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Revision995e2e9b3546b8a5852b518fde9c3bb041531467 (tree)
Zeit2019-05-27 08:48:31
Autorpierfrancesco A <pier4r4reich@yaho...>
Commiterpierfrancesco A

Log Message

text. notes on checklist manifesto that are also on wikidot

Ändern Zusammenfassung

Diff

--- a/thoughts_and_notes/books_summaries/notes_on_checklist_manifesto.txt
+++ b/thoughts_and_notes/books_summaries/notes_on_checklist_manifesto.txt
@@ -1,36 +1,146 @@
11 Checklist Manifesto Atwul Gawande
22
33 - To add the notes already collected on another system.
4+- way better! on a wiki. Pier4r.wikidot.com
45
5-+ page 114
6+The book is full of relatively convincing examples and stories in
7+hopitals and co (so no small sample size) of how checklists helped.
8+
9+page 8
10+medical fallibility. We cannot control everything.
11+https://onlinelibrary.wiley.com/doi/abs/10.2307/3560992
12+
13+ineptitude: failure to apply knowledge correctly
14+ignorance: missing knowledge
15+in the last seven decades we went from generally ignorant to
16+inept. We have the knowledge but we ignore how to apply it properly.
17+This is caused by the increasing amount of possible solutions known,
18+without knowing which solution should be applied
19+Pier: like searching for the effective chess move.
20+
21+page 12
22+failure is an occasion to learn and improve.
23+
24+page 13
25+To tackle the amout of possible solutions, one may rely on checklists.
26+Pier: well, what is a checklist if not a decision tree, so a way
27+to cut through the solution space properly? Nice.
28+
29+page 35
30+Although cases are different from one another, what can be more different
31+that people with deseases, one can capture the common points to all the
32+cases and one can capture the macro points of all the cases.
33+The details of the macro points may be different, but the overview is similar
34+enough for a checklist.
35+
36+page 36
37+checklist helps against routine (that decrease attention, or self suggestion
38+that one can skip steps) and interruptions.
39+all or none processes: either you do all the steps, or the result amounts to nothing.
40+Checklist tends to remind the minimum necessary steps to achieve good performance
41+on a task that was done before.
42+
43+page 40
44+People are reluctant to adopt checklist if they think they don't need them.
45+
46+page 48, 49
47+Checklist are not a solution from everything.
48+Some researchers say that problems are simple, complicated and complex.
49+Simple: one has to follow a known solution to have a high likelihood of success.
50+ The solution can be repeated if the problem appears again.
51+ Example: cooking with a recipe.
52+Complicated:
53+ one has to work on the problem that is more , maybe breaking it down in simpler
54+ solutions to then find the global solution. The solution can be repeated and
55+ improved if the problem appears again.
56+ Example: landing something on the moon.
57+Complex:
58+ solving one problem produces a solution that can be only partially applied
59+ to a new instance of the problem.
60+ Example: raising a child.
61+
62+page 50
63+from engineering forcing solutions: relatively clear solutions that force the necessary
64+behavior. A checklist.
65+
66+page 65
67+Without coordination autonomous teams working on the same projects more often than
68+not produce incompatible decisions and overlooked errors. Therefore one has to plan
69+(and make checklists) also for coordination.
70+
71+page 68
72+With complex work that have to coordinate you need someone or something that checks
73+if the various submitted plans fits or there are clashes. Those clashes then need to
74+be resolved earlier than late. So also the resolution of the clashes is scheduled.
75+Therefore coordination and communication in complex problems is crucial.
76+
77+page 79
78+Decentralizing decision making (but also responsibility) helps in case of complex,
79+unpredictable problems. What is required is still coordination.
80+
81+One needs a balance between extremes. Control and freedom of action,
82+specialization and group brainstorming, etc.
83+Therefore proper checklists provide at least two important features.
84+They provide a tool to avoid skipping menial but needed steps.
85+They provide a tool to force people to talk and coordinate leaving them room
86+to manage impredictable situation the best they know.
87+
88+According to the author checklists are needed in case of complexity, as
89+they provide ehnanched capabilities of judgment according to well tested
90+procedures.
91+
92+page 80
93+A way to ensure that detailed checklists are followed through is to put some
94+sample check actions here and there, that apparently could be skipped while not
95+that important. Only on the checklist one can mark them as important.
96+Then ask the one that execute the checklist if they went through it.
97+
98+page 82
99+Recipes for food. They are guidelines as they cannot cook the food for themselves
100+but one cook said "they are essential to keep the quality of produced food over time".
101+The same for a checklist, helping keeping high levels over time.
102+
103+page 100
104+A checklist may be useful but has no effect if it is not really implemented.
105+So a cultural change has to happen to follow it.
106+
107+page 107
108+Once again stressing how important is, in a team/organization where no one can do the entire
109+job (in time at least), that people or sub-groups talk with each other
110+to be synchronized on the work to do. To know what is going to happen, at least
111+as an idea of it.
112+
113+TOCHECK: gaps in between? See notes at work.
114+
115+page 114
6116 Checklist should be sized according to the context. Too long, and people won't use them,
7117 making their value nil.
8118
9-+ page 120
119+page 120
10120 One can have hundreds of checklist. The important part is that each is appropriately
11121 sized, effective, ____tested____ and people know where to find it and when to use it.
12122
13123 Checklist should not list every possible operation. People have brains and should be trained.
14124 They need to list what is to do as recall point for the person using it.
15125
16-+ page 121
126+page 121
17127 Training is crucial for checklist. People need to trust them, know that they exists,
18128 where, and they should be trained on the steps following the checklist.
19129
20-+ page 123
130+page 123
21131 From aviation (that faces no trivial cases).
22132 DO-CONFIRM checklists: people do their job, then they check it against the checklist to
23133 see if some things is missing.
24134
25135 READ-DO: people do the job of each step in the checklist.
26136
27-+ page 128
137+page 128
28138 Important point in the checklist. People have brains and likely in a procedure they
29139 never fail to do some actions, so those actions do not need to be in the checklist
30140 (unless order of action is important). Only the critical actions that need to not
31141 be forgotten and are not routine need to be there.
32142
33-+ page 133
143+page 133
34144 As competitive games shows. If one wants to have less failures, one has to analyze
35145 failures of the past (as soon as they happens) and build experience from them.
36146 And no one does it enough (I am the first).
@@ -38,6 +148,19 @@ And no one does it enough (I am the first).
38148 Another problem is: even if one learned a lesson, to apply it and to see it applied
39149 elsewhere may take a very long time. Because damn our habit to keep the status quo.
40150
151+page 137
152+Testing the checklist over and over, if possble in a rehearsal, helps a lot to
153+make it practical and useful. Otherwise there will be no time to fix it and
154+confidence in it will drop and won't be used.
155+
156+page 150
157+Incorporating a checklist is a cultural change, it takes time to adjust and people
158+need to be willing to do it.
159+
160+page 154
161+One needs to measure perfromance before and after a change (checklist) to be sure that
162+the change helped. It is not that easy.
163+
41164
42165 Log:
43166 2019-05-25