Thought of the day, 2010-11-10

“If one is the master of one thing and understands one thing well, one has at the same time insight into and understanding of many things.”
-- Vincent van Gogh

Thought of the day, 2010-11-06

"The world cares very little about what a man or woman knows; it is what a man or woman is able to do that counts." —Booker T. Washington

Thought of the day, 2010-10-19

“Lasting change is possible only when the need for change is both understood and internalized.”
—Denis Waitley

Thought of the day, 2010-09-23

"If I had eight hours to chop down a tree, I’d spend the first six sharpening the ax." —Abraham Lincoln

Thought of the day, 2010-09-20

"The difference between a successful person and others is not a lack of strength, not a lack of knowledge, but rather a lack of will." -- Vince Lombardi

Thought of the day, 2010-09-08

"We’re going to relentlessly chase perfection knowing full well that we will not catch it, because perfection is unattainable.  But we are going to relentlessly chase it, because in the process, we will catch excellence.  I’m not remotely interested in being good." – Vince Lombardi

Thought of the day, 2010-08-18

“A lifetime can well be spent correcting and improving one’s own faults without bothering about others.”
-- Edward Weston

Thought of the day, 2008-08-16

Courtesy of Brian Tracy's daily quote from yesterday:

"In the absence of clearly-defined goals, we become strangely loyal to

performing daily trivia until ultimately we become enslaved by it."

-- Robert Heinlein

Book review: The Checklist Manifesto by Atul Gawande

This is a great book that I would recommend anyone in the quality field read.  The key message of the book is that the complexity we face in our jobs is immense, and no amount of learning can help error-proof our jobs as much as well-designed checklists can.  Dr. Gawande follows two main professions and how checklists affect their jobs: airline pilots and surgeons.  He starts out by showing how the first implementation of checklists in each of these areas appeared: for airline pilots, the crash of the first B-17 test flight in the 1930s; for surgeons, the invention of a checklist to prevent IV line infections in the 2000s.  He shows how these checklists were for fairly “simple” problems (ensuring all airplane systems are in the right configurations at takeoff or taking all the proper steps to prevent contamination during IV line penetration), and then goes on to describe two other classes of problems that checklists can be applied to: complicated problems (a collection of simple problems) and complex problems (many independent variables and outside influences, a great number of which may beyond prediction).  While simple problem checklists tend to focus on ‘do this, do that’, complex problem checklists also focus on communication.  He illustrates this with the checklists required to build a skyscraper: first there is the Gantt chart that is a summation of checklists, but then there is the bin list of deviations (abnormalities) that the experts have to come in to evaluate and agree upon the correct next steps – but do so in an expeditious manner to keep the overall project on schedule.

Before he talks about the formation of more powerful checklists in his surgical field, Dr. Gawande highlights some of the properties of checklists.

• The checklists have to be unambiguous.  If it’s a “READ-DO” checklist (those that address simple problems), the DO items need to be simple to execute.  If it’s a “DO-CONFIRM” checklist (focusing on communication, letting the team be accountable for ensuring all necessary steps are completed), the CONFIRM needs to have a clear single yes/no answer.
• If a checklist needs to be followed, it should be followed – not analyzed.  If a plane is executing a recovery maneuver from a depressurization event, the pilots should be executing the checklist, not trying to figure out whether a depressurization alarm is really going off or is just malfunctioning.  (There will be always be time later to deal with it if it was malfunctioning; if not, precious time has been wasted troubleshooting rather than reacting.)
• Checklists should also be updated frequently with key learnings – not only are post-mortems very powerful events, but good checklists incorporate learnings from other people’s failures.  (The example he uses here is other well-known value investors learning lessons from Berkshire Hathaway’s failed investment in Cort Furniture; and yes, he cites a number of investing houses, both value and VC, that use checklists to help guide their investing.)
• Checklists for complex problems come with a caveat: if written properly, they actually promote teamwork (between pilot and co-pilot, between surgeon, nurse and anesthesiologist), which leads to lower error rates from improved communication and accountability.

When Dr. Gawande spearheaded the development of surgery checklists for World Health Organization, there was an initial disaster in the implementation – the first checklist he tried was too vague, and frustrated the doctors using it (including himself; he chose his team for the first pilot of the checklist).  But he learned a couple of key take-aways:

• The checklist should only have the “killer items”.  Even though operating room fires happen in surgery and are a major risk, their frequency is so low that having steps for prevention in the checklist slowed it down beyond his target execution time (no more than a minute per checklist execution).  But even though there were other steps for ensuring it was the right patient getting the right surgery, the bad publicity from such a mishap was worth doing a quick triple-check before starting the procedure.  So he used FMEA-style criticality (severity x occurrence) with an “is it a low-hanging fruit” approach to decide whether or not to include specific items.
• He made sure that he trained the management (hospital chief of staff, chief surgeon) when the checklist was implemented at each hospital, so that each facility could implement it within their own culture and structure.

Once his checklists were implemented, they saw improvements across the range of hospitals that were part of the pilot implementation (4 "high income" and 4 "low income" hospitals).  Even the most  highly accomplished hospitals (such as University of Washington Medical Center in Seattle) saw enormous improvements in avoiding “simple” errors that could lead to disaster.  And despite still having detractors (20% of the surgeons involved in an 8-hospital pilot in 2008 still didn't feel the checklists were necessary), the value was uniformly there (33% to nearly 50% reduction in post-surgical complications at each of the pilot hospitals); and even the detractors saw some of the benefit (93% of the surgeons in the pilots said that if they were going into surgery as a patient, they would want the checklists used for their surgery).  This demonstrates that even in a high-knowledge, high-expertise, fast-paced environment, checklists can be implemented in a way that minimizes bureaucracy, even improves efficiency (the time to complete the checks actually sped up surgeries because later double-checks weren’t needed) and delivers the ultimate benefit in the end. 

There are numerous parallels that can be gleaned from this book and applied to my business in semiconductor materials quality:

• the power of post-mortems relying on improving the checklist the next time around so others can benefit from the previous mistake;
• the use of checklists to promote expert review, not just execution of menial tasks;
• and in the larger picture, the fact that a well-designed checklist can provide a benefit in eliminating errors from any project no matter how complex (semiconductors are very complex, but last I checked, a patient under the knife in a surgical ward is infinitely moreso, in addition to far less predictable).

Dr. Gawande's work show great opportunities for application in a wide range of businesses (product and service) for driving error elimination toward achieving the goal of Quality Incident Free.

No Barriers

Today, our company sponsored a talk by adventurer and speaker Neal Petersen.  His story is amazing, but the takeaway lessons he provided were even more profound.


Growing up as a black man in Apartheid South Africa, Neal was not disadvantaged.  Coming from a poor family, Neal was not disadvantaged.  Having the physical handicap of a deformed hip socket, Neal was not disadvantaged.  In fact, Neal counted these three challenges as his three major advantages in life.  Through each challenge, Neal grew as a person and found more of himself: he developed the tenacity to go through, over or around the challenges to achieve his dreams.  Where others saw barriers, he saw "No Barriers - Only Solutions".


He decided at a young age that he wanted to be a sailor and to own his own boat.  He read everything he could on sailing.  He waited out on the dock as one of his heroes from his reading sailed into town - and that captain patiently answered all of Neal's questions as Neal helped him moor the boat.  To get real experience at sea, Neal pestered people at the local yacht club until he found someone to take him out sailing.  Then he started to work around the ships - first diving for lost items, then cleaning ships.  Early on, he bought a sailing jacket, which became a motivating symbol: it was his goal to be wearing that jacket when he captained his own boat someday.  Through a succession of jobs, he remained focused on his end goal of obtaining a boat.  It didn't matter whether he particularly liked the job or not, because the jobs were stepping stones to get to the destination.


Eventually, he built his own boat, a 38-footer, and entered it in a race from Plymouth, UK to Newport, Rhode Island.  During the race, he was hit in the head with a boom during a storm, and split his eyebrow open.  He didn't have a medical kit on board, but in a great moment of problem solving, he used a clothes pin to apply pressure to stop the bleeding and seal the wound.  Later, when he wanted to enter the Around Alone yacht race circumnavigating the globe, he needed a new boat since the minimum length for participation was 40 feet.  After failing at fundraising, he created his own solution by lengthening his boat by two feet.  While he didn't complete the 1994-95 race, he did finally succeed in the 1998 race.


There's a lot more to his story than I could possibly summarize here... so you may want to go read his autobiography, Journey of a Hope Merchant.  (I plan to!)  But I'm taking a few key things away from his story:

1. We are only limited by our dreams.  Dare to think big, to set Big, Hairy, Audacious Goals (BHAG), and be prepared to have to work hard to achieve them.
2. There are no barriers, only challenges.  It might take some work to find the solution, but there are solutions that can be discovered - or made.
3. Constancy of purpose.  Neal did not jump from BHAG to BHAG, but stayed focused on what his true goal was.  And utilized the smaller goals along the way as a means to move closer to the ultimate objective.
4. Creativity.  Using a clothes pin as a bandaid is not only creative, but very practical.  What can we do with the simple, every-day things around us if we just look at them in a different way?
5. Take the time for others.  The fifteen minutes of attention that the captain gave the 14-year old boy encouraged and enabled Neal to pursue his dreams, even if the captain didn't realize it at the time.

Final thought: Neal started his talk by bringing down a old, beat-up, hard-sided trunk down to the speaker's dais.  He asked a simple question to start: do you have baggage, or do you have a treasure chest?  If you view life as No Barriers - Only Solutions, you'll find that there are a wealth of riches in your treasure chest...

What I've Learned...

I've been very fortunate to work with a number of different cultures and companies in my 9+ years in the post-graduate workforce.  I've gotten to travel to Europe, Asia and the Middle East to solve problems or help others achieve their goals.  On every business trip, we have the policy of "take one thing, bring back three".  Go with your eyes and ears and mind open, because even if you're going as the expert or the teacher, there's so much more to be learned just from being observant.

The same applies outside of work as well.  Whether it's intentional personal development activities, or travel for pleasure or the everyday interactions with family and friends, there are always opportunities to learn.

And with knowledge comes something even more profound: the opportunity to share that learning with others, so the new knowledge is multiplied, not just added.  The goal of this blog is to allow what I've learned to be shared, so that others may benefit from the amazing and wonderful things I've seen...