Sunday, 16 October 2011

The Checklist Manifesto

A study conducted to analyse why people fail to perform in complex situations identified two major influencing factors -Ignorance and Ineptitude.

Ignorance - The lack of knowledge. This could be due to lack of experience or it could be in rare, complex or unfamiliar situations.

Ineptitude - The lack of application. In other words, the skills and expertise to solve a particular problem are available and are known, but we either fail to apply them or apply them inefficiently.

The former requires more research and it's attributed to the lack of training. For the latter, there is already enough training and expertise in place, but we still fail to apply it successfully. But, why?

In health care, vital signs are measured to assess the most basic body functions. Though the number of vital signs to be measured may vary according to the situation, the four basic ones are body temperature, pulse rate, blood pressure and respiratory rate. In most cases, when three of the vital signs are normal, the fourth one also tends to be normal. When we begin to notice that most of the times the fourth sign is good, we stop checking it when the first three signs are good. And this is not just in health care. Here's another example.

A few years back when I was living in Hyderabad, we were using a padlock for the main door of our apartment. This lock was broken. But it was broken in such a way that you could actually make it look like it was locked even when it was not. Just press it and it would hold together nicely. To unlock it, all you needed to do was just pull it down and no key was required. Though we knew how risky this was, we used this lock whenever we forgot to handover the key to the last leaving housemate. We used it a couple of times and never had any issues.
In the initial days we warned ourselves not to keep using it, but as the days passed, nothing bad happened and we slowly ignored the risks and took it for granted. Everything was good except for the day when our house was robbed! The robber didn't even have to break the door to get in. You could call it carelessness, stupidity or whatever, but the loss is a loss.

Then, there is this human memory which is fallible by nature and a simple fact that many of us don't want to accept. How many times have we been surprised by or surprise others with this question, 'how could you forget such a simple thing?'. It's typical of how our memory is. Our memory cannot retrieve everything whenever and wherever we want. The more we learn, the more information the brain has to store and the more it stores, the tougher it gets to retrieve something quickly, especially in a highly pressurized environment. So in adverse situations, sometimes the brain fails to retrieve or remind us even the most basic stuff. These are some typical examples of being inept.

Experts in various industries started realizing that to tackle ineptitude, just skills and expertise alone would not be sufficient. It requires something more than that.

Dr.Atul Gawande an endocrine surgeon at Brigham and Women's hospital in Boston who has done some extensive research in this area believes that the answer could be 'The Checklist'.

In the field of medicine, checklists are not completely new. They have been used on and off at different levels - for example, some nurses maintain a checklist to ensure that all the vital signs are tested. Dr.Peter Pronovost, one of the early advocates of checklists in the intensive care unit has reported that his checklists have saved 1500 lives and $100 million in the State of Michigan over a period of 18 months*.

In spite of these results, checklists are not popular and not widely accepted. That's possibly because of the way we define what checklists are for and who should be using them.

Ask yourselves a question, 'who do you think should be using a checklist in the real world?'

Was your answer just amateurs like beginners in a profession or for some one in a learning curve; or did it also include some one with extensive experience and specialization like a 'chief surgeon in an hospital who has some 15-20 years of experience in surgery' or 'a pilot with some 20,000 hours of flying experience' ?

If your answer didn't include the latter, then ask yourselves why you thought that an experienced professional would not need a checklist. If your answer did include both novice and experienced alike, then have you ever used or are using a checklist currently? If not why? Answering these questions would probably explain why checklists are not popular and why they are not widely accepted.

We often think checklists are silly. For the experienced, checklists are just a waste of time and its embarrassing to have one.

Few years back, when I was a Senior Tester I failed to test a basic business condition in the application. When the issue was escalated, I had no reason to explain why I had missed it. I just forgot to include the condition in the test case. As simple as that. Thinking about it now, I realize a checklist could have prevented it.

One might wonder what if we failed to include an item in the checklist itself. For this, Gawande insists that the checklist should be discussed with all the stake holders, optimized and made sure it is efficient. Moreover a checklist should neither be too long nor too short. It should be apt to the situation. When more than one pair of eyes are involved in preparing a checklist, chances are less for making mistakes in the checklist itself. Of course there will be exceptions and that's why Gawande suggests that the checklists should be inspected often and made sure they are relevant to the current situation.

During his research on checklists, Gawande observed that checklists have actually been in use for a long time now in other major industries like Aviation and Construction. The Aviation industry in particular has extensive checklists that are well organized and followed effectively. Gawande explains how emergency checklists helped experienced pilots to ditch the US Airways Flight1549 successfully in the Hudson river, saving all 155 on board resulting in the incident to be known as the Miracle on the Hudson .

Eventually when Gawande started working with the WHO on an initiative to improve safety in surgical processes around the world, he put forth the idea of using a checklist that could potentially save millions of lives without requiring the invention of any new medicines or technology. The Surgical Safety checklist was tried in 6 hospitals around the world to see how effective it would actually be. The outcome of the study indicated that, 'Postoperative complication rates fell by 36% on average and death rates fell by a similar amount'. More information on this study can be found here.

Below is the 2009 edition of the Surgical Safety checklist from the WHO. Some of the questions like - patient name and identity, operation procedure would sound so basic. But the reality is, even in the most advanced hospitals these basic things are often missed.

Dr.Gawande has observed multiple instances where checklists have repeatedly saved lives, even in the most improbable situations.

One such case was reported in this article 'The Checklist' - the scintillating story of a three year old girl who almost drowned in an icy fishpond in Alps.

The article published in 2007 in 'The New Yorker' was the forerunner of this book - 'The Checklist Manifesto'. An interesting and worthwhile read.

Saturday, 15 October 2011

Mulholland Drive

Four years back when i saw Memento I thought it was one of the most complicated movies ever made.Today after watching David Lynch's Mulholland Drive i feel this could be the big brother of Memento.

I think Mulholland Drive is non-linear, but then i havent understood enough to confirm whether the narration is linear or not. The movie made some sense only after reading the wiki entry. Actually i didn't sit and analyze after the movie, but i dont think analyzing would have helped as such.

The movie was entangled and complex, and i found it tough to interpret. May be there is no single interpretation for the movie or may be there is no interpretation at all. Even the director has actually refused to comment on the interpretation and symbolism of the movie*. One of theories in Wikipedia speculates that the movie could be just a Mobius Strip with no beginning or end.

Anyways if at some point of time, if you are planning to watch Mulholland Drive, here is a cheat sheet* that could help you to understand the movie better.

  1. Pay particular attention in the beginning of the film: At least two clues are revealed before the credits.
  2. Notice appearances of the red lampshade.
  3. Can you hear the title of the film that Adam Kesher is auditioning actresses for? Is it mentioned again?
  4. An accident is a terrible event — notice the location of the accident.
  5. Who gives a key, and why?
  6. Notice the robe, the ashtray, the coffee cup.
  7. What is felt, realized, and gathered at the Club Silencio?
  8. Did talent alone help Camilla?
  9. Note the occurrences surrounding the man behind Winkie's.
  10. Where is Aunt Ruth?
Good luck and Happy movie watching!!!

*Contained within the original DVD release is a card titled "David Lynch's 10 clues to unlocking this thriller - Source wiki.

Friday, 14 October 2011


"I took his heart in my hand and began compressing it - one-two-three-squeeze,one-two-three-squeeze -to keep his blood flow going to his brain" **

I think Doctors, Surgeons in particular is one of those professions that could make a man feel extremely powerful and arrogant or meek.

Just imagine holding a heart in the hand (literally) and squeezing it to give back its life. Every time when a life is saved from a similar improbable situation, it could make them feel like a creator. But on the contrary, when a life is lost right in front of their eyes, in their hands, where their knowledge and expertise are mere spectators, they could become the most humblest, realizing how Death makes one null instantly.

** - Excerpt from "The Checklist Manifesto" by Atul Gawande

Friday, 28 January 2011

Dhobi Ghat abstract.
Abstract like our life.
Life that started without meaning,
just with people,
people who are nothing but just characters.
Characters with their limitations,
with some that we adore,
and some that we despise.

But its the moments,
the moments that we share with these,
that gives meaning.
Meaning to the relationship,
relationship that defines life,
the life that started as abstract.

Sunday, 16 January 2011

So... when was it

So when was the last time you actually wrote something more than a line or two, i mean not typing, mere writing.The last time i remember was a few discreet lines of notes that i took during my project meeting.Before that i guess its again another few lines of notes during a training sometime early last year.

Thinking about it, its been years together since i wrote something continuous, something long.Long and continuous like the way we write exams in college.Probably that's the last thing i wrote continously for hours together i guess.

When i happened to write today a line of 5 words for about 44 times continuously i realized how my hands have actually forgot to write for years together now.

Its not that i miss it badly(though its nice to write at times),it just that my hands are not able to actually afford it now. I started feeling a bit of pain or uneasiness after i started writing a few times.There was a discomfort for sure.

Don't know if this is because i had to write the same sentence again and again repeatedly or is it because of the lack of physical writing or lack of exercise.

I can still type for long hours and carry a decent amount of weight, so i can excuse lack of exercise. Given that, I wish its because i was writing the same thing, but i guess its more because of not writing for a while now. Its just five years from college and i seldom write already. I wonder how the future is going to be.

Children of the future don't have to know how to cursive write, just CTRL+I and CTRL+B is what all they need. Probably they may not even have to type, just tell how they want it.

Technology is the Wor(l)d.

Thursday, 13 January 2011


The difference between a Nightingale and a Chicken is just not their voice alone. Looks like there is more to it. In an article about songbirds, the author explains why some are special than the other.

“Vocal patterns are hardwired in animals like chicken and frogs because they do not have to hear to be able to vocalize” remarks Dr. Ofer Tcernichovski

A nightingale, the Mozart or MS Subbulakshmi among the avians, on the other hand, has over 200 different songs in its repertoire. And it can improvise. First it might sing the note sequence ABCDEF and a while later it might sing BEDF

And it doesn't stop there.

Songbirds, just as humans, learn from listening and the younger ones learn and create more music than the older ones. Analysis of the brain circuitry (neuro-anatomy) of some songbirds shows a remarkable similarity with those of we humans.

It makes me wonder if it is from the nature humans learned to identify musical notes and its compositions.
Probably nature was the first teacher.

Thanks to wikimedia, you can listen to a song of Nightingale here
The full article on songbirds is here.

Monday, 3 January 2011


In matters of style, swim with the current; in matters of principle, stand like a rock. - Thomas Jefferson

The above quotes looks fancy to say, but its not that easy to stand like a rock when it comes to principles. When the incentives are high, let it be positive or negative, people could get easily tempted to compromise or give up.

When Hashim Amla was offered to play for South African cricket team, a dream for any sports man, he stood for his principle. He requested the alcohol logos to be removed from all his playing gears and he is successful so far*.

The point here is not about what his principle is,but the courage to speak up and stand for the principle. His stance is quite impressive and appreciable.

Just in case if he happens to be at crossroads in the future,where he has to give up one of them, it would be interesting to see his stance.

Next time when you see Amla playing cricket, you might understand why his t-shirt alone is different from rest of his team mates.


Saturday, 1 January 2011


சென்றாண்டுக்கு நீ மற்றொரு ஆண்டு
நேற்றைக்கு நீ இன்னது ஒரு நாளை
வெள்ளிக்கு என்றைக்கும் சனி
மணிக்கு வெறும் நொடி
மனிதனுக்கு மட்டும்
நீ தனி.

முதன்மையை வழிபடும் மானிடனின்
மற்றும் ஒரு முதன்மை திருவிழா.