Ritual and Changing Behaviour

As you've probably guessed, I've been reading Atul Gawande's The Checklist Manifesto, which is a well-written exposition of the power of simple checklists in driving efficiencies and performance. Atul uses lots of examples from healthcare (he's a general surgeon), aviation, engineering and construction to show how well-crafted checklists can be transformational in their impact.

I particularly liked a story he told about how establishing a new ritual through the introduction of a simple object had helped change behaviour in one children's hospital. Administering a pre-operation anti-biotic to patients can be a critical factor in preventing post-operative infection which can not only be dangerous but seemingly occurs with surprising frequency. It turns out that the precise time before incision that the anti-biotic is given is critical to making it work - too soon and it will have worn off by the time the operation starts, too late and it won't have time to take effect. 

Atul tells the story of how in 2005 Columbus Children’s Hospital discovered that, despite it seeming like a simple process, more than one-third of its appendectomy patients failed to get the right antibiotic at the right time:

'How hard could this be? Even people in medicine assume we get this kind of simple task right 100 percent of the time. But in fact we don’t. With all the flurry of things that go on when a patient is wheeled into an operating room, this is exactly the sort of step that can be neglected. The anesthesiologists are the ones who have to provide the antibiotic, but they are concentrating on getting the patient safely and calmly to sleep—and this is no small matter when that patient is a scared eight-year-old lying naked on a cold table in a room full of strangers getting ready to cut into her. Add in an equipment malfunction (“Is that red light supposed to be blinking like that?”), or the patient’s asthma acting up, or a page for the surgeon to call the emergency room, and you begin to see how something as mundane as an antibiotic can slip past. The hospital’s director of surgical administration, who happened to be not only a pediatric cardiac surgeon but also a pilot, decided to take the aviation approach. He designed a preincision “Cleared for Takeoff ” checklist that he put on a whiteboard in each of the operating rooms. It was really simple. There was a check box for the nurse to verbally confirm with the team that they had the correct patient and the correct side of the body planned for surgery—something teams are supposed to verify in any case. And there was a further check box to confirm that the antibiotics were given (or else judged unnecessary, which they can be for some operations). There wasn’t much more to it. But getting teams to stop and use the checklist—to make it their habit—was clearly tricky. A couple of check boxes weren’t going to do much all by themselves. So the surgical director gave some lectures to the nurses, anesthesiologists, and surgeons explaining what this checklist thing was all about. He also did something curious: he designed a little metal tent stenciled with the phrase Cleared for Take off and arranged for it to be placed in the surgical instrument kits. The metal tent was six inches long, just long enough to cover a scalpel, and the nurses were asked to set it over the scalpel when laying out the instruments before a case. This served as a reminder to run the checklist before making the incision. Just as important, it also made clear that the surgeon could not start the operation until the nurse gave the okay and removed the tent, a subtle cultural shift. Even a modest checklist had the effect of distributing power. The surgical director measured the effect on care. After three months, 89 percent of appendicitis patients got the right antibiotic at the right time. After ten months, 100 percent did. The checklist had become habitual—and it had also become clear that team members could hold up an operation until the necessary steps were completed.'

Another great example of the power of habit in changing behaviour.

The Three Types of Problem in the World


I rather liked this delineation of the three different types of problem in the world, featured in a paper on reform in the healthcare industry by Brenda Zimmerman of York University and Sholom Glouberman of the University of Toronto, and quoted in The Checklist Manifesto:

  1. Simple problems are ones like baking a cake from a mix. There is a recipe.
  2. Complicated problems are ones like sending a rocket to the moon. They can sometimes be broken down into a series of simple problems. But there is no straightforward recipe. Success frequently requires multiple people, often multiple teams, and specialized expertise. Unanticipated difficulties are frequent. Timing and coordination become serious concerns.
  3. Complex problems are ones like raising a child. Once you learn how to send a rocket to the moon, you can repeat the process with other rockets and perfect it. One rocket is like another rocket. But not so with raising a child, the professors point out. Every child is unique. Although raising one child may provide experience, it does not guarantee success with the next child. Expertise is valuable but most certainly not sufficient. Indeed, the next child may require an entirely different approach from the previous one. And this brings up another feature of complex problems: their outcomes remain highly uncertain. Yet we all know that it is possible to raise a child well. It’s complex, that’s all.


Zimmerman and Sholom go on to contend that we (in the context of the paper they are talking about healthcare experts) often:

'...implicitly describe complex problems as complicated ones and hence employ solutions that are wedded to rational planning approaches. These often lead to inappropriate solutions because they neglect many aspects of complexity. We are reminded of the old joke about the drunk who is stumbling around near a lamppost. He is asked what he is doing and says that he is looking for his car keys. 

“Oh, where do you think you lost them?”

“Down the block near my car,” he says.

“So why are you looking for them here?”

“Because the light is better.”

The sophistication of our models, theories and language for complicated problems can be as seductive as the lamplight. They provide better “light” and clarity and yet can lead to investigations that are ill-equipped to address complex adaptive systems.' 

Nicely put.

David Lee Roth and Brown M & Ms


From Atul Gawande's The Checklist Manifesto:

'I heard the story behind rocker David Lee Roth’s notorious insistence that Van Halen’s contracts with concert promoters contain a clause specifying that a bowl of M&M’s has to be provided backstage, but with every single brown candy removed, upon pain of forfeiture of the show, with full compensation to the band. And at least once, Van Halen followed through, peremptorily canceling a show in Colorado when Roth found some brown M&M’s in his dressing room. This turned out to be, however, not another example of the insane demands of power-mad celebrities but an ingenious ruse. As Roth explained in his memoir, Crazy from the Heat, “Van Halen was the first band to take huge productions into tertiary, third-level markets. We’d pull up with nine eighteen-wheeler trucks, full of gear, where the standard was three trucks, max. And there were many, many technical errors—whether it was the girders couldn’t support the weight, or the flooring would sink in, or the doors weren’t big enough to move the gear through. The contract rider read like a version of the Chinese Yellow Pages because there was so much equipment, and so many human beings to make it function.” So just as a little test, buried somewhere in the middle of the rider, would be article 126, the no-brown-M&M’s clause. “When I would walk backstage, if I saw a brown M&M in that bowl,” he wrote, “well, we’d line-check the entire production. Guaranteed you’re going to arrive at a technical error. . . . Guaranteed you’d run into a problem.” These weren’t trifles...The mistakes could be life-threatening. In Colorado, the band found the local promoters had failed to read the weight requirements and the staging would have fallen through the arena floor.'

The Future of Agencies


I'm currently conducting a major research project focusing on the future of agencies, working with Econsultancy. It's a revamp of the report I did three years ago on the same subject. As part of it I've been interviewing a large number of senior agency-side personnel from around the world working in all types of agency from the big management consultancies to traditional above the line creative agencies, from digital and technology focused agencies to major media agencies to newer content marketing focused outfits. Some truly compelling and (dareisayit) potentially transformative stuff has already come out of it. It seems as though a LOT has changed over the past two years. 

I'll be giving a first take on our findings in a webinar on 22nd of July. If you'd like to sign up for that, and get an early preview of the key findings you can do so here:

22nd July 9.00AM London time
22nd July 5.00PM London time