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Climbing Mount Audacity

Why checklists matter

27: Why checklists matter

Van Halen’s M&Ms - Demise of the master builder - How to build a skyscraper - What to do when the cargo doors blow - If you were having an operation, would you want a checklist to be used? - Guess what’s coming to Method Grid soon?

This blog takes a short side-step off the metaphorical Climbing Mount Audacity trail. Treat it like a short water break, to admire some local fauna and flora, before we hit the trail proper again. In the spirit of an occasional share of recommended entrepreneurial resources (books, blog forums, podcasts etc.), this week, I review a thought-provoking book: The Checklist Manifesto (Atul Gawande; Profile Books, 2011).

Why checklists matter

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Checklists, as it happens, are to be found in many unexpected places. Take the story of David Lee Roth, leader singer of heavy rock band Van Halen. Famously, Roth inserted a very specific clause into the band’s contracts with concert promoters that specified – wait for it – a bowl of M&M’s to be provided back-stage. Furthermore, this bowl had to be provided with every single brown M&M removed – upon pain of show forfeiture and full financial compensation. “Whoa … ” I hear you cry, “… that is off-the-scale primadonna behaviour”. The truth, however, is a little more nuanced. Whilst Roth probably liked non-brown M&Ms, his real intent was the stuff of management genius. Van Halen were one of the first bands to deliver live concerts as a major, scaled, high-production event. Turning up to major venues with nine eighteen-wheeler trucks, there was huge scope for technical, operational failure. The contract was necessarily detailed (not least from an event setup H&S perspective) so the M&M clause was, in reality, a fantastic ruse.

why checklists matter image 02On arriving at a new venue, Roth would walk straight to his back-stage area and check whether the non-brown M&Ms were in place. If not, he could immediately infer the quality of the venue management team. If they missed this clause, how sure could his team be confident that they had acknowledged the technical details with respect to, say, stage weight, or whether the lighting rigs would work to their specification? If the M&Ms were not in place, he might not necessarily cancel the gig but he would know that his team would need to manage the entire set up and production on a line-by-line basis. Effectively, he deployed a checklist to ensure delivery excellence

Such checklists, as Dr. Gawande describes deftly, have become a modern necessity. In every profession he surveys – medicine, aviation, construction – the complexity of modern operation has long since surpassed the idea of one-mind holding all the necessary knowledge and skill required to supervise the delivery of a service. Take construction for example; it is only until relatively recently that a master builder would have designed a major building, engineered it and, finally, overseen the construction from start-to-finish, from structure-to-decor. The sophistication of modern, large-scale public building makes this impossible – overwhelming the ability of any single individual to master the multiple skill domains. Nowadays, the architects, the engineers and the construction teams occupy very separate magisteria and, indeed, even within these realms there is multi-various sub-specialism (sixteen recognised trades): conveying systems, mechanical systems, masonry, concrete structures, metal structures, electrical systems, doors and windows, thermal and moisture systems, carpentry, site management, landscaping etc. You get the drift.

Modern construction is, effectively, a colossal team exercise. “So how is it managed? …” asks Gawande “… how does a modern skyscraper actually get built – especially so to our expected levels of public safety?”. As a leading surgeon, he is captivated by a search for transferable systems and ideas that he can take back to medicine. What he discovers, in essence, is that at the heart of complicated peak-performance lies checklists. On a visit to a 28-storey construction site, the author finds a modern project room with huge sheets of checklists – scheduling to minutiae every task, or check step, involved in the current phase of build. Alongside this, a communication checklist – essentially facilitating the necessary set of team conversations that needed to take place for current snags to be overcome, for integration clashes to be resolved and to look ahead to the information needed for the next phase to proceed.

And these checklists work. In the US, the construction record of success is staggering. With over five million commercial properties, one hundred million low-rise homes and eight million high rise residences, there is (according to an Ohio State University study) a failure rate of less than 0.00002%.

As a backstory to these benchmarking visits, Gawande explains how – as part of a World Health Organisation (WHO) task force – he is charged with finding ways in which interventionary surgery can be made safer across the world. It has, after all, a far higher failure rate than construction!

Sensing that checklists hold part of the answer, he meets also with aviation safety experts. On a visit to Boeing, a veteran pilot – Dan Boorman – explains the life saving role of checklists. Take for example, a 1989 United Airlines 747 flight from Honolulu to Auckland, New Zealand with 337 passengers on board. Over the sea, the “DOOR FORWARD CARGO” light comes on; an electrical short had caused the cargo door to come unlatched at 22,000 feet above sea level. At that altitude, that is a potentially catastrophic hazard; if it opens enough to leak air, then there is a potentially explosive difference between inside and outside air pressures. Within moments, this is exactly what happened: an explosion blew out the cargo door taking it with it several upper deck windows  and five rows of business class seats. Nine passengers were lost at sea and a stewardess nearly joined them – were it not for an alert passenger grabbing her by the ankles. Remarkably, the flight was returned to Honolulu with no further loss of life. How? In the utter chaos of this moment, the pilots grabbed their checklist book. From the flight recorder:

CAPTAIN: You want me to read a checklist?

FLIGHT ENGINEER: Yeah, I got it out. When you’re ready.

CAPTAIN: Ready.

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Figure: United Airlines Flight 811

Learning from such masters, Gawande introduced a nineteen step checklist into eight pilot hospitals around the world. The checks – typically initiated by a lead nurse (to symbolically break the formal surgeon-in-charge hierarchy) – took place at three key moments: before anesthesia, before incision and before leaving the operating theatre. The checks were simple. For example, the assembled team to introduce themselves to each other (basic team formation), to check for patient allergy, to review the risk of airway problems etc.

Many surgeons, arguably, have a quotient of “how can a checklist improve on my hero-professionalism?” type hubris but, despite some adopter resistance, the results were unequivocal. The final results (from 4,000 operations) showed that the rate of major complications for surgical patients – in all eight trial hospitals – fell by 36% after introduction of the checklist. Deaths fell by 47%!

When all WHO trial participating staff were subsequently asked: “If you were having an operation, would you want the checklist to be used?”, 93% said a loud “yes”.  

The Checklist Manifesto is a powerful read arguing as it does against the idea of a checklist as some rote, bureaucratic piece of management. Rather, done well, a checklist can be written in the blood of a thousand failures – quite literally in some domains, and metaphorically in others (e.g. complex programme delivery) thus facilitating repeatable future success. Nor are checklists in some way stifling teamwork or world-leading levels of craftsmanship, skill and mastery. Rather, if you look at leading professionals in many spheres beyond the ones mentioned, you will find that mistakes are genuinely learned from, and operational successes reinforced, by the introduction of institutional checklists. If anything, they are an integral component of high-performing teams – and – the base on which professional artistry can be founded.

The Checklist Manifesto is an easy-to-read (200pp), anecdote-rich romp through this topic and I commend it to entrepreneurs seeking to professionalise their operations. Which brings me on to some closing thoughts closer to home.

Capturing best-practice methodology is, clearly, at the heart of the Method Grid journey and, throughout the public beta trial, we noticed some interesting user patterns. A number of organizations, we observed, were using the platform to both create a master procedure and then (using the cloning functionality) are creating snapshot copies to track actual delivery instances. This got us thinking and, in conversation with many such users, we are now set on introducing a new content area into elements: task checklists!

Whilst still in UX design, the idea will be that a checklist content area(s) can contain multiple steps/tasks/checks for the owner of a delivery instance grid to tick off as they go. At a summary grid level, colleagues will be able to see the graphical progress of each element’s task completion via a %-complete line and, as user-configured, an element can change colour to denote 100% completion. In short, we hope to bring checklists to life very soon in a future release.

A closing thought. There are few professional service providers operating at the level of leading surgeons with respect to the acquired expertise, knowledge and technical skills they bring to bear. We can’t even excuse ourselves with the “every client situation is so different” line – more so than the next trauma patient to arrive in the operating room!? No. The brutal reality is, per Gawande’s illuminating treatise, that we all need to invest more time and effort in the systemization of best-practice!


So, what’s next?

Next week, I talk about the value of a board and how they should be optimally organised as a critical enabler of business growth. The blog will be relevant to even very early stage company founders!

Hopefully, you’ll join us on this journey. It’s totally free, and you don’t have to be a Method Grid customer (though you’re more than welcome to sign up for a free trial here).

We’ll be releasing a new post each week. To get each post emailed to you as soon as it’s published, sign up for the Climbing Mount Audacity mailing list below.

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See you next week. Have something you want to hear more about? Let me know in the comments below or via Twitter.

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