How to avoid the Silly Mistakes


Avoiding Silly Mistakes

Dealing With Increasing Complexity

In a world of ever-increasing complexity it is becoming very difficult to maintain high standards and control mistakes, especially the silly ones that seem to be repeated, even by competent people.  There is a surprisingly simple answer to this fundamental problem that many businesses suffer from.  But very few people want to implement it because it offends their ego.

On the 30th October 1935 a test flight of the new Boeing Model 299, nicknamed the Flying Fortress, took off in front of an elite group of executives and military top brass to show off its superiority over the competition.   To all present it was a given that the new aircraft would easily trounce the other designs on offer.  As it took off and soared into the clear blue sky over Dayton, Ohio it stalled, turned on one wing and fell out of the sky into a fiery explosion.  The investigation revealed that there was no mechanical failure; it was due to “pilot error”.  A local newspaper said that the new aircraft was “too much airplane for one man to fly”.  This incident lost Boeing the contract and they almost went bankrupt.

However, a small group of test pilots were convinced it was flyable and would give the US air superiority in any conflict.  Instead of implementing more training, which until then had been the answer to improving safety, they set about developing an ingeniously simple approach; a pilot’s checklist.  Early planes may have required nerves of steel but they were not very complicated, giving a pilot a checklist for takeoff would have been similar to asking a driver to use one for backing out of a garage.  Things had rapidly changed and the new plane was too complicated to be left to the memory of one person; no matter how well-trained they were.

If They Can Do It . . .

In his excellent book “The Checklist Manifesto” the expert surgeon and author Atul Gawande tells the story of how the humble checklist has been used to save thousands of lives in critical surgery around the world.  In one impeccably researched test including St. Mary’s Hospital, London and others in Jordan, Tanzania, Canada and New Zealand he recorded a one-third reduction of deaths and complications by using a ninety-second checklist.  It was achieved at virtually no cost for almost any operation.  This checklist is now being adopted throughout the NHS and around the world.

However, it was a challenging task to implement the checklist because there was massive resistance.  How could you create a checklist to deal with the extreme complexity of surgery?  One recent study of 41,000 trauma patients found they had 1,224 different injury-related diagnoses in 32,261 unique combinations.   Atul and his team of researchers also had to break through the egos of doctors and surgeons.  “Checklists are for nurses” they said, “We are specialists and experts, so don’t need them”.

One courageous surgeon named Peter Pronovost decided to give the principle of the checklist a try and developed a simple version for his doctors to avoid infection in Intensive Care.  It seems silly to make a 5 point checklist for items that all doctors knew about and had been taught for years, but initial observations identified that they skipped one of the 5 steps in at least a third of patients.

A Revolutionary Step

They then took a revolutionary step.  They authorised nurses to stop doctors if they saw them miss a step on the checklist and if a doctor ignored them there would be personal consequences for the doctor.   The results were so dramatic that at first Pronovost and his team didn’t believe them.  The 10 day infection rate went from 11% to zero.  In a 15 month follow up study they calculated that the checklist had prevented 43 infections and 8 deaths and saved $2 million in costs.

Even with these powerful statistics many doctors were reluctant and cried “Forget the paperwork. Take care of the patient.”  It just goes to prove that it takes strong leadership to implement behavioural change – or to make the new behaviour rewarding.  In one field test 80% of doctors used the checklist and confirmed it helped but 20% remained sceptical.  However, when these sceptical doctors were asked; “If you were having an operation would you want a checklist to be used?” 93% said yes.

Activating Everyone

In another checklist experiment Atul observed that one surgical team had added an interesting item to their checklist.  In large hospitals it is not unusual for a team to come together for the first time for a particular operation.  So every person in theatre had to introduce themselves and their role.  While this may seem very simple, it added to the considerable academic evidence that people who know each other’s names work better together.

It is called the ‘Activation Phenomenon’, when people get a chance to speak early on it seems that they are more likely to actively participate and take responsibility.  It also means that they are more willing to speak up and contribute.  After 3 months the number of team members reporting that they “functioned as a well-coordinated team” leapt from 68 to 92%.  The now famous ditching of an Airbus 320 into the Hudson River when both engines failed attributed the phenomenal teamwork of the crew to a similar protocol.  Consider the implications of this for getting more from your team.  What are you doing to activate them?

Maintaining Consistency And Saving Time

All the best restaurants maintain consistency with numerous checklists that are finely honed to ensure that all the final dishes are meeting the required standard.  The last check is usually the Head or Sous Chef observing, smelling or tasting the dish as it crosses the Hot Plate to the waiters.  However, chefs don’t call them checklists – they are referred to as recipes.

Back in the 1980’s when I was working as a chef in Michelin Starred restaurants my recipes were a short-hand of ingredients, techniques and timings.  It is interesting to note that I didn’t need a step by step list of each part of the process like domestic cookbooks; only the critical items and steps that made a difference.  This shorthand would be meaningless to others who lacked similar experience and skill.

With complex menus changing monthly, I developed a master checklist of key processes, components and critical ingredients all carefully written out by hand on a single sheet of A4.  I then made photocopies for each day of the month.  This meant I never had to write a daily to-do-list, I only needed to cross off all the things already done leaving the ‘to-do items’ for this shift.  I always left a small blank section on the sheets so I could write notes for the handover as required.  The chefs on other sections would let their egos get the better of them by scoffing at my neat lists on a clipboard.  But they were always fussing over scraps of paper and numerous to-do-lists, often forgetting to make or order some item that was only remembered in the heat of the moment.  This process was a big investment at the beginning of every new Menu but once it was done, it saved me lots of time and more importantly thinking space to focus on training more junior staff.

Develop Your Own

The development of checklists is a fine art that needs to be implemented with consideration not to overburden people but help them focus on the little – but critical – things that can cause inconsistency or persistent problems.   A good place to start is to look at the regular and repetitive mistakes or errors, and then get the people involved to review the process and come up with a list of the ‘critical factors / steps’.  In your business the job-holders are the best people to develop and hone the checklists that they will use, but they may need some help from a manager to get started.

Over the years, Inspired Working has developed a number of checklists in various forms to encourage consistency of communication and performance.  They are not always what you would expect in a traditional checklist.  For example, our FACT Based Appraisals™ focus on the 4 critical things that need to be addressed in an appraisal.  Not only do appraisals need to be based on ‘facts’ rather than opinions and impressions, you really want to have a conversation about:

  • Feedback on performance
  • Agreed priorities
  • Communicating the big picture
  • Training needs analysis

In our popular Appraisal Skills Workshops we cover a number of useful checklists regarding planning, preparing and conducting effective appraisals.  This ensures the appraisal process is meaningful and valued by both managers and staff.

We also have a number of checklists in the Resources section of our new website Inspired Working Online, for example:

  • Communication Strategy Checklist
  • The 7 reasons why people don’t do things
  • How to SET standards
  • How to set SMART Objectives
  • Choosing a Consultant

Just click here for a selection:

Because we believe in making life easy for our regular clients who are implementing the CLEAR Framework™, they get access to a number of other Checklists like:

  • The monthly Planning Checklist
  • The HR Personnel File Checklist
  • The Induction Checklist
  • The Management Skills Checklist
  • The Training Plan Checklist
  • Evaluating Training and Development Activity Checklist
  • Plus many, many more

If you would like to know more about how to implement effective checklists and a robust, yet practical, system for avoiding problems and driving performance please contact Amanda on to arrange a no-obligation call to discuss your needs.

Remember . . . Stay Curious!

With best regards

David Klaasen 

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