Sunday, June 06, 2010

More checklists

More from Checklist Manifesto by Atul Gawande

Gawande uses a number of non-medical examples to illustrate the role of checklists.

The Katrina Hurricane that devastated New Orleans provides examples of what can go well and what can go wrong. The main problem was that there were too many decisions to be made with too little information. However, authorities continued to work as if the normal way of doing things applied. This meant the federal government wouldn't yield power to the state, state wouldn't yield to local government and no one would involve the private sector. This led to trucks with vital supplies of water and food were not allowed entry because the authorities did not have them on their plan. Bus requisitions required for evacuation were held up for days. The root of the problem was people assumed the normal command and control structure would work for any situation and that there would be a big plan that was going to provide the solution. This case was far too complex for that.

Gawande uses Wal-Mart as an example of an organisation that did things much better. Apparently Lee Scott, the chief executive said in a meeting with upper management "a lot of you are going to have to make decisions above your level. Make the best decision you can with the information that's available to you at the time, and, above all, do the right thing." This was passed down to store managers and set the way for people to react. The initial focus was on the 20,000 employees and their families, but once they were able to function as stores local managers acted on their own authority to distribute nappies, baby formula, food, toiletries, sleeping bags etc. They even broke into the store pharmacy to supply the hospitals. Senior managers at Wal Mart did not issue instruction but instead supported the people who were in the position to assist. They found that given common goals, everyone was able to coordinate with others and come up with "extraordinary solutions."

Gawande sees the key message from this that under conditions of true complexity, efforts to exert central control will fail. People need to be able to act and adapt. There needs to be expectations, co-ordination and common goals. Checklists have a place here to make sure stupid things are not missed but they cannot tell people what to do.

This is something I can associate with. When suggesting the need for emergency procedures to cover specific types of event I am often given the response that 'you cannot write a procedure to cover everything.' This is something I totally agree with, but are cannot agree that the answer to provide nothing. Instead, people need brief prompt cards or checklists (of sort) to help them make the right decisions. Reading these may not be the first thing someone does when confronted with a situation, but they are very useful in training and assessment, and it is likely that others coming to assist can be pointed to the prompt card to make sure nothing has been forgotten about.

Gawande uses the example of US Airways Flight 1549, the plane that landed in the Hudson River in 2009 after it flew into a flock of geese, which caused both engines to fail. Captain Chelsey Sullenberger was held up as a hero for carrying out the "most successful ditching in aviation history," but he was very quick to point out that the success was down to teamwork and adherence to procedure. Sullenberger's first officer Jeffrey Skiles had nearly as many flying hours under his belt, although less on the Airbus A320. Gawande makes the point that this could have been a problem in an incident because both may have been inclined to take control, especially as the two men had never flown together. But before starting engines the two men had gone through the various checklists, which included requiring the team to introduce themselves, a discussion of the flight plan and how they would handle any problems. By having the discipline to go through this right at the start of the flight "they not only made sure the plane was fit to travel but also transferred themselves from individuals into a team, one systematically prepared to handle whatever came their way." This was a crew that had over 150 total yeats of flight experience, but they still went through the routine checklists, even though none involved had ever been in an air accident before.

The aviation industry has learnt from experience. The need for much better teamwork was identified following the 1977 Tenerife plane collision, where the Captain on the KLM plane had total command and the second officer was not able to intervene successfully. But it has also been learnt that checklists have to avoid rigidity or creating the situation where people follow them blindly. In the Hudson River incident the checklist of main focus was engine failure. Sullenberger took control of the plane and Skiles concentrated on trying to restart the engines, whilst also doing the key steps in the ditching procedure, including sending a distress signal and making sure the plane was configured correctly. Sullenberger was greatly helped by systems on the plane that assisted in accomplishing a perfect glide, eliminating drift and wobble; to the point of displaying a green dot his screen to give a target for optimal descent. All this freed him to focus on finding a suitable landing point. At the same time flight attendants were following their protocols to prepare passengers for crash landing and being ready to open doors. Gawande summarises this by saying the crew "showed an ability to adhere to vital procedures when it mattered most, to remain calm under pressure, to recognise where one needed to improvise and where one needed not to improvise. They understood how to function in a complex and dire situation. They recognised that it required teamwork and preparation and that it required them long before the situation became complex and dire. This is what it means to be a hero in the modern era."

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