I got a call recently from our next door neighbor – a call probably similar to calls that you all get during the holidays: they were going out of town for a four-day weekend, and they asked if we could watch the mail, get the paper, water the plants, and make sure the house doesn’t burn down. Sure, no problem. They called back three minutes later (a little embarrassed), asking me to check to see if they left a plastic trash bag on the back deck. They said they were rushing out the door, had at least 10 things on their mind (pack the car, lock the doors, turn down the thermostat, etc.), and may have forgotten that little detail. They did. And surely in four days, some squirrel or chipmunk would have made quite a mess out of their little mistake.
It got me thinking about my own busy life and how the little things (and sometimes not-so-little things) occasionally slip through the cracks…and how a seemingly innocent task (like taking out the garbage) can get interrupted by more important priorities…and how those seemingly innocent tasks – if not done and done well – can really mess things up. Believe it or not, one of the simplest of quality tools can help prevent common mistakes, reducing errors and improving accuracy in almost everything we do, personal and professional…
Now don’t scroll down to the next article or hit “close” in your browser. I’m serious: the checklist, as simple it is, can do wonders in promoting consistency, predictability, accuracy, and completeness in just about ANY organizational (or personal) task.
Why is this important? We’re all busy people – we’re juggling family, careers, social networks, our homes, travel, and many other things. And so it’s easy to miss details on occasion and make simple mistakes. To compound the issue, think of an organization (comprised of many busy people) and the extremely high probability of error, variation, and mistakes when you add up the human element in all of our processes.
When people are busy (or distracted, or tuned out, or on auto-pilot), you have the tendency to leave the garbage sitting on your back deck, or amputate the wrong limb during surgery, or forget to lower the landing gear of a 747, for example.
The impact of these errors on our organizations (and our society) is obviously huge.
A report in the New England Journal of Medicine (January 2009) indicates that the use of a 19-step Surgical Safety Checklist reduced deaths from surgery by more than 40% in eight participating hospitals (other reports have reached similar conclusions of 30-40% reduction in deaths and/or other negative medical outcomes). The report claims that use of the checklist in all hospitals could save tens of thousands of lives and $20 billon in medical costs each year. The checklist is said to only take two minutes to complete and is based on checklists used in the aviation industry (an industry that has embedded checklists in much of its operations, thankfully). In this context, the checklist helps guards against making simple – but major – mistakes.
And that’s just healthcare – think about other industries that are impacted by human error:
- the financial loss in banks or retailers when employees miscalculate transactions
- the economic and societal impact of a utility disaster caused by error human
- the waste and financial loss (not to mention erosion of goodwill and customer loyalty) of a manufacturing error that results in a product recall, consumer illness, or death
- and the list could go on and on…
Humans aren’t perfect. Mistakes happen. In fact, they happen all the time, and there is considerable research on why humans are prone to error.
I recently came across the 2009 book “Why We Make Mistakes: How We Look without Seeing, Forget Things in Seconds, Are All Pretty Sure We Are Way Above Average.” Author Joseph Hallinan sets out to explore the captivating science of human error — how we think, see, remember and forget, and how this sets us up for inevitable mistakes. He claims that human beings have design flaws: “our eyes play tricks on us, our stories change in the retelling, and most of us are fairly sure we’re way above average.”
According to Hallinan: “We learn to move rapidly through the world, quickly recognizing patterns, but overlooking details. Which is why 13-year-old boys discover errors that NASA scientists miss, and why you can’t find the beer in your refrigerator (even though it’s right there in front of you).”
Hallinan recants a (true) story about Burt Reynolds – yes THE Burt Reynolds. Burt walks into a bar early in his career, so no one really knows him yet, including a guy at the end of the bar with huge shoulders. Reynolds sits down two stools away and begins sipping a beer and tomato juice. Suddenly, the man starts yelling obscenities at a couple seated at a table nearby. Reynolds tells him to watch his language. That’s when the guy with the huge shoulders turns on Reynolds. According to Reynolds:
“I remember looking down and planting my right foot on this brass rail for leverage, and then I came around and caught him with a tremendous right to the side of the head. The punch made a ghastly sound and he just flew off the stool and landed on his back in the doorway, about 15 feet away. And it was while he was in mid-air that I saw…that he had no legs.”
Only later, as Reynolds left the bar, did he notice the man’s wheelchair, which had been folded up and tucked next to the doorway.
Hallinan claims that the important part in this story is not the guy’s legs, but Burt Reynolds’ eyes: even though Reynolds was looking right at the man he hit, he didn’t see all that he needed to see. Hallinan says this phenomenon is even labeled by researchers as the “looked but didn’t see” error. When we look at something (or at someone) we think we see all there is to see, but we don’t. We often miss important details, like legs and wheelchairs, and sometimes much larger things, like doors and bridges, or instructions to cut the left leg instead of the right.
Hallinan claims that this happens because of how our eyes and brains work. He claims that the eye is not a camera – it doesn’t take “pictures” of events, and it does not see everything at once. In fact, we only see a fraction of the total at any given time. So we deal with this natural constraint by constantly moving our eyes around, stopping roughly three times a second. We also fill in the gaps for what we think we see (but may not). And how we fill those gaps varies, depending on many things (gender, right versus left-handedness, and many other variables).
The point of all of this? We are wired to make mistakes – even highly educated surgeons, PhD physicists, and airline pilots. So as individuals and as managers, we have to devise ways to mitigate this natural tendency.
Hallinan comments on how we can make fewer errors: “It helps to second-guess, to play devil’s advocate with yourself,” he says. “Years ago, Shell Oil taught its geologists how to do this, and their ability at picking oil wells that actually struck oil improved markedly.”
He goes on: “Many of the tendencies that predispose us to error are so ingrained as to be automatic. We cannot override them even if we wanted to. So simply imploring ourselves (or others) to ‘work harder’ or ‘concentrate more’ won’t work. That’s why money is so often ineffective at reducing errors. It’s also why those baggage inspectors at the airport keep missing the fake bombs and guns that get sent through. What WILL work is designing products (or systems) in ways that block the errors that we know we are likely to make.”
We call that “mistake proofing” in the quality field (or “fool proofing” if you’re into colloquialisms). It’s about designing the system so that humans simply cannot get it wrong. Think of plugs that go into outlets only one way. Or all the web forms that now check for thoroughness and accuracy before letting you go to the next screen (“your zip code doesn’t match your state,” for example). Or cars that won’t let you put it in gear until your foot is on the brake.
But some processes cannot be fully mistake-proofed because human intervention and judgment is inherent in the process itself. That’s where I think humans need tools: because of the way we’re wired, we all need mental reminders, double-checks, and various tricks to break our natural tendencies to overlook things and focus on those darn details.
Enter the checklist. Checklists help ensure accuracy and consistency in process delivery. They help us avoid overlooking the small – but important – details. Or said a different way: checklists can be a key way to prevent mistakes made by otherwise smart, but very busy, people. Checklists can also be a way to ensure that everyone on your team is considering the same things or performing a task in a similar way: in other words, it’s a way to ensure consistency in our processes.
In some fields – such as healthcare, aviation, the military, and aerospace – checklists can be the difference between life and death. But most of us are not rocket scientists. So how can we benefit from this simple technique?
Checklists can help ensure accuracy in just about every other key process your organization deals with – the applications are unlimited. Checklists can be used for hiring employees (so you don’t get sued or start off on the wrong foot), for processing payroll, for closing the accounting books, for following up with key customers, for receiving supplier materials, for shipping and receiving, for saving on energy consumption and costs, for promoting employee safety, for disaster recovery or business continuity, for ensuring that IT conforms to user requirements, for managing change, for managing projects, for communication, and probably 200 other tasks in a typical organization.
I don’t recommend having checklists for everything your organizations does. But there is wisdom in considering checklists for processes that you would consider critical to ensuring customer satisfaction and safety, employee satisfaction and safety, company efficiency and profitability. The process for doing so could be:
- Identify key processes that are critical to your success that would benefit from a checklist.
- Using collective knowledge from within and outside that process, identify the key activities that have to be accomplished to promote a predictable outcome within that process. Sequence may or may not be important (which makes a checklist different than a process flow, by the way), but no step can be avoided or an undesirable outcome may result.
- Deploy the checklist to all appropriate stakeholders in the process, using communication, training, and other methods.
- Measure outcomes and adjust the checklist, as needed.
Mistakes are normal: we’re all human. But there are ways we can guard against missing those details that can result in mistakes and errors. Like a botched surgery, a plane crash, or even leaving garbage bags on the back deck.
Yours in Performance Excellence & Happy Holidays!
Brian S. Lassiter
President, Performance Excellence Network (formerly Minnesota Council for Quality)