Tag Archives: The Checklist Manifesto

Fixing Health Care by Learning from the Cheesecake Factory – Atul Gawande’s Latest

There is in fact a consensus out there.  The consensus is that health care costs are too high, and rising too rapidly.  But the consensus evaporates with the question of how to fix it.

One man who has thought a lot about this is Atul Gawande.  Dr. Gawande is a surgeon, he teaches surgery at Harvard Medical School, he led the Surgical Task Force for the World Health Organization (he developed the surgeon’s check list), he is a regular contributor to the New Yorker, and he is a Macarthur Fellow (commonly called the “Genius Grant.”) So, he has hefty credentials.  (I presented my synopsis of his terrific book The Checklist Manifesto at the First Friday Book Synopsis back in April, 2010).

He writes important long-form pieces about health care regularly.  Among his best was a look at why McAllen, TX has the most expensive health care in the country:  The Cost Conundrum:  What a Texas town can teach us about health care.  And he has this must-read piece on the Supreme Court Decision regarding the Affordable Care Act (“Obamacare”).  It includes this really insightful section:

In 1973, two social scientists, Horst Rittel and Melvin Webber, defined a class of problems they called “wicked problems.” Wicked problems are messy, ill-defined, more complex than we fully grasp, and open to multiple interpretations based on one’s point of view. They are problems such as poverty, obesity, where to put a new highway—or how to make sure that people have adequate health care.
They are the opposite of “tame problems,” which can be crisply defined, completely understood, and fixed through technical solutions. Tame problems are not necessarily simple—they include putting a man on the moon or devising a cure for diabetes. They are, however, solvable. Solutions to tame problems either work or they don’t.

And he ends this piece this way:

Beneath the intricacies of the Affordable Care Act lies a simple truth. We are all born frail and mortal—and, in the course of our lives, we all need health care. Americans are on our way to recognizing this.

One reason he is such a helpful and important author is that he learns from everywhere.  We live in an “everything is connected, learn from everywhere” world, and yet so few of us actually learn from outside our own narrow slices of the world.  Dr. Gawande learns from a much broader swath of the world than most of the rest of us.

Dr. Gawande is observant, curious, and determined.  I suspect that he walks up to people (as he did to the manager of the Cheesecake Factory where he ate a meal), and says, “look, you may not have time for me, but I think a bigger world needs to learn from what you do.  Will you show me?  Will you teach me?”  In The Checklist Manifesto, he described successful checklists from surgeons, and pilots, and chefs, and construction project supervisors, and….  He learns from everywhere!

And, right now, our health care system needs to learn from anywhere and everywhere.  This article reminded me of an example/story in Practically Radical: Not-So-Crazy Ways to Transform Your Company, Shake Up Your Industry, and Challenge Yourself by William C. Taylor, where he describes how a health care company in the Pacific Northwest takes a group of executives and team leaders to a Toyota plant in Japan to watch the way they make cars.

So Dr. Gawande’s latest is:  Big Med: Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care?  This short blog post will not be enough.  I urge you to read his article, and think not only about our health care challenges, but about this question:  “what can I learn from somewhere outside my narrow circle?”

Here are some excerpts of this wonderful essay.  First, his description of the Cheesecake Factory:

The place is huge, but it’s invariably packed, and you can see why. The typical entrée is under fifteen dollars. The décor is fancy, in an accessible, Disney-cruise-ship sort of way: faux Egyptian columns, earth-tone murals, vaulted ceilings. The waiters are efficient and friendly. They wear all white (crisp white oxford shirt, pants, apron, sneakers) and try to make you feel as if it were a special night out. As for the food—can I say this without losing forever my chance of getting a reservation at Per Se?—it was delicious.

Now his curiosity and inquisitiveness kicks in:

I wondered how they pulled it off. I asked one of the Cheesecake Factory line cooks how much of the food was premade.

And then, the problem he seeks to answer:

I’d come from the hospital that day. In medicine, too, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven’t figured out how. Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital.

I’m thinking a lot about problems these days.  I have a few myself…  I just presented my synopsis of The Goal by Goldblatt, and the book pretty much says one thing:

figure out what your problem is, then fix it. 

Goldblatt labels the “big” problem the bottleneck, and offers a path to follow to fix your problems.  And, by the way, he seems to argue that many (most?) problems are not equipment or software problems, but process problems.  That seems to be Gawande’s discovery also.

The successful people in the world do not attain their success because they never have problems and challenges.  They have them.  They just know how to identify them, and then fix them – and then, to find the next one and fix that one too.

So, I encourage you to read this Gawande article to learn about our health care challenges.  But also, to learn how to find, and face, and tackle, and solve your own problems and challenges.

He ends his essay with this:

The critical question is how soon that sort of quality and cost control will be available to patients everywhere across the country. We’ve let health-care systems provide us with the equivalent of greasy-spoon fare at four-star prices, and the results have been ruinous. The Cheesecake Factory model represents our best prospect for change. Some will see danger in this. Many will see hope. And that’s probably the way it should be.

We’ve all got problems to find, problems to solve.  Let’s get to it.

Getting the Basics Right (Like Communication, and Team Building) – It is Still, and Always, Hard To Do

Getting the steps right is proving brutally hard, even if you know them.
Atul Gawande, The Checklist Manifesto


This week, I am presenting synopses of Made to Stick by Chip and Dan Heath and Tribal Leadership:  Leveraging Natural Groups to Build a Thriving Organization, both to law enforcement professionals.  (And my colleague Karl Krayer is presenting another book on communication at the same gathering).


Because, these professionals, like so many others in practically every arena, deal with these two problems:

#1 – how to build, and maintain, effective teams.

#2 – how to communicate, clearly and effectively, to everyone on the team (and to those outside the team).

The more I speak, the more I listen, the more I “consult,” the more I realize this challenge.  It is not a new challenge, it is not a modern challenge.  It is an old challenge.

We don’t get the basics right.

Team building, communication – these are basics.  And after countless books and training seminars on both, we still have unclear communication and ineffective, dysfunctional teams.

My counsel to you – keep working on both of these.  Pay attention to your team members.  Pay careful attention to your spoken and written communications.  Do you listen, and encourage, and include, and support each one of your team members?  Are your e-mails clear – do you put your sentences together effectively?  Do you speak clearly?

Build Teams.  Communicate clearly and effectively.  These are two of the basics we just have to get right.

The Experts Can’t Figure It Out – Now What Do We Do? (We Still Don’t Know What Caused the Financial Crisis of 2008)

What do we do when the experts simply can’t figure it out?

Here’s a simple question:  are there failing companies?  Yes.  Are there less-than-excellent organizations?  Yes.  Do you do everything you could do, should do, as well as you possibly could – as well as it needs to be done?  The answer, I’m pretty sure, is no.

So, “less-than-excellent” is all around us.  As we reflect on failures and deficiencies, we ask the next question:  why are we not better?  Why are our companies, our organizations, our own lives, not better?

Atul Gawande hinted at it when he wrote:

We have just two reasons that we may fail. 
The first is ignorance – we may err because science has given us only a partial understanding of the world and how it works.  There are skyscrapers we do not yet know how to build, snowstorms we cannot predict, heart attacks we still haven’t learned how to stop. The second type of failure the philosophers call ineptitude – because in these instances the knowledge exists, yet we fail to apply it correctly. 
(Atul Gawande, The Checklist Manifesto:  How to Get Things Right).

Or, to put it in simple terms:  we don’t know; or, when/if we do know, we don’t do.  Back, yet again, to the “knowing-doing gap.”

Now, on the “we don’t know” part of this equation….  Sometimes, we have not yet learned.  On the news last night, there was a report on an amazing breakthrough drug for lung cancer.  It looks like it might actually work, and they profiled a woman (with two young children still at home) who was on her death bed, and she is practically back from the dead.  We now know something we did not know, and she is alive, maybe for quite a while longer.  Wonderful.

And there are, we suspect, so many more such wonderful discoveries around the corner.

But, as much as we have come to rely on the breakthrough discoveries and insights of “experts” – they simply don’t yet know everything.

Which brings me to the paragraph of the day.  This came in on my AtlanticWire Five Best Columns e-mail this morning.  The article referenced is:  What Caused the Financial Crisis? Don’t Ask An Economist.  I end this post with the paragraph summary of the article from the AtlanticWire.  And I remind you that there are some questions for which we simply do not know the answers — yet.  And the more complex the question, the bigger the problem this presents.  It really is quite a paragraph on lack of consensus, the limits of experts and their expertise, and a little on the drawbacks of this contentious age we live in.

Here’s the paragraph (AtlanticWire here; the article linked to from the FiscalTimes here):

Mark Thoma on the disabling divide in macroeconomics  “What caused the financial crisis that is still reverberating through the global economy?” asks Mark Thoma in The Fiscal Times. “Last week’s 4th Nobel Laureate Meeting in Lindau, Germany–a meeting that brings Nobel laureates in economics together with several hundred young economists from all over the world–illustrates how little agreement there is on the answer to this important question.” Economists offered all sorts of conflicting answers like “the banks, the Fed, too much regulation, too little regulation, Fannie and Freddie, moral hazard from too-big-to-fail banks, bad and intentionally misleading accounting, irrational exuberance, faulty models, and the ratings agencies.” This lack of consensus among the world’s most renowned economists is troubling, Thoma writes, because we cannot find a solution to a problem we do not agree on. Perhaps we could try to fix all the potential problems cited. “But that unnecessarily constrains a whole range of activities in the hope that we limit the particular behaviors at the root of the crisis. That’s an inefficient way to fix the problem. And in any case, how do you proceed when some of the causes cited by economists are at odds with each other?” The truth is, macroeconomists have not yet agreed on a single model for the economy. Because economic theories are applied to historical, not experimental, data, economists can come up with multiple theories that explain the past equally well. “This problem is not just of concern to macroeconomists; it has contributed to the dysfunction we are seeing in Washington as well. When Republicans need to find support for policies such as deregulation, they can enlist prominent economists–Nobel laureates perhaps–to back them up. Similarly, when Democrats need support for proposals to increase regulation, they can also count noted economists in their camp.” Thoma says he hoped that a cycle-interrupting cataclysm like the 2008 crisis would provide enough new macroeconomic data to support one theory over another–he thinks it supports demand side over supply side. In fact, economists have just used it to back up their previously held positions and “dig in their heels,” making our debates “larger and more contentious than ever.”

What if the Worst Happens? — What Then?

I’ve been thinking about business, preparing for the expected, and then facing the unexpected…

Many products have faced delays in delivery of products due to the earthquakes/tsunami in Japan.

And now, the tornadoes that have sliced through and devastated portions of cities, specially in Alabama…  What will that do to the economy?

(Of course, the first thought, always, is the human loss – and the tragedy of lives snuffed out, some so very young…)

But the ripple effects on the economy also get our attention.

For some reason, I go back to one of the main ideas in The Checklist Manifesto by Atul Gawande:

We have just two reasons that we may fail. 
The first is ignorance – we may err because science has given us only a partial understanding of the world and how it works.  There are skyscrapers we do not yet know how to build, snowstorms we cannot predict, heart attacks we still haven’t learned how to stop. The second type of failure the philosophers call ineptitude – because in these instances the knowledge exists, yet we fail to apply it correctly  This is the skyscraper that is built wrong and collapses, the snowstorm whose signs the meteorologist just plain missed, the stab wound from a weapon the doctors forgot to ask about. 
For nearly all of history, people’s lives have been governed primarily by ignorance. 

When a company faces a problem of its own making, it is the fault of that company.  Some ineptitude has crept in, gone unchecked, and now created something between a small problem to great havoc.  In this case, the company is to blame, and the company leaders and employees have to learn, quickly and thoroughly, from their mistakes.

But when something happens from “outside” – something the company has no control over, then the company is not to blame.  A tornado; a tsunami…  these are some things no company can control.

There are a few other such examples that are equally disturbing to business success, like…  practically every business is facing the ripple effects of the rising gasoline prices.  If the prices continue to rise, then the ripple effects will be a genuine drain on a whole lot of bottom lines.  This is not the fault of the company, or its own ineptitude.  But the effects may soon be felt in every industry, in every company.

But…  on the other hand, I think there is a simple lesson in all of this.  Maybe every company needs to spend a little time on “what if the worst happens?  Then what do we do” planning.

Because I think I am learning this – there are a whole lot of “what if the worst happens” possibilities out there.

Are We Truly A “Flabby Lot?” – In A 10,000 Hour Rule World, Why Are We So Flabby?

Discipline is hard – harder than trustworthiness and skill and perhaps even than selflessness. We are by nature flawed and inconstant creatures.  We can’t even keep from snacking between meals.  We are not built for discipline.  We are built for novelty and excitement, not for careful attention to detail.  Discipline is something we have to work at.
Atul Gawande, The Checklist Manifesto

The list of posts on this blog referring to the 10,000 hour rule, the need for deliberate practice, the books Outliers by Malcolm Gladwell and Talent is Overrated by Geoff Colvin, is long.  We have chronicled the ascendancy of, the centrality of  — call it what you will – “work ethic,” “it take s10,000 hours to master anything…” thinking.


The quote that indicts me personally, in a way that I cannot escape, is the one from Gawande:  “We can’t even keep from snacking between meals.”

This morning, Pulitzer winner Kathleen Parker has a column about Wikileaks.  In the midst of this column is this section:

With the exception of our military, we are a flabby lot, and I’m not just talking about girth. We are merely disgusting in that department. I’m talking about our self-discipline, our individual will, our self-respect, our voluntary order.
Note the operative words: self, individual and voluntary.
We don’t need bureaucrats and politicians to dictate how to behave; how to spend (or save); what and how to eat. We need to be the people we were meant to be: strong, resilient, disciplined, entrepreneurial, focused, wise, playful, humorous, humble, thoughtful and, please, self-deprecating. We have all the tools and opportunities a planet can confer.

We are a flabby lot.  And it shows – not in a good way.  We’ve read all about 10,000 hours, but how many of us actually put in the work?

As always, we are back to the “knowing-doing gap.”  We know, we just don’t do

Take inventory.  Be honest with yourself.  Are you flabby, undisciplined, unfocused?  If so, you’ve got your work cut out for you (as do I).  Let’s get to it.

Management Practices and Processes – 2 Lists from Gary Hamel

In Atul Gawande’s The Checklist Manifesto, he reminds us that checklists are needed because: Every day there is more and more to manage and get right and learn.  And defeat under conditions of complexity occurs far more often despite great effort rather than from a lack of it.

Recently, someone asked me just what all is involved in management.  “There is much to get right,” but I remembered these lists from Gary Hamel’s book, The Future of Management.  Yes, this is a lot to work on, to get right, to master.  But here are the lists for every manager to work on:

• The practice of management entails (has entailed):
• Setting and programming objectives
• Motivating and aligning effort
• Coordinating and controlling activities
• Developing and aligning talent
• Accumulating and applying knowledge
• Amassing and allocating resources
• Building and nurturing relationships
• Balancing and meeting stakeholders demands

• Management processes include (have included):
• Strategic Planning
• Capital budgeting
• Project management
• Hiring and promotion
• Training and development
• Internal communications
• Knowledge management
• Periodic business reviews
• Employee assessment and compensations