Which near misses are costing your business time and money?

Thursday 07 July 2016

The single most important checklist question you must ask if you are truly serious about avoiding costly mistakes in your business.  Every business in the land has operations, procedures and activities that are carried out every day, every week, every month. Some of these activities are useful for the smooth running of other background processes and others are business critical, for example…
In a small office, having the printer paper or ink run out is an irritation that has an impact on the smooth running of that office that day. Easily remedied by a quick trip to the local stationers to stock up - Irritating to the team? yes
Who is affected by this?    your team - who are waiting for that paper and the ink to get on with their day to day admin tasks? – yes, your customer - who will be unaware of the paper and ink issue? - no, business critical? no 
In a printing business, having to restock on paper or ink in the middle of a big print run for a client is a different kettle of fish altogether.  Irritating to the team, very stressful, deadline likely to be missed?  yes.  Who is affected by this? Your team - who are now very stressed as the workflow/delivery time of a customer’s job has been interrupted, which in turn has a knock-on effect to all the other jobs that day also? o your customer - who may receive their order late and your other customers whose jobs may be delayed whilst trying to catch up? - yes,  business critical?  yes
For this printing business, investment in skilled staff, state of the art equipment and a classy office won’t win them more business if they have failed to deliver on time – even just once.   A business critical stage in their processes was missed out. 
Why, when everyone knows you can’t print without paper or ink was a print run scheduled in without paper or ink to do it with?  maybe the team were under time pressure and feeling stressed? Maybe a tricky job was looming and they were focused on solving that challenge? Maybe the person who always remembers stuff like that was off that day? A well thought-out, well placed and timely checklist could have avoided this situation.   When could you, should you, use a checklist on business critical tasks? – yes  

The Good Versus The Bad  
The 4 vital components that make a GOOD checklist.

1. Precise

2. Efficient and to the point

3. Practical – authored by the people that actively do the job 4. Relevant – composed of reminders of only the most critical and important  tasks.

The 4 vital components that make a BAD checklist.

1. Imprecise 

2. Vague 

3. Impractical - not authored by the people that do the job 4. Perceived as not relevant – too detailed - turns peoples’ brains off  

As Atul Gawande points out in his book ‘The Checklist Manifesto’ the power of checklists is limited.  A checklist can help experts follow complicated procedures safely a checklist can make priorities clearer and help people to function better as a team  HOWEVER a checklist cannot make anyone follow it.
A checklist, however good, must have buy-in from its users – the team must WANT to follow the checklist and understand and have faith in the value of it.   This means the users must also have authority to challenge missed steps in the checklist – including their seniors (just like the nurses in the ICU who were authorised to stop doctors if they failed to follow every step in the checklist.) Above all, there must be clear evidence that, by following the seemingly mundane task checklist on jobs that “you could do with your eyes shut”, a difference can be made to your task results, your team and your customers.

Atul Gawande presents lots of evidence in surgery, aviation and public health settings – but how is that relevant to your business?  For a checklist to gain the confidence of users it must have made a measurable difference and to make a measurable difference you must know where you are starting from. 
In the case of the World Health Organisation (WHO), in order to establish the credibility and value of the ‘surgery safety checklist’, it required hospitals to ‘own up’ to their post-operative infection rates.   It’s not an easy thing to do to formally collate your shortcomings, failures and share them! 
To implement effective checklists in your business you must be ready to face some pain.  You must:  establish what near misses or direct hits which resulted in failure to follow a particular part of a process has cost you, your team and your customers – make the pain and downside obvious  determine a way of measuring those near misses before and after you have implemented the checklist – make the pain and downside measurable  involve your team in the entire process – ask them about their own near misses and establish a culture of getting it right above who got it wrong

The Checklist Checklist

Define what your ‘business critical tasks’ are and focus on one at a time. These are the things that have had you waking up in the night with a jolt, that niggle away at you because you know they are a risk but haven’t quite got around to addressing them. Business critical tasks are also steps that didn’t get taken in the past that have lost you customers, team members or revenue.  Establish what the current measure of these business critical failures is in your business, hHow many times have you missed a deadline for delivery? missed a meeting with an important client? had to reissue faulty goods? refund customers? or lost a customer in the last year/six months/month? (you can choose the time frame).  

With your team assess and discuss what steps would have caught these ‘cock-ups’.  Was it due to lack of communication? a diversion onto another job part way through? a time constraint? missed training? faulty components? etc.
With your team create the first draft checklist that if followed would have avoided the failure of the business critical task,  use the good checklist bad checklist elements (section 2) to fine-tune the wording of the checklist and the steps.  Concise, clear and relevant is key.
Implement the checklist and agree a date when you will review the first draft checklist with your team,  compare the measurements’ ‘before’ and ‘after’ results and revisit the checklist for fine-tuning.  

The Hudson River Story… or what really saved US Airways Flight 1549

When aeroplanes crash, it’s usually because a series of unexpected things go wrong all at once, or one after the other. Something dramatic clearly went wrong with US Airways Flight 1549, which lost power in both engines and crash-landed on the Hudson River on January 15 2009. A lot of things went right too. 
Capt. Chesley Sullenberger has earned plaudits for “heroism,” but that oversimplifies what it took to land the crippled Airbus A320 and get all 150 passengers off safely, before the plane sank. A significant factor that helped everybody aboard Flight 1549 survive was the embedded use of checklists.
Sullenberger may be a model aviator, but it wasn’t heroism that brought Flight 1549 down safely. It was rigorous training that’s inbred in the U.S. aviation system. Pilots have to fly for years before they can command an airliner, and even experienced pilots must routinely train in simulators and pass “check rides” at least once a year under the supervision of Federal Aviation Administration inspectors. Pilots sometimes complain about overzealous FAA inspectors, but the inspections contribute to a culture of accountability and fastidious attention to detail in the cockpit.
For airline pilots, training focuses on dire scenarios, such as the US Airways crew encountered. Pilots spend their training time doing nothing but flying in all sorts of emergencies. Even emergencies become just another set of procedures when repeatedly trained. 
It’s clear that because Capt. Sullenberger had confidence in the well-designed checklists and procedures for emergencies, he was able to keep a cool head during this emergency.
Keeping a cool head enabled him to make further vital decisions, not covered in the checklist, that ultimately saved the lives of his entire passenger list.

The book:   ‘The Checklist Manifesto’ by Atul Gawande 
We love this brilliant book ‘The Checklist Manifesto’ by Atul Gawande Atul Gawande focuses in on how in a world of greater and greater complexity the impact of human error or omission becomes more and more significant.  He explains in this book how the simple and humble checklist when adopted whole heartedly has saved lives in aviation, hospitals around the world, construction, investment banking and beyond.   We hope if you get a chance to read this book you will gain some valuable insights that you can apply to your everyday life at home and at work.