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As if on cue... (Checklists, round 2)

Feb 142010

Yesterday, I wrote about an absolute must-read book: The Checklist Manifesto: How to Get Things Right

It has been shown in an extensive world-wide study that a simple checklist used in surgery cuts infection rates, cuts death rates, and saves costs. It does all of these by substantial margins, everywhere they’ve been implemented. But so far only a minority of hospitals (Dr. Gawande mentioned 10 percent) have started using the safe surgery checklist, or any others, for that matter.

Yet today, the New York Times has an article titled “Results Unproven, Robotic Surgery Wins Converts.” Here are the most important quotes:

But robot-assisted prostate surgery costs more — about $1,500 to $2,000 more per patient. And it is not clear whether its outcomes are better, worse or the same.

[...]

Last year, 73,000 American men — 86 percent of the 85,000 who had prostate cancer surgery — had robot-assisted operations, according to the robot’s maker, Intuitive Surgical, the only official source of such data. Eight years ago there were fewer than 5,000, Intuitive says.

[...]

[O]nce a hospital invests in a robot — $1.39 million for the machine and $140,000 a year for the service contract, according to Intuitive — it has an incentive to use it. Doctors and patients become passionate advocates, assuming that newer means better.

[...]

And the robot is slow; it typically takes three and a half hours for a prostate operation, according to Intuitive, twice as long as traditional surgery.

So in this particular kind of surgery, a majority of surgeons quickly take up a new technology that has yet to show it can provide any sort of benefit! The same procedure is now slower and much more expensive. And the same doctors are resisting adopting a simple checklist (for little to no cost) that conclusively show improved results.

Not to make too much of a political situation here, but our health care system is clearly a mess. Doctors clearly don’t always know what’s truly important for their patients. I’m not saying surgeons shouldn’t use robots, but exhaust the easy, cheap, and conclusively better tools first! Use a damn checklist!

The Checklist Manifesto - A hugely important book

Analysis, Books, Business, Highly Recommended, Inspiration, Navy View Comments

Feb 132010

Back in 2007 I read a fascinating article called “The Checklist” written by Dr. Atul Gawande in the New Yorker. Atul Gawande is a practicing surgeon, MacArthur Fellow, Rhodes Scholar and professor at Harvard Medical School and Harvard School of Public Health. The article described how a doctor convinced a group of hospitals in Michigan to do a wide-spread trial of a simple experiment: a checklist. The checklist aimed simply at making sure staff completed five key steps to limit central line infections, an unfortunately common source of infections in hospitals.

The result?

In one hospital:

10-day infection rate went from 11% to ZERO
Prevented 8 deaths
Saved $2million in costs

Across ICU’s in Michigan:

In three months cut infections by 66%!
Typical ICU cut infection rate to ZERO
In 18 months, prevented 1500+ deaths
In 18 months, saved $175,000,000

These are amazing results, and his book on checklists, “The Checklist Manifesto,” was recently published. Click below to order it from Amazon.

This book is inspiring, educational, engaging, riveting and fascinating. It’s extremely well-written, and is a fairly easy read. I’ve never written a blog post immediately after finishing a book, but I am now because not only is it GOOD, but this book is IMPORTANT.

Dr. Gawande led a huge study of a “safe surgery” checklist, a simple set of steps to be checked in each surgery. It was used and studied in eight hospitals: four in the developed world (US, UK, etc.) and four in the developing world (Tanzania, New Delhi, Jordan, Manila). Thousands of patients were studied for months before and after checklists were implemented. The results?

Rate of complications fell by 36%
Deaths fell by 47%
Infections fell by nearly half
Even in advanced hospitals in developed world, complications were decreased by one-third

I mean…. WOW! Cutting infection rates and death rates in surgery by half (with marginal differences between developed and developing countries) is simply incredible.

But here’s a choice quote from the book:

Take the safe surgery checklist. If someone discovered a new drug that could cut down surgical complications with anything remotely like the effectiveness of the checklist, we would have television ads with minor celebrities extolling its virtues. Detail men would offer free lunches to doctors to make it part of their practice. Government programs would research it. Competitors would jump in to make newer and better versions. If the checklist were a medical device, we would have surgeons clamoring for it, lining up at display booths at surgical conferences to give it a try, hounding their hospital administrators to get one for them – because, damn it, doesn’t providing good care matter to those pencil pushers?

Checklists are powerful, and not just for surgery. Gawande writes about data from investment managers and venture capitalists that shows that those that use checklists are much more successful than those that don’t. They’ve been used in aviation for 70+ years, ever since airplanes became so complicated as to be dangerous without checklists. The modern construction industry uses checklists to ensure their projects are safe and properly constructed.

I’m very familiar with checklists; operating a nuclear reactor in a US Navy submarine means you live with checklists in everything you do. But I accepted it without too much thought since we had no idea there was any other way of running such a complicated machine. It’s amazing to me that other complex professions don’t also use the same procedures.

Checklists are threatening to many people and professions. Using them implies that professionals don’t know what they’re doing, that they don’t have the ability to do their jobs. Even with the results described in surgery above, many surgeons still don’t use them. (Despite the fact that they continually prove to save patients’ lives, everywhere.) As Dr. Gawande describes above, if the same results were achieved through a pill or machine, doctors and hospitals would be racing to adopt them!

Dr. Gawande goes into real detail not only in what makes a good checklist and how to develop them, but also why they work. They work by simply making sure that key simple steps are accomplished, and by freeing your brain from concerning itself about the easy stuff (since the checklist will catch anything you miss). This frees the brain to think about the hard stuff, and able to deal with complications more directly. Good checklists also make communications easier, so that when things do go wrong, the experts involved can address them more directly.

Fundamentally, time after time, in study after study… checklists WORK.

Summary

This is a hugely important book, and I honestly can’t recommend it more highly, It doesn’t matter what industry you’re in, if you deal with or manage complexity, you NEED to read it.

If you want to efficiently improve your performance or your teams’ performance quickly and substantially, a checklist is your way to do it.

Hacking the GMAT

Books, Cambridge MBA View Comments

Dec 032008

I was thinking recently that it was only about a year or so ago that I finally decided to apply for business school. Registering (and paying!) for the GMAT was a first big step into making it real.

For those people that are reading this and have yet to take the GMAT, I have just a couple of simple tips for hacking the GMAT.

However, before all that, are you aiming to get into a top-tier school? Get a 700+ and you’ll be setting yourself up for success. You can certainly still get into top schools with significantly poorer scores. In fact, I’ve heard of a student who got into a top school with a GMAT score in the 400′s. (What happened in that case was the GMAT wasn’t at all consistent with the person’s CV/resume and work history. The interview clearly showed that the GMAT was an outlier; the person turned out to be a superstar.)

That said, the higher score you get the easier it is for schools to accept you.

Tip 1 – Challenge yourself

My first and most important tip is to really challenge yourself. If you really want to kick ass on the GMAT, forget 90% of the study books out there. Those are written for people who want to do above average on the GMAT, not kick ass. If you want to get that 700+, only go for the books that are trying to get you the mythical 800. Kaplan GMAT 800 is the book that I used.

Why do this? Well, instead of picking a representative sample of test questions, it only focuses on the really difficult questions. This is what you need to get comfortable with and master if you’re going to hack the GMAT. Forget your other study books; focus on the ones that challenge you.

Tip 2 – Prepare your body and mind

The second and final tip is to be very careful in the days before your exam. Get good sleep, and not just the night before the exam. Make sure your head is in the right place by getting good sleep consistently for a few days before the exam. Whatever you do, don’t be stupid and try cramming so much that you lose sleep the night beforehand.

So that’s it… my tips on how to Hack the GMAT. A good score won’t guarantee you entry, but neither will a bad score necessarily prevent it. But the better you can do, the easier it is for your chosen schools to accept you.

Meditations - the start of a series

Books, Highly Recommended, Inspiration, Meditations, Quote View Comments

Jul 272008

I picked up a book recently that’s been both a fascinating and inspirational read: “Meditations,” by Marcus Aurelius. (This book is the translation I actually own, which is a bit newer and has an unnecessarily pompous title.)

I’ve found it a great little book to keep with my bag as I ride the Tube into work. There are a lot of short but important thoughts that help remind me of what’s important in life and what I really need to be focusing on.

To be fair, it’s also clear it was written over 2000 years ago, so certain bits aren’t very applicable. Some of it is on the metaphysical side, some on the nature of physics, etc. But so much of it is a leader meditating on how to be a better person, and still rings very true today.

I’m going to periodically post quotes from this book; things that I find interesting or important. Perhaps you’ll find them as intriguing as I do!

Today’s closing quote:

Claim your right to say or do anything that accords with nature, and pay no attention to the chatter of your critics. If it is good to say or do something, then it is even better to be criticized for having said or done it. Others have their own consciences to guide them and will follow their own lights. Don’t be gazing after them, but keep your eyes on the straight path ahead of you, [...]

-Meditations, Book Five, #3

A couple of recent reads

Books, Politics View Comments

Mar 312008

I wanted to write about two books that I’ve read recently. The Nine, by Jeffrey Toobin, and Imperial Life in the Emerald City, by Rajiv Chandrasekaran.

The Nine: Inside the Secret World of the Supreme Court

I bought “The Nine” a number of months ago as I browsed in a Washington DC bookshop. I’m fascinated by the Supreme Court, though I have zero interest in becoming a lawyer. (While I don’t have any irrational hatred of lawyers at all, it’s just not work that suits me.)

This book goes into really interesting detail about all of the recent Supreme Court justices. They each have really interesting personalities and approaches to the law. The book does a great job of really rounding out their personalities, with both positive and negative elements. But a couple of justices just don’t come out looking so well… Thomas and Kennedy in particular. Kennedy seems to be quite a shallow person, and interested largely in his image. Thomas comes off as a man obsessed by his critics, and quite isolated professionally.

Strangely I found myself fascinated by David Souter. He’s a man who seems very defined by his home state of New Hampshire. A life-long bachelor who still lives on the family farm/homestead, doesn’t use a computer or the internet, writes with fountain pens, and allegedly never even plugged in his television! (He wasn’t in attendance for Chief Justice Rehnquist’s funeral simply because no one could get in touch with him in time.) But underneath those personality quirks, he comes across as deeply devoted to judicial principles and stability, so much so that he seriously contemplated resigning after the debacle of the Bush vs. Gore decision in 2000. His role in landmark decisions such as Planned Parenthood vs. Casey is explored in much more detail that I have seen elsewhere.

What I found most interesting in the book was the balance of power issues, and how various blocks of justices come together to hash out agreements on opinions, and the diplomatic tactics used within the Court to make that happen. It’s really fascinating, and could itself serve as an excellent study in organisational dynamics.

Unfortunately the core of this book ends around the death of Chief Justice Rehnquist and the retirement of Sandra Day O’Connor. While it covers Samuel Alito and John Roberts, there’s little detail there as they had just gotten to the Court as the book was finished.

Overall, I highly recommend it!

Imperial Life in the Emerald City: Inside Iraq’s Green Zone

Most recently I read Imperial Life in the Emerald City. This book blew my mind! If you are at all interested in what the hell went wrong in the Iraq occupation, you MUST read this book. It’s only after this that I began to understand how many different ways the United States screwed up the aftermath of the original invasion.

This book details the year and a half or so at the end of the Iraq invasion and the beginning of the occupation; particularly the Coalition Provisional Authority. If the stories that the author tells were in a fiction book, it would be high black comedy. Unfortunately, they’re all true.

The crux of the problem that the author describes is an unyielding ideology. People weren’t selected because they would do an outstanding job; they were selected to go to Iraq because they had excellent Republican/neo-conservative principles. (Those that were extremely qualified but not reliably conservative were often prevented from these jobs.) This led to such things as a 24-year old recent university graduate (with no background in finance) being put in charge of getting Baghdad’s stock exchange up and running! WOW!

There are so many excellent vignettes of complete incompetence, but also of extreme competence trying to do their best in the environment of incompetence. It was a great read from beginning to end.

Incredible bookstore!

Books, Design, Geeking out, Inspiration View Comments

Nov 082007

A while ago I read about this absolutely INCREDIBLE new bookstore in the Netherlands. (H/T to John at Brand Autopsy.) An old (essentially unused) church in the heart of this city was turned into the most incredible bookstore you’ll likely ever see.

The building hadn’t been used as a church for years. In more recent times it had been used for bicycle storage, of all things, which seems like an inappropriately poor use for a building of that significance.

Well, a bookstore has now moved in and really done a good job of melding a bookstore into the space and beauty of a good-sized cathedral.

These photos are fantastic.