You know those near misses or mistakes that jolt you into wideeyed disbelief or give you a cold sweat at night? Those near misses or mistakes that, if people did what they should do, would never happen? Yet they are easily avoided, if only people followed your system, followed your rules, followed your processes. So why don’t they follow your processes, every time? Because we (the human race) don’t like checklists and don’t want to use them. Following checklists is beneath our skills, knowledge and capabilities. And yet… …would you fly on a plane if you knew your pilot ignored the pre-flight checklist and ‘winged it’? Would you want a surgeon to operate on you if they didn’t follow a life-saving checklist recommended by the World Health Organisation?
In a nutshell: You, me, everybody would prefer not to follow a checklist, yet they keep us alive in many walks of life. Checklists can keep your business alive too and help it thrive.
5-point checklist saves 8 lives and £1.5million…
The number of tasks happening every day in every intensive care unit (ICU) in every hospital is vast. In 2001 a consultant decided to test a checklist on just one of the many ICU tasks – the insertion of a central line (a long needlesized tube into a vein for delivering drugs and fluids to patients). The simple 5 five-point checklist:
1. Wash your hands with soap
2. Clean skin with antiseptic
3. Put sterile drapes over the patient
4. Wear sterile clothing including mask and hat
5. Fit a sterile dressing to the site of the central line Obvious, no-brainer instructions to doctors who know this already.
Shocking failure rate…
And yet nurses reported that with more than a third of patients the doctors skipped at least one step. Insist it happens… The hospital then authorised nurses to stop doctors if they failed to follow every step. 12 months later the ‘10-day line-infection rate’ went from 11% to zero. 15 more months later and the checklist had prevented 43 infections, prevented 8 deaths, and saved £1.3million in post-infection costs.
Soap and a 3-step checklist saves lives…
In the slums of Karachi, Pakistan in the 1990s, virtually all water sources were contaminated with sewage. 1 in 10 children died before they were 5 years old. Diarrhoea was a major cause. A young public health worker, Stephen Luby, had an idea that anti-bacterial soap might help. The idea failed. Anti-bacterial soap was no better than normal soap.
But the checklist worked…
Luby’s test achieved a better use of soap, reduced the rate of diarrhoea by 52%, and reduced pneumonia by 48%. How come? Luby’s researchers gave out instructions
and managed to make the use of soap more systematic. The checklist they shared: 1. Wet both hands completely 2. Lather well 3. Rinse all the soap off Simple and obvious, yes. But, in the difficult circumstances of the Karachi slums it was life changing – even if they then mostly dried their hands on their clothes!
Checklists help manage massive complexity…
3 storeys underground, 11 storeys above ground, 3,885 tons of steel, 16 lift shafts, 47 miles of conduit, 64,000 feet of copper piping, 95 miles of electrical wire. And when complete the building has to withstand an earthquake. Dozens of different trade jobs to be completed on every floor. Many different machines are used. Up to 300 people on-site at any one time, all working in sequence from floor to floor and all with their own safety, design and technical requirements. All having to work around unexpected problems. The scale of the complexity is overpowering. Too much for one person in charge to manage. But these complex buildings never seem to fall down. All because the business of building them works – failure is not an option for the builders of these buildings. One checklist dominates the many complex building projects – the communication checklist. The communication checklist dictates how all the specialists get agreement with each other, especially when something does not go to plan.
Another checklist for very clever people…
Surgeons are, thankfully, very clever people. Their training is long, intensive, thorough. A renowned surgeon was asked by the World Health Organisation (WHO) to help save lives in operating theatres all over the world. After considering many options, the simple solution of a ‘surgical safety checklist’ became a WHO directive.
Nobody wants to use checklists, not even the author!
How does the surgeon who created the WHO ‘surgical safety checklist’ feel about using his own checklist in his own operations? He doesn’t really want to! He doesn’t believe the checklist will make any difference. And yet he tries it.
Another checklist success
Each and every week this checklist prevented a missed step that could have caused disaster. In his words: “I am not sure how many important issues would have slipped by us without the checklist and actually caused harm.” In one operation, the ‘pre-op’ checklist more than did its job: “…the checklist saved my patient’s life.”- Atul Gawande Very clever people like surgeons shouldn’t need checklists, but they do. Checklists work. Checklists work reliably when people use them reliably. So shouldn’t you and your business make better use of checklists? Even if everyone would prefer not to use them? “Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is.” - Atul Gawande
Key but difficult insight…
Getting your people to use checklists in a disciplined way is tough – even for the checklist creator. Checklists require discipline and teamwork. Who wants to fly on a plane with no pre-flight checklist? One of the reasons air travel is the safest form of travel is the disciplined use of checklists. In the downloadable tools you’ll see how checklists helped 155 people survive the Hudson River crash in New York in 2009. The Hudson River flight proves the value of teamwork, discipline and checklists. The WHO ‘surgical safety checklist’ does the same
Time to Disagree.
“There’s just no way I can get my people to use a checklist every time they do a job they do every day.” Your challenge is a common one. Even on a plane or in surgery, where the use of the checklist will save lives, you find resistance to using a checklist. Most humans want to avoid using checklists. Especially if it’s for something they do every day or several times a day. Two things can help you:
1. Keep your focus narrow. Start by insisting everyone (including you) use a checklist on your business critical jobs only – just work out what your business critical jobs are. Check out the downloadable tools for help in working out your business critical tasks.
2. Make sure your checklist physically shows up at the right time, at the right place in the right way. Does the ‘load the van’ checklist show up on the van door? Does the meeting agenda (agenda = meeting checklist) show up as Page One of your meeting folder? Surgeons, pilots, builders and others use a checklist every day for a job they do every day. Shouldn’t your people do the same? Your business success depends on it.
“My people know what they should be doing – they don’t need checklists to slow them down.” A surgeon has to be reminded to wash her hands before an operation.
Are your people more or less likely to know what to do in their job than a surgeon does in hers? The cost of doing a job wrong, even slightly wrong, can be greater than the savings of doing it right.
This is crystal clear for a surgeon or an airline pilot – lives are involved. But your business could lose a sale or lose a customer if a job isn’t done as it should be. At a recent Rugby Premiership match a friend of ours attended, it took more than 45 minutes to be served at the bar, despite joining the queue before the first half was over. The checklist for setting up the bar wasn’t followed and so they did not stock-pile drinks in advance of half time. The result? Hundreds of unhappy customers because a simple, obvious checklist wasn’t followed. “Even if I insist my people follow a checklist they’ll soon go back to working without them.” Do you really want to allow business critical jobs in your business to happen without a checklist?
To begin with using a checklist may feel alien. Your job is to help your people make the disciplined use of checklists a habit – something that happens automatically. Use the habit checklist(!) in the tools and resources download to help you. Tell me more We love the straightforward and ‘jaw-droppingly’ simple approach to checklist success proposed by Atul Gawande in his book ‘The Checklist Manifesto … how to get things right.’ We hope we’ve inspired you to build checklists into your business daily and make your business more successful. If we have, please check out this practical, no nonsense book. And download the supporting tools and resources for this edition of Business Bitesize.
Your next steps: It pays to use a checklist every time you perform a business critical task in your business. A checklist helps prevent mistakes, drives standards up and drives results up too. Build and use a simple checklist for the important jobs in your business and you’ll experience greater success. Start by seeing checklists as a fundamental part of running your business well. “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” – Atul Gawande More tools and information for you: As well as the checklist here, you can use the exercises, checklists and tools by downloading the supporting resources. Together they’ll help you make more of this bitesize business breakthrough.
Make checklists a habitual part of running your business and achieve record results…
If checklists work in the slums of Karachi and halve the rate of illness, and if checklists bring success to surgeons, airline pilots and builders, they’ll help you and your business succeed too. Don’t let our natural human tendency to ignore checklists derail your efforts at using checklists for your business critical tasks:
1. Choose a business critical task that needs a checklist Work on 1 or 2 business critical tasks and work with your team to make your checklists work. Warning: A checklist for everything will prevent your team from committing to the habitual use of checklists, so start with just 1 or 2 business critical tasks. Check out the tools and resources download link below for guidance on how to choose your business critical tasks.
2. Build a checklist for your chosen business critical task Ask your best person to carry out your business critical task in the best way they can. Whilst they work on the task, you create the checklist, recording all the points of action.
3. Test and refine your checklist with your people Fine-tune your checklist using the ‘checklist rules’ suggested in the tools and resources.
4. Make disciplined use of your checklist a habit Discipline is tough. But teamwork and a focus on the science of habit can help you ensure your checklist gets used every time your business critical task happens.