Management Assignment

The Checklist Manifesto: Book analysis

Chapter 2: This chapter talks about the importance of checklists in extremely
complex fields like military aviation. The author elucidates this by referring to
the 1935 Boeing crash that occurred at the Wright Air Field in Ohio during a
flight competition held by the U.S army Air Corps.
Boeing Model 299 crash
Boeing’s model 299 had trounced the designs of all its competitors in the initial
evaluations and the competition was a mere formality. The army was so
confident and impressed by it that it had already placed an order of 65 such
bomber aircrafts. But on the eventful day of the competition the ‘Flying
Fortress’ as it was popularly known stopped midair and came crashing down in
a fiery explosion killing the pilot and two other crew members.
An investigation revealed that no mechanical or technical defects were spotted.
It turned out that the extremely complex four engine aircraft ‘had been too
much for the one pilot to fly’ After the contract was cancelled, Boeing nearly
went bankrupt.
But a few planes were still purchased by the army. Together, the test pilots
came up with a novel and unexpectedly simple approach. Instead of extending
the training duration of the model 299 pilots they devised a pilot’s checklist.
They made it simple, brief and concise. With the checklist, the pilots could fly a
total of 1.8 million miles without any accident. Eventually, after the army had
inducted almost 13000 B-17s, it gained an exponential and unprecedented aerial
advantage in WW2.
The two difficulties such cases highlight are: 1) the fallibility of human memory
2) Carelessness, or the habit of laxing and skipping steps even while
remembering them.
4 Vital Signs
The author relates this concept of to the routine of recording the ‘4 vital signs’
in the medical field namely pulse, blood pressure, temperature and respiratory
rate.
The author laments how the use of checklists was prevalent in nursing but not
within doctors, but in 2001 a visionary named Dr. Peter Pronovost started his
checklist campaign addressing the notorious problem of central-line infections,
which brought about the acceptance of the checklists within the community of
doctors worldwide. A year after the checklist was administered in the Johns
Hopkins Hospital, they observed dramatic results. The rate of CLI declined
from 11% to zero. They calculated that one simple checklist had prevented 43
infections and 8 deaths, moreover it saved about 2 million dollars in costs as
well.
“The checklists helped with memory recall and explicitly stated the minimum
necessary steps in a process thereby establishing a higher standard of baseline
performance”, Atul Gawande says.
Keystone Initiative
Each hospital following Pronovost’s program, assigned a project manager to
ensure the checklist was being followed and report back to Pronovost, in a bi-
monthly conference, for troubleshooting.
Pronovost further insisted that the hospitals assign a senior executive to each
unit who were suppose to visit the site once a month at least and hear the
complaints of the hospital staff and help them solve problems. Within weeks
every ICU in Michigan had a ready supply of the soap and drapes they were
lacking before, all thanks to the managerial genius of Pronovost and executive
managers.
Within first 3 months the CLI in Michigan decreased by 66%. In the first 18
months, the hospitals saved an estimated 175 million dollars in costs and more
than 1500 patients.
This can be related to what we learnt in class about Rational Decision Making
When the test-pilots came up with the alternative of a pilot’s checklist this is
what they applied. In this case the limiting factor was novel and unprecedented,
i.e the complexity of the bomber, and since no one other than Major Hill could
have been more experienced and adept at flying this aircraft, the pilots made a
non-programmed decision to make a checklist to address this volatile and
complex situation.
Chapter 3:
In this chapter the author talks about identifying the problems that the
checklists can and cannot help with.
One of the primary jobs of a checklist is to force functions. Forcing functions, a
concept used by engineers, in layman terms, are simple solutions and
reformative measures that force a certain necessary behavior. These are often
simple problems like forgetting a court deadline or forgetting to wear a mask
and follow proper hand washing techniques before a surgery. The checklists
prevent such trivial elementary errors that can develop into huge problems if
ignored by reminding the person and forcing that particular behavior.
“Checklists provide a kind of cognitive net, they catch mental flaws of memory,
attention, and thoroughness inherent in all of us” Atul Gawande, Chapter 3, The
Checklist Manifesto

Two professors who study complexity Brenda Zimmerman and Sholom

Glaberman propose that three types of problems exist:

1. Simple Ex: baking a cake from a mix

2. Complicated Ex: sending a rocket to the moon
3. Complex Ex: raising a child

Can checklists solve these problems with varying levels of complexity is

the question that arises at this point in the book. The author elucidates the
answer to this question with help of an example from the construction
industry

He marvels at the ability of the builders to make such complex structures and
wonders how they know that the building is not going to fall, how do they know
they have the right knowledge and are applying it correctly while managing to
leave room for creativity and unique and unexpected problems that arise during
the process.

Managing complexity requires balancing freedom and discipline, creativity and

protocol, specialized ability and coordination.

Checklists help achieve this by

1. ensuring the elementary but critical things do not get overlooked

Forcing functions like ensuring communication and coordination, division and

acceptance of labour and responsibilities, while keeping in mind not to encroach
over creative space, critical thinking and out-of-the-box ideas to manage
nuances and unpredictable situations
Chapter 4
This chapter deals with the idea of decentralized decision making and pushing
the power out to the periphery away from the center
Hurricane Katrina
On August 29 2005, at six in the morning Katrina hit New Orleans. While more
than half the city was under water, Michael Brown, the director of the Federal
Emergency Management Agency, told a press conference that the situation was
largely under control.
In such a crisis, the author argues, command-and-control system becomes
ineffective. Nevertheless, the federal government wouldn’t yield the power to
the state government, the state government wouldn’t give it to the local
government, and giving it to the private sector was out of the question.
As a result there was anarchy and Orwellian bureaucracy with horrifying
consequences, the author observes.
Ironically, it was a private organization that best responded to such a
catastrophe.
Harvard Kennedy School of Government Case Study on Wal-Mart’s response to
Hurricane Katrina

The CEO of Wal-Mart, Lee Scott gave its employees a free-reign and
implemented the idea of decentralization. As a result Wal-Mart was able get
more than half of the 126 shut-down stores up and running within 48 hours.
Moreover, Wal-Mart’s store managers began distributing diapers water baby
formula and ice to residents without any orders from higher authorities, whereas
FEMA still had not managed to requisition supplies. The managers came up
with a paper slip system providing them with food, sleeping bags, toiletries,
medicines and rescue equipment on credit. The team also opened 24-hour call-
centers which expanded to 80 call-operators, they set up mobile pharmacies
with a plan to provide medication free of cost for evacuees with emergency
needs even without prescriptions along with opening temporary clinics to
provide inoculations against flood-borne diseases. Most importantly, the
company’s logistics team contrived ways to get tractor trailers with food, water
and emergency supplies past the roadblocks into the city. They became the
lifeline of the dying city. They were able to supply food and water to the even
the National Guard before the government.
At the end of this perfect storm Wal-Mart had sent 2498 trailer loads of supplies
and donated $3.5m in merchandise to shelters.
Here if we analyze this situation from a managerial point of view, we can see
that the type of leadership practiced by Lee Scott, based on the use of authority
is the ‘free-reign’ , ‘subordinate-centered’ type of leadership. The power and
authority is highly decentralized and push out to the periphery. Where as the
leadership shown by FEMA and the state government is the ‘autocratic’ kind.
The government was unwilling to distribute power to the state, local bodies and
private organization, and such type leadership is often detrimental in crisis
situations like these.
Furthermore, the approach towards decision making under risk and volatility
should be to devote resources to preparedness and stockpiling inventories,
which is exactly what Wal-Mart did, being a retailing giant, they already had
these pre-requisites and focused on distributing them by making creative, non-
programmed decisions like setting up credit systems, clinics, mobile pharmacies
etc.
Van Halen’s Brown M&M Clause
Many people may assume this to be one of the eccentric demands high-profile
musicians make, but David Lee Roth’s idea to include this clause in his
contracts was a genius business move. One could say it was included as a test
buried somewhere between hundreds of pages. Basically, the contract stated that
a bowl of M&M has to be provided backstage with every single brown one
removed, upon the pain of forfeiture of the contract, with a 100% compensation
to the band.
Firstly, it ensured that the concert promoted had thoroughly read the brand’s
contract.
Secondly, it aimed at reminding everyone to line-check the entire production
every time a brown M&M was found, because he was sure that something
would definitely be amiss or in need of attention. This saved them from many
technical errors like preventing the flooring from sinking in or making sure the
girders could support the weight of the stage.
Rialto Restaurant, Boston
This example elucidates the managerial principle of planning covered in ch 4
The author talks about the fact that a checklist is already in use in most
professions where planned decision making has to take place, like a fine-dining
restaurant’s kitchen. The food there is different from fast-food which involves a
tailorized assembly-line, here food is refined, ever-evolving and customized to
the guests’ specifications. And when it comes to food, recipes are a basic
necessity, and what are recipes if not the most basic checklist. Jody Adams, the
head chef made everyone follow this checklist religiously other than her
“Kitchen Notes” which were basically the corrections that the dishes needed.
There was also a checklist for every customer, VIPs, large guest parties and
everyone’s allergies and preferences had to be taken in to account. At 5 o’clock
every day she would hold a ‘pow-wow’ session where everyone gathers around
and discuss the unanticipated issues like -menu changes, absent staff members,
delays etc. Everyone was given a chance to speak while they made plans to
solve issues. At least, 5% dishes sent for evaluation came back and sometimes
entire recipes had to be changed, this involved taking a corrective action to
produce a desirable change. This is an example of informed or programmed
decision making in an autocratic type of leadership.
Citations
1)Hurricane KatrinaWal-Mart's response to Hurricane Katrina: Striving for a public-private
partnership (sequel). HKS Case Program. (n.d.). Retrieved October 26, 2021, from
https://case.hks.harvard.edu/wal-marts-response-to-hurricane-katrina-striving-for-a-public-private-
partnership-sequel/.
2) Zeveloff, J. (2016, September 6). There's a brilliant reason why Van Halen asked for a
bowl of m&ms with all the brown candies removed before every show. Insider.
Retrieved October 26, 2021, from

https://www.insider.com/van-halen-brown-m-ms-contract-2016-9.

Riya Lalchandani

BBA LLB SEC-E