I recently read the book The Checklist Manifesto by Atul Gawande – a respected surgeon, noted author, MacArthur fellow, New Yorker staff writer, and a professor at Harvard Medical School.

The premise of the entire book is the author’s dive into the concept of a checklist and how they have dramatically improved the efficiency and reliability of professionals in the medical profession, the aeronautical industry, the architecture industry and even the venture capital industry.

So what is a checklist? It is the minimum set of critical steps for any task to be achieved.

Why are they useful? Because checklists protect against many kinds of dangers. For example:

1. “Faulty memory and distraction are a particular danger in what engineers call all-or-none processes – if you miss just one key thing, you might as well not have made the effort at all (whether it is buying ingredients for a cake or preparing an airplane for takeoff).”
2. “People can lull themselves into skipping steps even when they remember them. Especially in busy and stressed workplaces (such as hospitals). In complex processes, certain steps don’t always matter, may be it affects only 1 out of 50 times. But when it does, it can be catastrophic.”

One of my favorite passages in the book is as follows (it’s a longer excerpt than I would have liked, but all the parts were really important, so please read the whole passage to understand what’s going on):

Checklists remind us of the minimum necessary steps and make them explicit. They not only offer the possibility of verification but also instill a kind of discipline of higher performance. Which is precisely what happened with vital signs – thought it was not doctors who deserved the credit.

The routine recording of the four vital signs did not become the norm in Western hospitals until the 1960s, when nurses embraced the idea. They designed their patient charts and forms to include the signs, especially creating a checklist for themselves.

With all the things nurses had to do for their patients over the course of a day or night – dispense their medications, dress their wounds, troubleshoot problems – the “vitals chart” provided a way of ensuring that every six hours, or more often when nurses judged necessary, they didn’t forget to check their patient’s pulse, blood pressure, temperature and respiration and assess exactly how the patient was doing.

In most hospitals, nurses have since added a fifth vital sign: pain, as rated by patients on a scale of one to ten. And nurses have developed yet further such bedside innovations – for example, medication timing charts and brief written care plans for every patient. No one calls these checklists but, really, that’s what they are. They have been welcomed by nursing but haven’t quite carried over into doctoring.

Charts and checlists, that’s nursing stuff — boring stuff. They are nothing that we doctors, withour extra years of training and specialization, would ever need or use.

In 2001, though, a critical care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give a doctor checklist a try. He didn’t attempt to make the checklist encompass everything ICU teams might need to do in a day. He designed it to tackle just one of their hundreds of potential tasks, the one that nearly killed Anthony DeFilippo: central line infections.

On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting in a central line. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a mask, hat, sterile gown, and gloves, and (5) put a sterile dressing over the insertion site once the line is in. Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years. So it seemed silly to make a checklist for something so obvious. Still, Pronovost asked the nurses in his ICU to observe the doctors for a month as they put lines into patients and record how often they carried out each step. In more than a third of patients, they skipped at least one.

The next month, he and his team persuaded the Johns Hopkins Hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask the doctors each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. Nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder (“Um, did you forget to put on your mask, doctor?”) to more forceful methods (I’ve had a nurse bodycheck me when she thought I hadn’t put enough drapes on a patient). But many nurses aren’t sure whether this is their place or whether a given measure is worth a confrontation. (Does it really matter whether a patient’s legs are draped for a line going into the chest?”) The new rule made it clear: if doctors didn’t follow every step, the nurses would have backup from the administration to intervene.

For a year afterward, Pronovost and his colleagues monitored what happened. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from 11 percent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths and saved two million dollars in costs.

If that, my friends, does not explain the power of a simple checklist, I don’t know what can.

And yet, despite these results, people were reluctant to adopt checklists. In fact, I know you are dismissing the idea right now. Try writing down 5 reasons why checklists are stupid and won’t work for you. Now write 5 reasons why it will work. Think over it. I bet most people find the 5 reasons against checklists, easier to write, but will be convinced about it after writing the 5 reasons for it.

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Every now and then, I try to build a group of people to talk about specific topics but it quickly dies because of inactivity. Although I really saw the value in having such a community, I just didn’t know how to build one. Even if one person keeps pumping in content, how do you actually get the community to interact with each other?

It is the same kind of problem being faced by, say StartupBuzz.org which, I am guessing, wants to be the Hacker News of India. There are indeed topics that apply only to startups in India, from “Startup Morning”, to India’s first in-taxi magazine. Such interesting events and ideas are worthy of discussion.

There is value in such a community, but again, how to build it? StartupDunia has already put its thoughts on the subject but the question still remains.

Here are some of my thoughts.

Does it require credibility?

• Hacker News has Paul Graham and YCombinator behind it.
• ProBlogger Forums have ProBlogger’s Darren Rowse behind it.
• And the most recent example of StackOverflow.com that has Joel Spolsky and Jeff Atwood behind it.

So the question is whether there each community should be backed by up by a credible person who has a reasonable authority on the subject?

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I attended a Bangalore South Lok Sabha Candidates’ debate yesterday, this time held at NMKRV Jayanagar and organized by the Rotary Clubs of South Bangalore.

Only Capt. Gopinath (Independent) had arrived on time. Ananth Kumar (BJP) arrived a bit late but immediately greeted each and every individual in the hall and asked them to vote. When the organizers decided to go ahead even though there were only 2 candidates, Prof. Radhakrishna of JD(S) arrived. Krishna Byregowda (Congress) never turned up at all.

The session was mostly about questions asked by Mohandas Pai (Times of India) to the candidates and gave them roughly a minute each to answer.

Most of the questions were good and thankfully the answers were also forthcoming.

IMHO, Prof. Radhakrishna was rambling more than making sense. Since Krishna Byregowda didn’t show up, I don’t know much about him even though he has spoken well in interviews. Ananth Kumar and Capt. Gopinath were both impressive, made a lot of sense and had vision. It is going to be very tough to choose between these two candidates for me.

Plus points for Ananth Kumar include that he has been an MP four times, been the Civil Aviation Minister, etc. and he answered questions to the point. He indulged in rhetoric about why Congress has brought India down, and why things were great during Vajpayee’s tenure – ignoring these aspects, he seemed like a good candidate.

Plus points for Capt. Gopinath include that he has been an entrepreneur himself – Deccan Aviation made flying possible for the average person, he has been in the army and fought a war in Kashmir, and he voices Bangaloreans’ concerns well. He was vocal about the state of the Metro and questioned why trees in Lalbagh has to be cut down, and the whole crowd cheered for that statement.

Towards the end of the session, the audience also got turns to ask questions, but it turned out to be rhetorical provoking questions rather than questions with real value.

For more details about Bangalore candidates, read the full interviews at SmartVote.in. I’m sure there are more sites out there for the other constituencies in India.

I think there are two takeaways from the day for me.

First, vote for the candidate, not the party. If you think voting for an independent candidate is going to be a “waste” of your vote, think again. Is it better to have 500 excellent people in the Lok Sabha regardless of which party they belong to, or is it better to have 500 people, whose usefulness is doubtful, belonging to 2-3 big parties in the Lok Sabha?

There are good people stepping into politics trying to make a difference and we should encourage them. After all, we don’t jump into politics, let us support those who do. For example:

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I had grown up among engineers, and I could remember the engineers of the twenties very well indeed: their open, shining intellects, their free and gentle humor, their agility and breadth of thought, the ease with which they shifted from one engineering field to another, and, for that matter, from technology to social concerns and art. Then, too, they personified good manners and delicacy of taste; well-bred speech that flowed evenly and was free of uncultured words; one of them might play a musical instrument, another dabble in painting; and their faces always bore a spiritual imprint.

– Aleksandr Solzhenitsyn, in his book “The Gulag Archipelago”

Though the Lok Sabha elections are just a month away, more than 50 per cent of voters in Bangalore still do not have Electoral Photo Identity Cards (EPIC).

Ramakrishna blamed lackadaisical attitude of citizens, especially software professionals, for low EPIC coverage. “People working in IT and BT firms show indifference towards EPIC. Even though our officials go to their doorstep on weekends, they do not respond. They say that EPIC is of no use of them,” he pointed out.

However, there has been a good response from those living in slums, the official added.

– Deccan Herald on March 20, 2009

The ABIDe, i.e. Agenda for Bengaluru Infrastructure and Development Task Force (setup by the current government) is working on a roadmap for development of Bengaluru along with deadlines and regular 100-day monitoring, etc.

The comprehensive reports are available in PDF format on a public website with even discussion forums (although the forums have poor participation).

• ABIDe Agenda
• Plan Bengaluru 2020
• Secure Bengaluru
• Govern Bengaluru
• Urban Poor
• Roads, Traffic Management and Transportation

Comments and suggestions should be sent to abide@abidebengaluru.in .

I’m surprised by the level of openness and invitation for public participation. I’ve heard that all these developments have started due to the initiative of Mr. Rajeev Chandrasekhar, a Rajya Sabha MP. If so, kudos to him!

On the other side, hopefully all those people who spend a significant time everyday cursing the infrastructure and traffic will spend a few minutes to review these reports and contribute suggestions and comments, to get rid of the very same problems.

And the process has already started. The government is launching Kendra Sarige AC buses today, which I think, is to influence people who can afford it to make using these buses more appealing than using their cars:

The Kendra Sarige is a bus service, also called the Hop on Hop off (HOHO) bus service, will run in the central business district only. The route covers the whole area from the Police Housing Corporation, Hosmat Hospital to Trinity Circle.

Almost 20 bus stops in the anti-clockwise manner and around 13 clockwise are planned. Nine air-conditioned Volvo buses will run clockwise and anti-clockwise in this circle itself. The longest trip on this route will take a maximum of 20 minutes.

There will be nine buses running every hour on the route. Bus frequency at the stops varies from three to seven minutes.

And another announcement is the “Big-10 buses” which connect 10 major roads in Bangalore to the outer ring roads, and these buses are going to be on trial for a week to see if it eases congestion.

To sum it up, they are making plans together with reputed citizens in the committee, actively asking for feedback from the public, they are conducting trials and making data-based decisions, and actively launching services. Isn’t this what we all want? If we can dismiss the cynics in us for five minutes, I think we can see all this as very positive steps.

Note on the Kendriya Sarige buses: To see the routes these buses will take, just visit the Bangalore Traffic Information System website.

Note on the Bangalore Traffic Information System / MapUnity : If you have some ideas on how IT / computers can really help traffic, then why you can send these ideas to the MapUnity folks who are doing a kick-ass job. And start/join a carpool while you’re at it – there are just 1676 carpoolers for an IT city of > 50 lakhs! That reminds me of the car vs. bus vs. bicycle photo…

Last weekend, I was back in Sharavathy Valley in Shimoga, but this time for some water sports.

Here’s a photo essay of the trip:

When we were reaching our camp area, the entrance itself was impressive, and I was excited by such clear blue water.

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I read Outliers, The STORY of SUCCESS by Malcolm Gladwell last week and found it fascinating.

Here’s an excerpt:

Cultural legacies matter, and once we’ve seen the surprising effects of such things as power distance and numbers that can be said in a quarter as opposed to a third of a second, it’s hard not to wonder how many other cultural legacies have an impact on our twenty-first-century intellectual tasks.

What redeemed the life of a rice farmer, however, was the nature of the work. It was a lot like the garment work done by the Jewish immigrants to New York. It was meaningful.

First of all, there is a clear relationship in rice farming between effort and reward. The harder you work a rice field, the more it yields.

Second, it’s complex work. The rice farmer isn’t simply planting in the spring and harvesting in the fall. He or she effectively runs a small business, juggling a family workforce, hedging uncertainty through seed selection, building and managing a sophisticated irrigation system, and coordinating the complicated process of harvesting the first crop while simultaneously preparing the second crop.

And, most of all, it’s autonomous. The peasants of Europe worked essentially as low-paid slaves of an aristocratic landlord, with little control over their own destinies. But China and Japan never developed that kind of oppressive feudal system, because feudalism simply can’t work in a rice economy. Growing rice is too complicated and intricate for a system that requires farmers to be coerced and bullied into going out into the fields each morning. By the fourteenth and fifteenth centuries, landlords in central and Southern China had an almost completely hands-off relationship with their tenants: they would collect a fixed rent and let farmers go about their business.

Here’s a second excerpt:

Every four years, an international group of educators administers a comprehensive mathematics and science test to elementary and junior high students around the world called TIMMS. The point is to compare the educational achievement of one country with another’s.

When students sit down to take the TIMSS exam, they also have to fill out a questionnaire. It asks them all kinds of things, such as what their parents’ level of education is, and what their views about math are, and what their friendss are like. It’s not a trivial exercise. It’s about 120 questions long. In fact, it is so tedious and demanding that many students leave as many as ten or twenty questions blank.

Now, here’s the interesting part. As it turns out, the average number of items answered on that questionnaire varies from country to country. It is possible, in fact, to rank all the participating countries according to how many items their students answer on the questionnaire. Now, what do you think happens if you compare the questionnaire rankings with the math rankings on the TIMSS? They are exactly the same. In other words, countries whose students are willing to concentrate and sit still long enough and focus on answering every question in an endless questionnaire are the same countries whose students do the best job of solving math problems.

Think about this another way. Imagine that every year, there was a Math Olympics in some fabulous city in the world. And every country in the world sent its own team of one thousand eighth graders. Boe’s point is that we could predict precisely the order in which every country would finish in the Math Olympics without asking a single math question. All we would have to do is give them some task measuring how hard they are willing to work. In fact, we wouldn’t even have to give them a task. We should be able to predict which countries are best at math simply by looking at which national cultures place the highest emphasis on effort and hard work.

So, which places are at the top of both lists? The answer shouldn’t surprise you: Singapore, South Korea, China (Taiwan), Hong Kong, and Japan. What those five have in common, of course, is that they are all cultures shaped by the tradition of wet-rice agriculture and meaningful work. They are the kinds of places where, for hundreds of years, penniless peasants, slaving away in the rice paddies three thousand hours a year, said things to one another like “No one who can rise before dawn three hundred sixty days a year fails to make his family rich.”

See how the two excerpts are related? This explains how your cultural legacies matter (and don’t worry, maths is not the criterion for success, this is just one example in the book). Another example is how cultural legacies are related to plane crashes of the respective national airlines.

There’s a lot more in the book like the Matthew Effect, the 10,000-Hour Rule, why “practical intelligence” matters, why “concerted cultivation” matters, about the KIPP schools, and so on.

The book is a must-read IMHO, just for the thought-provocativeness, even if not how to learn to be “successful.”

If you want to make new friends, there is no use in just saying hi to people, something of value should be exchanged or there should be a common activity. That’s when they become friends. Real friends.

I’ve added a page on my wiki to list the type of common activities possible in India right from cycling to movie appreciation. Let me know if I can add more variety to the given mix of activities. I’m interested in figuring out what activities do people take up.

If there’s one thing that I wish could change in India, I would vote for having a retirement age for politicians.

When there is a concept of retirement for many other careers like engineers, bankers, CEOs, etc. why shouldn’t the same apply for politicians?

If the reason for a retirement age in the private sectors is that the capacity to contribute becomes lesser, the same applies for politics. If the reason is that they should have a relaxed retirement life, the same applies for politics.

If the old people retire, it will give a chance for younger people with fresher perspectives to come in (with the hope that ‘remote control’ possibilities will be minimal), and at the same time the bureaucracy gets refreshed more often with lesser influence by the older people.

Of course, I know it’ll never happen, because the law would have to be passed by the very same people whose careers will be shortened.

I wonder why people consider “social networks” to be a “new thing”. It’s the “rage these days”, they say. Actually, they’ve been around for a while but in a different disguise.

Take the case of the Erdos number:

In order to be assigned an Erdos number, an author must co-write a mathematical paper with an author with a finite Erdos number. Paul Erdos is the one person having an Erdos number of zero. If the lowest Erdos number of a coauthor is k, then the author’s Erdos number is k + 1.

Erdos wrote around 1,500 mathematical articles in his lifetime, mostly co-written. He had 511 direct collaborators; these are the people with Erdos number 1. The people who have collaborated with them (but not with Erdos himself) have an Erdos number of 2 (8,162 people as of 2007), those who have collaborated with people who have an Erdos number of 2 (but not with Erdos or anyone with an Erdos number of 1) have an Erdos number of 3, and so forth. A person with no such coauthorship chain connecting to Erdos has no Erdos number (or an undefined one).

There is room for ambiguity over what constitutes a link between two authors; the Erdos Number Project website says “Our criterion for inclusion of an edge between vertices u and v is some research collaboration between them resulting in a published work. Any number of additional co-authors is permitted,” but they do not include non-research publications such as elementary textbooks, joint editorships, obituaries, and the like. The “Erdos number of the second kind” restricts assignment of Erdos numbers to papers with only two collaborators.

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Erdos numbers have been a part of the folklore of mathematicians throughout the world for many years. Amongst all working mathematicians at the turn of the millennium who have a finite Erdos number, the numbers range up to 15, the median is 5, the average Erdos number is 4.65; and almost everyone with a finite Erdos number has a number less than 8.

So, Erdos numbers is essentially a social network that counts the degrees of separation.

Somewhat relatedly, there is also an interesting theory called Dunbar’s number:

Dunbar’s number is the supposed cognitive limit to the number of individuals with whom any one person can maintain stable social relationships: the kind of relationships that go with knowing who each person is and how each person relates socially to every other person.

Dunbar has argued that 150 would be the mean group size only for communities with a very high incentive to remain together. For a group of this size to remain cohesive, Dunbar speculated that as much as 42% of the group’s time would have to be devoted to social grooming.

I wonder what would be the Dunbar number of the social circles that I know of.