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Design checklists to “Do, Sync & Act”

This article is the second one on checklists, the first one being “The power of checklist

Checklists seem to defend everyone, a kind cognitive net designed to catch flaws of memory and attention.

Atul Gawande in his book “ The Checklist Manifesto” states that there are three kinds of problems in the world:

  1. SIMPLE: Individualistic in nature, solvable by application of simple techniques.e.g. Bake a cake.
  2. COMPLICATED: Can be broken into a set of simple problems, requires multiple people, often multiple specialized teams. Timing, coordination becomes a serious concern. e.g. Launching a rocket.
  3. COMPLEX: These are problems where the solution applied to two similar problems may not result in the same outcomes. e.g. Raising a child. Expertise is valuable, but most certainly not sufficient.

He continues on to say that checklists can provide protection against elementary errors in the case of simple problems that we are designed with. This can be accomplished by simple activity task checklist.

In the case of complex problems that require multiple specialists to coordinate and be in sync, a simple activity task checklist won’t do, what is needed is a checklist with communication tasks to ensure that experts discuss on the matter jointly and take appropriate action.

“Man is fallible, but maybe men are less so” Belief in the wisdom of the group, the wisdom that multiple parts of eyes are on the problem and letting watchers decide what to do.

So how can checklists help in solving simple/complex problems? Using simple activity task checklists to ensure simple steps are not missed or skipped and checklist with communication tasks to ensure that everyone talks though and resolves hard and unexpected problems.

Building tall buildings is a complex problem and the success rate of the construction industry’s checklist process has been astonishing. Building failure is less than 0.00002%, where building failure is defined as the partial or full collapse of a functioning structure. (from a sample size of a few million buildings!).

Now let us turn our attention to the complex problem. How does one deal with complex, non-routine problems that are fundamentally difficult, potentially dangerous and unanticipated? In these situations, the knowledge required exceeds that of any individual and unpredictability reigns. To solve these it is necessary to push the power of decision making from a central authority to the periphery, allowing people to make the decision and take responsibility.

So the checklist needs to allow for judgment to be used in the tasks rather than enforce compliance, so that actions may be taken responsibly. This needs to have set of checks to ensure stupid but critical stuff is not overlooked, a set of checks to ensure coordination and enable responsible actions to be taken without having to ask for authority. There must be room for judgment, but judgment aided and even enhanced by a procedure. Note that in COMPLEX situations, checklists not only help, they are *required* for success.

So, how does one make checklists that work? Aviation industry thrives on checklists in normal times and also to tackle emergencies. The advice from Boorman from the “The Checklist Factory” of Boeing for making checklists that work are:

  1. Good checklists are precise, easy to use in the most difficult situations. They do not spell out everything, they only provide reminders of critical and important steps, the ones that even the highly skilled professionals would miss.
  2. Bad checklists are too long, hard to use; they are impractical. They treat people as dumb and try to spell out every step. So they turn people’s brain off rather than turning them on.

“The power of checklists is limited, they help experts remember how to manage a complex process or machine, make priorities clearer and prompt people to function well as a team. By themselves, however, checklists cannot make anyone follow them.” (Boorman, Boeing)

So how should a good checklist look like?

  1. Keep the length of checklist between five to nine items, the limit of human memory.
  2. Decide on whether you need a DO-CONFIRM checklist or READ-DO checklist. With a DO-CONFIRM checklist, individuals perform jobs from memory and experience and pause to CONFIRM that everything that was supposed to be done was done. With the READ-DO checklist, individuals carry out the tasks as they tick them off, it is like a recipe. So choose the right type of checklist for the situation. DO-CONFIRM gives a people a greater flexibility in performing the tasks while nonetheless having to stop and confirm at key points.
  3. Define clear pause points at which a checklist should be used
  4. The look of checklist matters, they should be free of clutter and fit into a page

In summary

  • Ticking boxes is not the ultimate goal
  • Checklist is not a formula, it enables one to be smart as possible
  • It improves outcomes with no increase in skill
  • Checklists aid efficient working

As smart individuals, we don’t like checklists. It somehow feels beneath us to use a checklist, an embarrassment. The fear is that checklists are about mindless adherence to protocol.

Hey, the checklist should get the dumb stuff out the way so as to let you focus on the hard stuff. We are all plagued by failures – by missed subtleties, overlooked knowledge, and outright errors. Just working harder won’t cut. Accept the fallibilities. Recognise the simplicity and power of the checklist.

Try a checklist. It works.


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The power of checklist

Recently I read the book “The Checklist Manifesto” by Atul Gawande. 

“An essential primer on complexity in medicine” is what New York Times states about his book whilst The Hindu states this as “An unusual exploration of the power of to-do list”.

As an individual committed to perfection, in constant search of scientific and smart ways to test/prevent and as an architect of Hypothesis Based Testing, I was spellbound reading this brilliantly written book that made the lowly checklist the kingpin, to tackle complexity and establish a standard for higher baseline performance.

The problem of extreme complexity The field of medicine has become the art of managing extreme complexity. It is a test whether such complexity can be humanly mastered: 13000+ diseases, syndromes and types of injury (13000 ways a body can fail), 6000 drugs, 4000 medicines and surgical procedures each with different requirements, risks and considerations. Phew, a lot to get right.

So what has been done to handle this? Split up knowledge into various specializations, in fact, we have super specialization today. But it is not just the breadth and quantity of knowledge that has made medicine complicated, it is also the execution of these. In an ICU, an average patient required 178 individual interactions per day!

So to save a desperately sick patient it is necessary to: (1) Get the knowledge right (2) Do the 178 daily tasks right.

Let us look at some facts: 50M operations/year, 150K deaths following surgery/year (this is 3x #road-fatalities), at least half of these avoidable. Knowledge exists in supremely specialized doctors, but mistakes occur.

So what do you when specialists fail? Well, the answer to this comes from an unexpected source, nothing to do with medicine.

The answer is: THE CHECKLIST

On Oct 30, 1985, a massive plane that carries 5x more bombs roared and lifted off from the airport in Dayton, Ohio and then crashed. The reason cited was “Pilot error”. A newspaper reported, “this was too much airplane for one man to fly”. Boeing the maker of this plane nearly went bankrupt.

So, how did they fix this issue? By creating a pilot’s checklist, as flying a new plane was too complicated to be left to the memory of any one person, however expert. The result: 1.8 million miles without one accident!

In a complex environment, experts are against two main difficulties: (1) Fallibility of human memory, especially when it comes to mundane/routine matters which are easily overlooked when you are strained to look at other pressing matters of hand (2) Skipping steps even when you remember them, as we know that certain steps in a complex process don’t matter.

Checklists seem to provide against such failures and instill a kind of discipline of higher performance.

Peter Provonost in 2001 decided to give a doctor’s checklist a try to tackle central line infections in ICU. So what was the result after one year of usage? Checklist prevented 43 infections and 8 deaths and saved USD 2M! In another experiment, it was noticed that patients not receiving recommended care dipped from 70% to 4% and pneumonia fell by a quarter and 21 fewer parents died.

In a bigger implementation titled the “Keystone Initiative” (2006) involving more hospitals of 18-month duration, the results were stunning- USD 17M saved, 1500+ lives saved!

ALL BECAUSE OF A STUPID CHECKLIST!

So where am I heading? As a Test Practitioner, I am always amazed at how we behave like cowboys and miss simple issues causing great consternation to the customer and users. Here again, it is not about lack of knowledge, it is more often about carelessness. Some of the issues are so silly, that they can be prevented by the developer while coding, and certainly does not demand to test by a professional. This is where a checklist turns out to be very useful.

In an engagement with a product company, I noticed that one of the products has a product backlog of ~1000 issues found both internally and by the customer. Doing HBT level-wise analysis, we found that ~50% of the issues could have been caught/prevented by the developer preventing the vicious cycle of fix and re-test. A simple checklist used in a disciplined manner can fix this.

So how did the checklists help in the field of medicine or aviation? They helped in memory recall of clearly set out minimum necessary steps of the process. They established a standard for higher baseline performance.

Yes! HIGHER BASELINE PERFORMANCE. Yes, this is what a STUPID CHECKLIST CAN DO!

So how can test practitioners become smarter to deliver more with less? One way is to instill discipline and deliver baseline performance. I am sure we all use some checklist or other but still find results a little short.

So how can I make an effective checklist and see a higher performance ? Especially in this rapid Agile Software world?

This will be the focus of my second part of this article to follow. Checklists can be used in many areas of software testing, I will focus in my next article on ‘How to prevent simple issues that plague developers making the tester a sacrificial goat for customer ire by using a simple “shall we say unit testing checklist”.

Related article: Design checklists to “Do, Sync & Act”


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