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Sketched Book – The Checklist Manifesto: How to Get Things Right – Atul Gawande

Posted: - Modified: | kaizen, visual-book-notes

Atul Gawande’s The Checklist Manifesto: How to Get Things Right (2009) emphasizes the power of checklists for improving reliability. Errors creep in when we forget things entirely or skip over things we should have done. In medicine, these errors can be fatal.

Gawande draws on his experience as a surgeon, the research he conducted with the World Health Organization, and insights from construction, finance, and other industries that take advantage of checklists to improve processes.

The book discusses ways to address the cultural resistance you might encounter when introducing a checklist. It recommends making sure that checklists are precise, efficient, short, easy to use, and practical. You need to develop a culture of teamwork where people feel that they can speak up as part of a team. You may even need to modify supporting systems to make the checklist doable.

I’ve sketched the key points of the book below to make it easier to remember and share. Click on the image for a larger version that you can print if you want.

I like the reminders that you should design your checklists around logical “pause points,” keep checklists focused on the essentials, and treat people as smart instead of making the checklist too rigid.

The book distinguishes between “Do-Confirm” checklists, which allow experienced people to work quickly and flexibly with a confirmation step that catches errors, and “Read-Do” checklists, which walk people step-by-step through what they need to do. I’m looking forward to applying the book’s tips towards systematizing my sharing. For example, I’m working on a YASnippets in Emacs that will not only display a “Read-Do” checklist for doing these sketched notes, but will also assemble the links and code to do the steps easily. Sure, no one will die if I miss a step, but I think discipline and thoroughness might yield dividends. I also want to develop a good “Do-Confirm” process for writing and committing code; that could probably save me from quite a few embarrassing mistakes.

I’m interested in the diffusion of ideas, so I was fascinated by the book’s coverage of the eight-hospital checklist experiment the WHO conducted. The book discussed the challenges of getting other people to adopt checklists, and adapting the checklists to local conditions. Here’s an excerpt:

… By the end, 80 percent reported that the checklist was easy to use, did not take a long time to complete, and had improved the safety of care. And 78 percent actually observed the checklist to have prevented an error in the operating room.

Nonetheless, some skepticism persisted. After all, 20 percent did not find it easy to use, thought it took too long, and felt it had not improved the safety of care.

Then we asked the staff one more qusetion. “If you were having an operation,” we asked, “would you want the checklist to be used?”

A full 93 percent said yes.

There’s a comparison to be made between the reluctance of doctors to accept checklists and the committed use of checklists by pilots and builders. I came across a quote from Lewis Schiff’s Business Brilliant in this comment by Rich Wellman:

The following quote sums up the essential difference between a checklist for a doctor and a checklist for a pilot.

“How can I put this delicately? Pilots are seated in the same planes as their passengers. Surgeons are not under the same knives as their patients. To paraphrase an old joke, surgeons may be interested in safety, but pilots are committed.”

So checklists are a good idea when you’re dealing with people’s lives, but what about the rest of us? Checklists are good for catching errors and building skills. They’re also great for reducing stress and distraction, because you know that the checklist is there to help you think. That’s why packing lists are useful when you travel.

Already a fan of checklists? Tell me what you have checklists for!

Somewhat related:

Shrinking my learn-do-share-review cycle

Posted: - Modified: | learning, sharing

Sometimes I read too much without doing anything about what I learn. By the time I get around to applying ideas, my memory is fuzzy and I have to dig up my notes anyway. Sometimes I never get around to applying what I've learned.

Sometimes the tasks on my TODO list are too big to fit into a single session of thinking-about or doing, so I end up procrastinating them. Or sometimes I do them, but I feel like I'm wandering around.

Sometimes I let myself focus too much on learning and doing, moving onward. By the time I want to share what I've learned, I feel like there's just so much background I need to cover before people can get to the point of being able to do things. Or I've forgotten what those first crucial steps were.

Sometimes I get so caught up in learning, doing, or sharing, that I forget to spend time thinking about how I'm doing things. I've been keeping a journal, but the entries are often very short – just keywords that describe what I did, without notes on how I might do it better.

Have you felt like that too? Tell me I'm not the only one who has to think about the balance. =)

I've been working on reducing waste by shortening this learn-do-share cycle. Instead of spending a week reading five books about a topic, I might spend a couple of hours reading one book, extracting the key points from it, and identifying one or two actions I can try. Instead of doing an exhaustive search to find the best tool for what I want to do, I'll do a quick search, pick one, try it out, and then use that experience to help me learn. Instead of waiting until I feel confident about a topic (or even until I've worked out all the bugs), I'll share while I learn. Instead of trying to fill in all the gaps between where a beginner might start and where my post ends up, I write just the part that's fresh in my memory, and then I might fill in other gaps when people ask.

In fact, I've been moving towards posting more of my rough notes using index cards. That way, I don't even have to wait until I've summarized the cards into a more coherent blog post. They're out there already, easy to link to or share in conversations. I still suspect it's a bit of a firehose of incoherence, but I'm pleasantly surprised that some people actually find them interesting. =)

A fast learn-do-share cycle results in a new challenge: What do you do with all these little pieces? This matters for both organizing your own notes and making it easier for other people to learn.

I've been refining my workflows for organizing my index cards, snippets, and posts into outlines. Picking descriptive titles definitely helps. Fortunately, other people have given this challenge of personal knowledge management much thought. Zettelkasten looks like an interesting keyword to research, and I'm looking forward to picking up ideas from other people's techniques.

When it comes to organizing notes for other people, I'm still rather haphazard, but I'm planning to braindump a large outline of questions and use that to create maps for people.

As for the actual division of time, the pomodoro technique isn't part of my habitual workflow yet, but I've heard good things about it. Maybe I'll experiment with a pomodoro-based schedule: one for learning, one for doing, and one for sharing. But my learning cycle's actually a lot more intertwined. At its best, I'm learning as I'm doing (flipping between windows as needed), and the notes that I take while I'm learning and doing (thanks to Org Mode and literate programming!) can easily be shared as a blog post. So maybe each chunk of time represents a topic instead, and I can track whether I'm successfully getting things all the way through to the sharing stage.

Sure, some topics require deeper reflection and integration. For instance, you can't expect instant results from philosophy. But it might be interesting to shorten the distance from learning to action and from action to sharing.

I like the tips in Christian Tietze's "Use a Short Knowledge Cycle to Keep Your Cool" on how to figure out a good "size" for your research tasks so that you don't feel overwhelmed by them. It's a good reminder to iterate: you don't have to research everything before you start trying things out, you don't have to know everything before you start writing, and you don't have to have a perfect process – you can keep improving it.

So we'll see how this works out. For example, this post took me half an hour to research/think about, and another half-hour to write. It could be more interesting if I researched some more (found similar techniques, contrasting opinions, etc.), and it could be richer with more experiments and experiences, but here it is. I can always add to it in the future, or write another post and link to the previous one.

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Tell the difference between diminishing returns and compounding growth when it comes to investing in skills

Posted: - Modified: | learning, productivity

When is it worth improving a skill you're already good at, and when should you focus on other things?

I started thinking about this after a conversation about what it means to master the Emacs text editor. Someone wondered if the additional effort was really worth it. As I explored the question, I noticed that skills respond differently to the investment of time, and I wondered what the difference was.

For example, going from hunt-and-peck typing to touch-typing is a big difference. Instead of having to think about typing, you can focus on what you want to communicate or do. But after a certain point, getting faster at typing doesn't give you as much of a boost in productivity. You get diminishing returns: investing into that skill yields less over time. If I type a little over 100 words per minute, retraining bad habits and figuring out other optimizations so that I can reach a rate of 150 words per minute isn't going to make a big difference if the bottleneck is my brain. (Just in case I'm wrong about this, I'd be happy to hear from people who type that fast about whether it was worth it!)

Some skills seem shallow. There's only so much you can gain from them before they taper off. Other skills are deeper. Let's take writing, for instance. You can get to the point of being able to competently handwrite or type. You can fluently express yourself. But when it comes to learning how to ask questions and organize thoughts I'm not sure there's a finish line at which you can say you've mastered writing. There's always more to learn. And the more you learn, the more you can do. You get compounding growth: investing into that skill yields more over time.

I think this is part of the appeal of Emacs for me. Even after more than a decade of exploring it and writing about it, I don't feel I'm at the point of diminishing returns. In fact, even the small habits that I've been focusing on building lately yield a lot of value.

No one can objectively say that a skill is shallow or deep. It depends on your goals. For example, I think of cooking as a deep skill. The more you develop your skills, the wider your possibilities are, and the more enjoyable it becomes. But if you look at it from the perspective of simply keeping yourself fueled so that you can concentrate on other things, then it makes sense to find a few simple recipes that satisfy you, or outsource it entirely by eating out.

It's good to take a step back and ask yourself: What kind of value will you get from investing an hour into this? What about the value you would get from investing an hour in other things?

Build on your strengths where building on those strengths can make a difference. It can make a lot of sense to reach a professional level in something or inch towards becoming world-class. It could be the advantage that gets you a job, compensates for your weakness, opens up opportunities, or connects you to people. On the other hand, you might be overlearning something and wasting your time, or developing skills to a level that you don't actually need.

When you hit that area of diminishing returns – or even that plateau of mediocrity – you can think about your strategies for moving forward. Consider:

These questions are helping me decide that for me, learning more about colours is worthwhile, but drawing more realistic figures might not be at the moment; learning more about basic Emacs habits is better than diving into esoteric packages; and exploring questions, doing research, and trying things out is likely to be more useful than expanding my vocabulary. I'll still flip through the dictionary every now and then, but I can focus on developing other skills.

How about you? What are you focusing on, and what helps you decide?

Related: Good enough, good, awesome: Thinking about what I want to get to – March 2014

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Break down what people mean so that you can learn from the specifics

Posted: - Modified: | learning

People are vague. You are vague. I am vague. We say things without digging into the details; we often use the first word that comes to mind. This makes sense — otherwise, we'd spend all our time clarifying.

You can learn a lot from digging into things and making them more specific. (… she writes, self-conscious about the use of the vaguest word of all: "things.")

I'm fascinated by the challenge of understanding what people mean. I realized this while looking at it from two different directions:

Let me start with the example of inspiration, because it's something I want to translate into concrete feedback and action. I thought about the different responses I have to things that inspire me.

2015-01-14 Understanding different types of inspiration -- index card #inspiration #breakdown

In what ways do I want to inspire others? How can I get better at that?

Breaking a general statement down into more specific statements helps me learn a lot. I ask myself: "What would I or someone say that captures a different aspect of this?" and I write that down. When I split off different aspects, I can understand those aspects better, and I can understand the whole thing better too.

This technique is good to use for excuses, too.

2015-01-14 Breaking down excuses -- index card #excuses #breakdown

I'm getting better at catching myself when I give an excuse, drilling down with "Why?" and splitting it out into different excuses. (I guess, thanks to my parents' patience, my inner toddler never stopped asking questions.) Then I can check if those excuses match what's getting in my way, or if they don't resonate with me.

A technique I often use is to imagine other people giving those excuses, since sometimes my mind is perfectly willing to ascribe weakness to others even when it gets defensive about itself. ;)

I like sharing these excuses because that might help other people get over theirs. It's often easier to recognize one of your excuses instead of trying to articulate it yourself. "That's it! That's what's getting in my way!" you might say. Or even if you don't find something that completely fits, you might find something close, and then you can ask yourself: "What's missing here?"

For example, what does it mean when someone says something "takes too much time"? What's really getting in their way? Here are some ideas I came up with:

2015-01-14 What does it mean when something takes too much time -- index card #excuses #breakdown

"Too much time" is too vague to address. On the other hand, if you think something takes too much time because you're trying to do something complicated, you might be able to ask yourself: "What do I really need? Can I get away with doing something simpler?" and then reduce the task to something small enough for you to get started with.

Break things down. Find the statement behind the statement or the excuse behind the excuse, and you'll have more to work with. Instead of getting frustrated because you can't come up with one specific answer, come up with lots of them, and then see if you recognize yourself in any of them. Almost there, but not quite? Come up with more answers, maybe combining aspects of the ones you already have. This will not only help you understand yourself, but also understand others–and help others understand themselves and you.

If you find my posts inspiring, would you consider helping me understand more about what kind of inspiration you get and how I can get better at it? If you're reading this because you recognize one of your excuses in it, would you mind figuring out what your more specific reasons are and what could address them? I'd love to hear from you in the comments below. Thanks!

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Learning from people

Posted: - Modified: | connecting, learning

I have a friend who's focusing on learning how to ask better questions. Actually, he realized his goal is probably to ask more questions in the first place, since even simple questions ("Where did you come from?") can lead to interesting stories.

It got me curious about getting better at learning from people. I think this will help me learn about the stuff that I can't find in books because:

I think getting better at asking questions and learning from people involves figuring out:

So that gives me specific things to focus on in terms of learning from others and trying things out myself.

I've been thinking about two aspects of learning from people: working with mentors/coaches/trainers, and having casual conversations with other people.

2015-01-24 Imagining awesomeness at learning from people -- index card #learning #people

Mentors/coaches/trainers

I've been lucky to have many mentors (both formal and informal) who helped me learn how to navigate organizations, find opportunities, build skills, and so on. But I haven't been as deliberate about learning as I could have been. I periodically consider finding a coach for my writing or coding, but haven't taken the leap.

I've heard from people who weren't sure if therapy was working out for them; they couldn't evaluate their progress. I think I'm hesitant for similar reasons. I'm uncertain about choosing candidates, asking useful questions, evaluating the results, and balancing the value and the opportunity cost.

This is precisely the sort of situation for which an opportunity fund is useful, because it pushes me to Just Try Things Out. I'm slowly warming up to that idea, hence all the blog posts thinking out loud.

Here are some areas I'm considering:

For example, an editing experiment might help me develop a better mental model of an editor, forcing me to search for more specific vocubulary (down with "stuff"!), testing to see if something I've written makes sense, and checking for gaps.

2015-01-24 How can I learn from observation feedback -- index card #learning #people

In addition to directly asking for specific help, I might learn a lot from general observation. A friend suggested Atul Gawande's Better for its approach to learning: a surgeon inviting other surgeons to observe him and give feedback, even though this technique was mostly used by people with less experience. It makes sense to do that even when you're more experienced, and it's probably even more useful because people can swap tips or explain things they unconsciously do.

Other people

2015-01-24 Mixed feelings about learning from people -- index card #learning #people

I noticed that I have a strong bias towards online conversations instead of offline ones. Sure, online conversations might be lower-bandwidth or not as nuanced. But blog posts and comments expand the conversations to include other people, and it's easier to follow up on threads of ideas. I think this preference is among the reasons why, compared to several years ago, I now spend much less time going to parties or meetups. Instead, I focus on writing and connecting online.

But I get plenty of writing time already, so maybe I should mix more offline conversations into my life. This would follow the principle that I shouldn't always do what's fun and easy. It makes sense to develop skills and routines in other areas as well. For example, I can imagine getting better at cultivating acquaintances through shared activities like cooking at Hacklab and hosting board game afternoons. I can test and refine several quick stories for small talk, which frees me up to focus on learning more about the other person through questions. It's like the way foreign language learners can boost their feeling of fluency by anticipating common questions ("Where are you from?" "What do you do?") and practising answers to those.

I think that getting better at asking questions and learning from people starts mostly from getting to know people as individuals. What makes them different? What's interesting about their lives? There's always something to find. The next step after that is to gradually build the acquaintance or the friendship through things like lunches or get-togethers. It makes sense to open my world so that I can come across good people. I enjoy their company, I grow in helping out, and I learn from the conversations with them and the mental models of them.

More thoughts

2015-01-25 Learning from people -- index card #learning #people

Thinking about this, I realized that I'm not bad at learning from people. I'm pretty good at learning from books, blogs, and online conversations, which is why I rely on those so much. But there are some aspects of learning from people that I can improve, and I can play around with those without cutting too much into the time I spend learning in other ways.

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Learning from artists: making studies of ideas

Posted: - Modified: | drawing, learning, writing

When people are starting out with sketchnoting, it's helpful to remember that sketchnoting's about "ideas, not art" (as Mike Rohde says in The Sketchnote Handbook). It's easy to get intimidated by the visually-impressive sketchnotes people post, so the reminder is useful.

I've been using sketchnotes to explore my own thoughts instead of recording other people's content. I like flipping things around, so that got me thinking: What can I learn from the way artists work, and how can I apply that to learning and drawing?

Here are a few ideas:

2015-01-05 What can I learn from artists about learning -- index card

I was particularly curious about this idea of making studies or sketching things in order to experiment with different views or to focus on small parts before composing the whole, so I dug into that further.

2015-01-05 Why studies for drawing or writing thoughts -- index card

The limits I want to address are:

2015-01-05 Quick idea studies -- index card

Using index cards for "studies" of an idea might be a useful technique. Each card is a small chunk, quick to capture, complete in itself, and yet linkable with others. The cards are easier to rearrange. If each card represents one idea or summary, I can keep more ideas in view.

There are trade-offs, naturally. Sometimes the desire to fill a large sheet makes me to sit with a question longer, letting me discover more. Large sheets gives me the ability to draw and describe relationships between ideas. If I have many small chunks, I need to invest more time in summarizing and filing in order to make the most of them.

2015-01-05 Managing my idea pipeline -- index card

Artists might make studies in preparation for a specific work, or they might make studies just because. If I have a specific question in mind, it's easy to sketch my way around the topic and then organize those thoughts into a whole. I'm not as good at managing fragments over an extended period of time, although I'm getting better at linking to and building on previous blog posts.

What can I learn from the way artists keep working on something? Artists might work on a piece for weeks or more, keeping it visible on an easel, taking a step back from time to time, looking at it in different light. They might have several such pieces on the go. I still prefer publishing early instead of waiting until something is a masterpiece. Feedback is great, and even small chunks can be surprisingly useful.

If I improve the way I manage my studies, though, I might get better at refining ideas. I think it's like the way an artists might clip photos or sketch things that have caught their eyes, and then return to that inspiration years later when they think of something that needs it.

Speaking of archives: I've written about index cards before as a way to develop thoughts (2014; much like this post), plan my life (2007), and prevent boredom by writing (2005!). I haven't quite mastered this yet, but I'm getting somewhere. What can I add to this based on this reflection on artists?

I don't do enough zoomed-in focus or variations on a theme yet, I think. Studies aren't just about capturing the gist of a thing so that you can reproduce it later in your studio. They let you minutely observe a specific aspect, and they let you experiment with different ways to portray something.

What would that look like, if I could do it really well? For observation, I might have index cards that focus on sub-topics, like the way I've built up this post from the sub-questions in the illustrations. For variety, I might experiment with visual vocabulary and metaphors, improving my creative expression.

There's also something to be said about sheer practice in exploring thoughts, like the way artists might sketch for sketching's sake. James Altucher recommends coming up with ten ideas a day (also related: his post from 2012). I've been experimenting with setting myself a minimum of five index cards a day. I write the dates for all of them before I start on the first one so that the desire to fill in the blanks pushes me to complete all of them. This usually leads to even more cards as the first set of ideas sparks more questions.

Actually, the challenge isn't generating ideas. Artists never run out of things to sketch – they can look around and find more! I have an archive of ideas I haven't exhausted and a cornucopia that generates more every day.

2015-01-05 Thinking about my archive -- index card

This leads me back to skills that I think might be good to borrow from the art world and adapt to what I want:

What would masters of this be like, and how can I emulate them? I think of Leonardo da Vinci's studies, asking and observing. I think of writers who name and describe things, and in so doing, they help me see better – the way the light behind an object separates it from the background. I may never draw or write a thousandth as well as they do, but I can grow through emulating the way they slow down and pay attention, the way they turn things over and over instead of rushing on.

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Read business books more effectively through application, visualization, or reviews

Posted: - Modified: | learning, reading

This Quora question on "What is the most effective way to read a book and what can one do after reading?" got me thinking about how I read business books and what I do to make the most of them.

2015-01-08 How to use what you read -- index card

2015.01.08 How to use what you read – index card

Application: The best way to get value from a book is to apply it to your life. Reading The Lean Startup is one thing. Using its Build-Measure-Learn loop to run a business experiment is another. Reading Your Money or Your Life is one thing. Calculating your true hourly wage and using that to evaluate your expenses is another. Do the work.

As you apply an idea, you'll probably want to refer back to the details in the book, so it's good to keep the book itself handy. Write notes about your questions, ideas, TODOs, experiences, and follow-up questions.

Visualization: Not ready to do the work yet? Slow down and think about it. Imagine the specific situations where you would be able to apply the ideas from the book, and how you would do so. What do you need to learn or do in order to get there? See if you can get closer to being able to act on what you've learned.

Spend some time thinking about how the ideas in the book connect to other books you've read or ideas you've explored. What do they agree with or disagree with? Where do they go into more detail, and where do they summarize? What new areas do they open up?

Think about specific people who might be able to use the ideas in the book. Get in touch with them and recommend the book, explaining why they might find it useful. Imagine what kind of conversation the book might be relevant to so that you'll find it easier to recognize the situation when it arises. (This is a tip I picked up from Tim Sanders' Love is the Killer App, which I often recommend when people want to know more about how reading helps with networking.)

Review: Can't act on the book yet, and can't think of specific people or ideas to relate it to? Take notes so that you can review them later, and maybe you'll be able to think of connections then.

I don't like writing in books. Here's why:

2015-01-09 Take notes while you read books -- index card

2015.01.09 Take notes while you read books – index card

I prefer to write my notes on an index card or a piece of paper. If I'm near my computer, I might draw my notes on a tablet or type quotes into a text file. Keeping my notes separate from the book lets me review my notes quickly without thumbing through the book. I want to be able to refer to my notes while reading other books or while writing my reflections. Index cards, pages, and print-outs are easy to physically rearrange, and text files can be searched. Even if I read an e-book, I take my own notes and I copy highlights into my text files.

The best way to remember to review a book is to schedule an action to apply an idea from it. The second-best way is to connect it to other ideas or other people. If you don't have either of those hooks, you can review on a regular basis – say, after a month, six months, and a year, or by using a spaced repetition system. You might even pull a book out at random and review your notes for inspiration. When you do, see if you can think of new actions or connections, and you'll get even more out of it. Good luck, and happy reading!

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