I mentioned earlier about “The Checklist Manifesto” book. The post was originally written in Portuguese but you can find a Google translation here. In this post I mentioned about the use of checklist in surgeries and other medical procedures and how we could use checklists in the IT environment.
I was reviewing my Kindle highlights for this book and found this highlight:
Surgery has, essentially, four big killers wherever it is done in the world: infection, bleeding, unsafe anesthesia, and what can only be called the unexpected. For the first three, science and experience have given us some straightforward and valuable preventive measures we think we consistently follow but don’t. These misses are simple failures — perfect for a classic checklist. And as a result, all the researchers’ checklists included precisely specified steps to catch them. But the fourth killer — the unexpected — is an entirely different kind of failure, one that stems from the fundamentally complex risks entailed by opening up a person’s body and trying to tinker with it. Independently, each of the researchers seemed to have realized that no one checklist could anticipate all the pitfalls a team must guard against. So they had determined that the most promising thing to do was just to have people stop and talk through the case together — to be ready as a team to identify and address each patient’s unique, potentially critical dangers.
Surgery has, essentially, four big killers wherever it is done in the world: infection, bleeding, unsafe anesthesia, and what can only be called the unexpected. For the first three, science and experience have given us some straightforward and valuable preventive measures we think we consistently follow but don’t. These misses are simple failures — perfect for a classic checklist. And as a result, all the researchers’ checklists included precisely specified steps to catch them.
But the fourth killer — the unexpected — is an entirely different kind of failure, one that stems from the fundamentally complex risks entailed by opening up a person’s body and trying to tinker with it. Independently, each of the researchers seemed to have realized that no one checklist could anticipate all the pitfalls a team must guard against. So they had determined that the most promising thing to do was just to have people stop and talk through the case together — to be ready as a team to identify and address each patient’s unique, potentially critical dangers.
Dr. Gawande found out that in order to address the unexpected, checklists should not only include task checks but also communication checks. Dr. Gawande got to that conclusion visiting a 700,000-square-foot office and apartment complex construction site with between two to five hundred workers on-site on any give day managed by a man called Finn O’Sullivan. The volume of knowledge and degree of complexity O’Sullivan manages is impressive and it was as monstrous as anything Dr. Gawande had encountered in medicine. Here’s the explanation:
It was also a checklist, but it didn’t specify construction tasks; it specified communication tasks. For the way the project managers dealt with the unexpected and the uncertain was by making sure the experts spoke to one another — on X date regarding Y process. The experts could make their individual judgments, but they had to do so as part of a team that took one another’s concerns into account, discussed unplanned developments, and agreed on the way forward. While no one could anticipate all the problems, they could foresee where and when they might occur. The checklist therefore detailed who had to talk to whom, by which date, and about what aspect of construction — who had to share (or “submit”) particular kinds of information before the next steps could proceed. The submittal schedule specified, for instance, that by the end of the month the contractors, installers, and elevator engineers had to review the condition of the elevator cars traveling up to the tenth floor. The elevator cars were factory constructed and tested. They were installed by experts. But it was not assumed that they would work perfectly. Quite the opposite. The assumption was that anything could go wrong, anything could get missed. What? Who knows? That’s the nature of complexity. But it was also assumed that, if you got the right people together and had them take a moment to talk things over as a team rather than as individuals, serious problems could be identified and averted.
It was also a checklist, but it didn’t specify construction tasks; it specified communication tasks. For the way the project managers dealt with the unexpected and the uncertain was by making sure the experts spoke to one another — on X date regarding Y process. The experts could make their individual judgments, but they had to do so as part of a team that took one another’s concerns into account, discussed unplanned developments, and agreed on the way forward. While no one could anticipate all the problems, they could foresee where and when they might occur. The checklist therefore detailed who had to talk to whom, by which date, and about what aspect of construction — who had to share (or “submit”) particular kinds of information before the next steps could proceed.
The submittal schedule specified, for instance, that by the end of the month the contractors, installers, and elevator engineers had to review the condition of the elevator cars traveling up to the tenth floor. The elevator cars were factory constructed and tested. They were installed by experts. But it was not assumed that they would work perfectly. Quite the opposite. The assumption was that anything could go wrong, anything could get missed. What? Who knows? That’s the nature of complexity. But it was also assumed that, if you got the right people together and had them take a moment to talk things over as a team rather than as individuals, serious problems could be identified and averted.
So next time you design a checklist, remember to include not only task checks but also communication checks.
Jason Yip just reminded me about the “under pressure” situation:
When people are pressured to meet targets they have three ways to respond: Improve the system Distort the system Distort the data
When people are pressured to meet targets they have three ways to respond:
Fonte: Jason Yip’s blog
Yip is reading what seems to be a very good book on variation, Understanding Variation: The Key to Managing Chaos. In this book the author Donald J. Wheeler, according to an Amazon.com reviewer, “provides managers a rational way to look at daily, weekly, monthly, and yearly figures and tell whether the actions they take have resulted in improvement”. It seems to be a very interesting book from what Yip’s been posting:
Understanding Variation
Well, another book for my future reading list. Hopefully it will have a Kindle version soon.
Going back to the “under pressure” topic:
That’s a good way to see the possible outcomes of a group of people under pressure.
I like to use balloon as a metaphor to help understand under pressure situations.
Balloon
Here’s why:
Esse post é só para fazer um link para um texto muito interessante do Akita sobre vários temas que ele e eu temos conversado ultimamente sobre gestão de desenvolvimento de produtos de tecnologia:
Off-Topic: O Manifesto Ágil, ou Como se Tornar o Google
Akita recentemente me deu algumas dicas muito legais de livros:
- Linked: How Everything Is Connected to Everything Else and What It Means- The Black Swan: The Impact of the Highly Improbable- The Misbehavior of Markets: A Fractal View of Risk, Ruin & Reward
As dicas todas vem do post Off-Topic: Matando a Média do blog do Akita.
Tem a ver com temas como caos, complexidade e emergêngia de comportamento organizado em sistemas complexos, temas esses que têm aplicação em áreas tão diversas como mercado econômico, origem da vida, administração de empresas, organização celular, sociedades, entre outras. É muito fascinamente. Há até relação entre a teaoria de sistemas complexos adaptativos e as metodologias ágeis. Outro texto sobre essa relação não está mais disponível no endereço original, mas sobrou uma cópia no cache do Google.
Mas enfim, esse post era para falar sobre audiobooks, então vamos lá. Com tantas coisas interessantes pra ler, o difícil lé achar tempo. Foi quando Akita me deu a dica de usar audiobooks. Estou ouvindo o livro Linked e realmente é ótimo. Dá para aproveitar momentos em que não se consegue ler por limitações físicas, por exemplo, quando se está no tr^nsito, ou quando se está comendo sozinho. Esses são excelente momentos para o audiobook, e de quebra, damos oportunidade para nosso ouvido praticar ouvir inglês.
Fica a dica para aqueles que querem ler mais do que conseguem!
