The Importance of Checklists
“For nearly all of history, people’s lives have been governed primarily by ignorance,” writes acclaimed surgeon and best-selling author, Atul Gawande. But today, he says, supported by huge gains in science and technology, we seldom fail for lack of knowing, instead, “the problem we face is ineptitude…making sure we apply the knowledge we have consistently and correctly.”
Gawande, a world-renown expert on patient safety, wrote the book, The Checklist Manifesto: How to Get Things Right, primarily for doctors. However, sales and marketing professionals share the surgeon’s experience of working under turbulent circumstances where you frequently get only one chance to get things right with a customer.
The complexity level at which we now work exceeds the limits of our individual cognitive ability. The lowly checklist provides a powerful tool. Let’s not be so vain or so stupid as to ignore it just because it is simple.
The Checklist Manifesto, first published in 2009, follows Gawande and World Health Organization (WHO) on their quest to reduce avoidable death and harm from surgery. What they find – the simple checklist – prevents an average of 47% of deaths from surgery complications. This holds true at amazingly different hospitals ranging from Johns Hopkins to the St. Francis Designated District Hospital in Infakara, Tanzania, a lone rural hospital serving over one million people. Importantly, 78% of their study participants personally witnessed a serious error averted by a checklist and 93% of participants would want a checklist used if they were getting surgery. A recent book, When We Do Harm: A Doctor Confronts Medical Error by Dr. Danielle Ofri highlights similar success stories.
Gawande and Ofri discover how checklists help other professions succeed under turbulent situations: aviation (pilots like Sully Sullenberger use airline checklists to avert disaster), construction (skyscrapers are safe due to checklists), and entertainment (Van Halen’s David Lee Roth famously demanded removal of brown M&Ms in his backstage room in order to test checklist adherence.
I’ve witnessed firsthand how checklists boost quality in complex marketing programs requiring speed and customization. For example, I once led a team for a service company that used checklists for evaluating and responding to RFP’s. A checklist reduced time to delivery by weeks and substantially improved our win rate.
Gawande and Ofri report that not all checklists are created equal. Checklists that work have specific attributes. Checklists that get results stress the critical role of teams – especially the empowerment of people, such as nurses, who are close to the action but aren’t typically aren’t the highest status workers. A great checklist implementation includes “time-out” pauses in the middle of multi-step processes, and stresses how simplicity and the careful selection of checklist items determines success or failure.
My proposal team’s successful checklist process included factors common in agile marketing. Great bids were created by a team – sales, marketing, bid writers, and various subject-matter-experts. Teams held short, frequent, meetings to prioritize, check off critical items, and solve problems. We stopped for “time-outs” to re-evaluate our course. For example, we paused after bid-scoring. Did we think we could win? If not, we opted out.
Checklists are not always popular. Resistance typically comes from one of these reactions:
Heroics. Even the brightest among us cannot remember everything. Yet, some experienced people erroneously think of checklists like training wheels – okay for beginners, but not for an “expert like me.” To paraphrase Abraham Lincoln “we can remember everything some of the time, and some things all of the time, but we can’t remember everything all of the time.” Gawande offers a candid, but frightening, example of a tragedy that he himself nearly causes, averted at the last minute by a colleague’s insistence on checklist adherence. Checklists serve as tools to ensure that all the “stupid, but critical” items get remembered.
Emotion. I resonated with how one successful venture capitalist describes why he uses a checklist. He wants to guard against “cocaine brain”. “Cocaine-brain” is so-called because the prospect of making money lights up the same neurons as cocaine. Neuroscience has shown that emotions overrun our circuits. The proposal team I ran faced the “cocaine brains” of the sales team who brought in the RFP. Checklists offer a dispassionate way to bring us back to reality.
Fatigue. Checklists have been dramatically successful in ensuring quality. But overuse – especially combined with poor implementation – can cause people to “check the boxes” without really doing the checklist work. You can get inadvertently get 100% compliance without any of the benefits.