Get It Right With Checklists - RD277

The reason to use checklists.

I first talked about checklists way back in episode 89 of Resourceful Designer. In it, I shared various types of checklists you can use for your business. I even shared my now outdated checklist for starting a new WordPress website.

Today, I’m not going to share checklist ideas with you. Instead, I want to talk about the importance of using checklists. To emphasize their importance, I want to start by telling you a story.

I heard this story while listening to an audiobook called My Best Mistake, Epic Fails and Silver Linings written by Terry O’Reilly. It’s a great book of stories about failures that led to amazing things. Check it out if you have the chance. One of the stories O’Reilly tells in the book inspired is what inspired what you’re reading here.

It’s estimated that the average American undergoes seven surgeries in a lifetime, and surgeons perform over 50 million surgeries annually. That’s a lot of operations.

In 2009, roughly 150,000 patients died immediately after surgery—3 times the number of fatalities from road accidents. What’s scary about that number is that half of those deaths were completely avoidable. That number caught the attention of Doctor Atul Gawande, a Boston surgeon and professor at Harvard Medical School.

It’s the 21st century. How can all these complications happen despite the accumulated knowledge of professionals? Gawande wondered if there was a way to reduce the number of operating room errors that resulted in these deaths. To find an answer, Gawande looked at other fields for ideas.

Back in 1935, The U.S. Army was looking for the next generation of long-range bombers. They held a competition between top airplane manufacturers to come up with a new design. Although the issued tender was fair for all involved. It was a known fact that Boeing’s technology was miles ahead of their rivals Martin and Douglas.

Boeing’s new Model 299 could fly faster than any previous bomber, travel twice as far, and carry five times as many bombs as the Army requested. The Army was prepared to order sixty-five of the aircraft before the competition was even over.

The big brass of the Army Air Corps gathered for the first test flight of the Model 299. The impressive machine took to the sky with its 103-foot wingspan and four gleaming engines (instead of the usual two found on most planes.) It was quite a sight to see.

As the plane took flight, it climbed to three hundred feet, stalled, and crashed in a fiery ball of flames. Two of the crew died that day, including the pilot who was the Army Air Corps’ chief of flight testing.

The Army decided to award the contract to Douglas instead. And Boeing almost went bankrupt.

However, The follow-up investigation revealed that there was nothing mechanically wrong with the plane. And it was determined that the crash was due to pilot error. But how could that be? How could the chief of flight testing, one of their most experienced pilots, make a mistake that would lead to the crash of such a sophisticated plane?

As the investigation showed, the Model 299 required the pilot to monitor the four engines. Each one requiring its own oil-fuel mixture. He also had to attend to the landing gear and wing flaps, adjust the electric trim to maintain stability at different airspeeds and regulate the constant-speed propellers with hydraulic controls. And that was only a few of the things on which the pilot needed to concentrate.

It turns out that while attending to all of these things, the pilot forgot to release a new locking mechanism on the elevator and rudder controls. It was a simple oversight that led to the crash.

Boeing was ready to scrap the plane, but a group of pilots believed the Model 299 was flyable. So they got together to find a solution. When they later approached Boeing, they didn’t request any mechanical changes to the plane. Nor did they think pilots needed to undergo extended training on how to fly it. Instead, they came up with a simple and ingenious solution. They created a pilot’s checklist.

They made a list that was short enough to fit on an index card. It covered all the mundane step-by-step tasks required for takeoff, flight, landing and taxiing. In other words, the checklist covered all the dumb stuff.

With the new checklist, pilots flew the Model 299 over 1.8 million miles without one single accident.

To distance themselves from the previous failure during the test flight, Boeing changed the name of their new plane to the B-17. The Army ordered 13,000 of them, which gave the Air Corps a decisive advantage in WWII. All because of a checklist.

Since the 1960s, nurses have relied on charts, a form of a checklist, to know when to dispense medicine, dress wounds, check pulse, blood pressure, respiration, pain level, etc. And although doctors would look at these charts when visiting a patient, they viewed these checklists as “nurse stuff.”

In the late 90s, a study determined the average hospital patient required 178 individual actions by medical staff per day. Any one of which could pose a risk. The researchers noted that doctors and nurses made errors in only 1% of these actions. But that still adds up to almost two errors per day, per patient.

When you multiply that by every hospital worldwide, it means millions of people around the globe are potentially harmed by the very medical staff assigned to help them.

In 2001, a doctor at Johns Hopkins designed a doctor’s checklist for putting in a central line; a tube inserted in a large vein used to administer medication. It’s a standard procedure that just about every doctor is familiar with. It was also a widespread cause of infection in patients.

So this doctor devised a simple checklist listing the five steps involved in carrying out the procedure. He then asked the nurses to observe the doctors for one month and record how often they carried out each step. They found that in over 1/3 of all patients, doctors omitted at least one of the five steps.

The following month, hospital administration instructed the nurses to insist doctors follow each of the steps. The doctors didn’t like being told what to do by the nurses, but the nurses had the backing of hospital administration, so they grudgingly complied. When the new data was later tabulated, they thought maybe a mistake had been made. The infection rate for central lines dropped from 11 percent to zero.

They continued the study for longer, to be sure, but the results were the same. It was estimated that a simple checklist had prevented 43 severe infections and possibly eight deaths in that one hospital, saving $2 million in costs.

And yet, even with this evidence, many doctors refused to grasp the importance of this precaution. They were offended by the very suggestion that they needed a checklist. They already had so much to do that they didn’t want one more sheet of paper to worry about.

To prove his point, the doctor who wrote the checklist introduced it to other hospitals in Michigan. There was pushback, but in just three months, the rate of bloodstream infections dropped by 66 percent. Many of the test hospitals cut their quarterly infection rate to zero. A cost savings of nearly $200 million. All because of a simple little checklist.

All checklists have an essential function. They act as a “mental net” to catch stupid mistakes.

In 2005, the director of surgical administrator in a Columbus, Ohio hospital created a checklist for operating rooms. It contained simple things such as verifying they had the correct patient on the table and the right body area prepared for the surgery. This little addition improved surgical success rates by 89%.

There’s a lot more to this story. In his book, O’Reilly shares stories of how more and more hospitals started implementing checklists for various things, but I’m not going to bore you with them.

Back to the original story. In 2008, after conducting his research, Atul Gawande devised a checklist to be tested by a group of pilot hospitals worldwide. Some operating rooms embraced it, while others protested it as a waste of time.

During a knee replacement surgery to be performed by one of the checklist’s most vocal critics, it was discovered while checking the boxes that the prosthesis on hand was the wrong size. If they had started the surgery, the patient might have lost his leg. That surgeon became an instant checklist evangelist.

In all the hospitals using the checklists, surgical teams began working better together, and the surgical success rates soared. Complications fell by 36 percent, deaths by 47 percent and infections by 50 percent. And patients needing return visits to the operating room fell by 25 percent.

What’s amazing about using checklists is that they dramatically improved an outcome without increasing skill or expenditure. Instead of adding rigidity to their lives, checklists free people by getting the dumb stuff out of the way.

Today, 90 percent of hospitals in North America and 70 percent worldwide use a checklist.

And you want to hear something funny. When Gawande’s original pilot project was completed, doctors were asked to fill out an anonymous survey. Seventy-eight percent said the checklist had prevented errors. But there was still 20 percent who didn’t like the checklist saying it took too long to implement and didn’t think it was worth it. However, when those 20 percents were asked if they had to undergo surgery, would they want the checklist to be used? Ninety-three percent of those who opposed the checklist said yes.

I hope you found these facts as interesting as I did.

Now you may be saying, sure, a checklist in a plane or an operating room makes sense. It can save lives, after all. But I run a graphic design business, so I’m good. I don’t need checklists.

I used to think that way as well. But remember, checklists are freeing because they help get the dumb stuff out of the way, which frees you up for the more important things you do.

I remember a couple of years ago. I was doing routine maintenance on one of my websites I had launched a couple of years prior. While verifying and updating things, I noticed something that almost made my heart stop. The little checkbox next to “Discourage search engines from indexing this site.” was still checked. Meaning, for close to two years, my website was telling search engines, “I’m good. Don’t pay any attention to me. Go look somewhere else.” That’s a stupid mistake that I could have avoided with the use of a pre-launch checklist.

Today, I have several checklists I use regularly. I now have a website pre-launch checklist. A WordPress install checklist. A first client contact checklist. A podcast client checklist. A Resourceful Designer podcast checklist. And many more.

As I said earlier, these checklists help ensure the dumb stuff gets done so that you can concentrate on the more important things without worrying.

If you are not already using checklists in your business, I suggest you start now. And if you think that your checklists are in your head, remember the story about doctors putting in a central line. There are only five steps involved, steps that every doctor knows. And yet, when observed, nurses noted that over 1/3 of all patients, doctors missed at least one of the five steps.

Your memory is failable. A checklist is not.