily basis. The book is really about Standardization and describes the discipline to follow procedures. In it, Dr. Atul Gawande gives great examples. Like the terrifying case, that happened a few years ago, where an US Airways flight had to land in the Hudson River. In that case, Dr. Gawande, examines how a goose strike had the plane lost both engines, forcing Captain Sullenberg to land on the icy waters of Hudson. This January, was five years from that "lucky" event. As I was explaining, Dr. Atul examines and concludes that it was due to the exceptional discipline of captain and his first officer, that this miracle was possible. There is no surprise, Standardization requires a great degree of discipline to make sure we stick to the procedure. And often, the results are surprising. That´s why in my studio Checklists didn´t work. But to me, the book talks more about why is Standardisation needed. I believe it is first of all, because it helps to stabilize any process. Removes variation from it. Sets the ground for improvements. Not easy, but the benefits outlooks the sacrifice. I believe this is why, the captain following the procedure, was able to land on Hudson River. Also, the process was really robust and helped the captain to get a good result. In the Book you will read about Dr. Atul´s attemps to set up a checklist for his operating room, and how experimentation was vital, and allowed innovation. This is key. This is really what Lean is about. Experimenting, learning and evolving.

This is really what Lean is about. Experimenting, learning and evolving.

The other nice part that I found in this book, was when Dr. Atul tells how he joined an organization to improve safety across different hospitals in the world. That story reminded me, the old one about the Toyota Sienna development for the American market. I found similarities in the way Dr. Atul went to Gemba and visited the hospitals that would implement the Checklist. How he saw the problems each hospital faced and how each hospital adopted the Checklist, twisting a little bit, to make it fit to each organization, talks about experimentation, learning and improvement.

I´m sure there are other details that I forgot to mention, but this two principles are so clear in the book. So I urge you to read it with fresh eyes. My advice is to read it and see if you can identify some other similarities to the ones explained here, and why not, comment weather or not agree with this review.

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Western Obsession for recipes and The five why`s technique.

These days I have thought a lot about how western culture seems to be seeking recipes for success in all areas. In general we all look to follow a method, a scientific way to find solutions, to find success, to achieve what companies such as Toyota has in almost a century of making cars. I guess that`s why people in general is a fan of Checklists. Speaking of which, I will be reviewing The Checklist Manifesto by Dr. Atul Gawande in a future post. But anyway. I believe we like this tools because we believe it is a safe way to go into the wild. To reduce risks, and to maximize the chances of success.

This is no trivial because this obsession I believe, lead Motorola & GE to develop the well know 6 sigma methodology.

I have no evidence to support this last statement but I believe that`s why 6 Sigma was born on this side of the planet, well a little bit up North. But as the next article about Six Sigma in Asia sort of explains, difference between Western and Asian Cultures are noticeable.

Lean on the other hand, comes  (as we all know) from Japan, born within the walls of Toyota and to my eyes, Lean is first about people and principles, and when followed and applied, derive in efficient tools that can be apply to a wide range of situations. I believe that cultural difference were significant and were crucial when the first western learners took these information and export them into the US. Of course language was the greatest barrier to fully understand the principles and tools from Toyota. But I think that it was also the obsession to have a recipe for success, which lead to receive some sort of distorted tools and lack of understanding of principles. Fortunately there are leaders such as Mark Graban, Steven Spear, Karen Martin, John Shook, and many others that have helped to clarify and expand the knowledge across industries.

Why?

All this introduction is to support the following story. I was recently working with a crew making a root cause analysis. Claims have been high for the past weeks and we wanted to know why. It is a requirement that the root cause analysis would be conducted through a Fishbone diagram, a 5 whys technique or both. I prefer other techniques or tools since I believe this could be biased if these tools aren´t supported by evidence. I will explain later why. In this sense, I have always asked myself, how did the creator of the 5 whys defined that 5 were enough? Why asking why and not when, how, who, and others? And why corporations are so emphatic to specifically use 5 whys only? I believe this tool didn´t captured correctly the spirit of improvement, when first brought to America. The key point here is to dive into the issue and asking why,  accompanied by who, when, how, how many etc. Of course, also having facts, and/or data. Understand the problem is the main idea. During the session to capture ideas and define what was the root cause, I didn´t use the 5 whys as the company demands. Instead, requested evidence, data, facts and it was more like a dialogue. A discussion with the team members, to understand the underlying issue causing all of the symptoms. I guess we did a pretty good job, and more important is that people got involved. My personal conclusions are that sometimes you got to use the tool that fits better the problem you`re facing. Or as the Lean practitioners say, according to the problem that you`re trying to solve.

Why do I think these tools could be biased?

Because the way they have been thought. For example, I was taught that a 5 whys technique, you should start asking why is this problem happening? answering because..., and then ask why again on the response given, and answer again, and after asking 5 whys you´ll have the root cause. But if this is based on unverified assumptions our mind can trick us, and lead the solution where our subconscious wants. I´ll give an example:

On the same exercise, one of the team members pointed out the valid fact that we had new personnel and if training was´t complete and properly executed of course quality would decrease. We have an unusual high rotation, influenced by a number of different factors. So we dived on the lack of training of new personnel. Everybody agreed that it would be an issue. But is it an issue today? not sure. One of the supervisors said, "I think it does´t have anything to do. We know our training isn´t the best but is not the main issue right now".

Lets conduct a 5 whys before knowing how the story ends.

Lack of training on new personnel.

Why? Because there isn´t enough time to train. 

Why? Because our supervisors are in a hurry. 

Why? Because they need the job done. 

Why? Because they don´t like to give explanations. 

Why? Because they may be under evaluated. So the problem is originated by the trimestral evaluations right? But wait, what if we dive a little bit?

What if the issue isn´t due to the evaluations?

The issue must be due to the training program right?

Ok, will see what the 5 whys reveal.

Lack of training on new personnel.

Why? Because the training program isn´t properly designed. 

Why? Because it was designed by HR. 

Why? Because no operator or supervisor was involved. 

Why? Because they were busy. Why? because they didn´t have time. 

Why? Because needed to get the jobs done. Wow! this tool is really efficient right?. Both analysis lead to the semestral evaluation. So if we wanted to fix this issue, all we have to do is get rid of the semestral evaluations.

That would have been the answer if we didn´t have evidence. Note that I just conducted this analysis just with assumptions. The action on eliminating the semestral evaluations would have an effect on the organization. No doubt about it, but I`m not sure that would have an impact on claims.

I asked why to the supervisor, and he replied:

"Because the people with higher mistakes, are experienced people and relatively new people, look". And showed his graph were it was clear that something in the process apart from training, was causing the claims. But the  evidence suggested that training, even though, might be susceptible of improvement was´t the primary source of variation creating claims. Everybody agreed and we moved on to the next possible cause.

Thank`s for reading. If you liked this post, please share. If you do not agree with me, please share some knowledge. If you didn´t like it, please tell me why. That´s how we can improve.