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Checklists + Team Collaboration = Excellent Results
- 1. Checklists + Team Collaboration = Excellent Results Jeff Tanner, Engineer @ TUNE
- 2. Take Away: Tools to help success minded Experts better: 1)agreed to work as a team with a single mindset goal... 2)to jointly and fully verify well prepared checklists to assure success
- 3. Introduction
- 5. Many have reviewed “Checklist Manifesto” Praising checklists. How they help Experts.
- 6. However almost none take away from the book… 1)Creating Good Checklist is Hard. 2)Good Checklists only work if Used. 3)Using Checklists well requires joint collaboration with a Team.
- 7. However almost none take away from the book… 1)Creating Good Checklist is Hard. 2)Good Checklists only work if Used. 3)Using Checklists well requires joint collaboration with a Team.
- 8. However almost none take away from the book… 1)Creating Good Checklist is Hard. 2)Good Checklists only work if Used. 3)Using Checklists well requires joint collaboration with a Team.
- 10. Man is fallible, but maybe men are less so. Atul Gawande
- 11. We are flawed decision-makers with unreliable memories
- 12. Because we are flawed Checklists seem able to defend anyone even the experienced against failure.
- 13. Before Issuing Important Projects Before Making Critical Decisions Checklists have an excellent track record of producing high-quality work.
- 14. Before Issuing Important Projects Before Making Critical Decisions Checklists have an excellent track record of producing high-quality work.
- 15. Before Issuing Important Projects Before Making Critical Decisions Checklists have an excellent track record of producing high-quality work.
- 16. ● Delivers repeatable results ● Saves time ● Reduces risk Checklists used within Team Collaboration
- 17. ● Encourages trust ● Increases consistency ● Provide clear accountability ● Make less mistakes Checklists used within Team Collaboration
- 18. Ingeniously Simple Approach: Checklist
- 19. When the world was simple, There were those who were masters of their trade and they were the overlord over their subordinates.
- 20. Then the world got more complex.
- 21. Major Ployer P. Hill Boeing Model 299 “Flying Fortress” October 30, 1935
- 24. Checkless are our defence because they catch mental flaws inherent in all of us: ● Memory ● Attention ● Thoroughness
- 25. Creating a Good Checklist
- 27. Reasons for Failure ● Ignorance (Did not know or Know Partially) ● Ineptitude (Know but fail to apply) ● Miscommunication ● Missed Communication
- 28. Types of Checklists DO-CONFIRM ● Allows more freedom to complete tasks or checks from memory before consulting the list. ● Once the tasks are completed, a pause point occurs. ● Checklist can be consulted to confirm that no tasks have been overlooked.
- 29. Types of Checklists READ-DO ● Works a bit like a recipe. ● Reading each item on the list, then Complete it before moving on.
- 30. Bad checklists are: ● vague and imprecise ● too long ● hard to use ● impractical ● treat people as dumb ● spell out every single step ● turns brains off Daniel Boorman
- 31. Good checklists are: ● reminders of only the most critical and important steps ● makes priorities clear ● easy to use even in the most difficult situations ● efficient, 60 to 90 seconds to complete ● do not try to spell out everything Daniel Boorman
- 32. Pause Points Before going to the next step, pressing go button
- 33. Pause Points Before going to the next step, pressing go button Speedy 5-9 “Killer” Items < 60 seconds
- 34. Pause Points Before going to the next step, pressing go button Speedy 5-9 “Killer” Items < 60 seconds Supplement to Existing Knowledge Concise Reminders
- 35. Pause Points Before going to the next step, pressing go button Speedy 5-9 “Killer” Items < 60 seconds Supplement to Existing Knowledge Concise Reminders Field Tested and Updated Lessons Learned
- 36. Using a Good Checklist
- 37. Construction Checklists foundation electrical plumbing roof Checklist throughout the building process to ensure that work meets building standards.
- 38. Aviation Checklist pre-flight before takeoff before landing shutdown Despite hundreds of flights and thousands of hours of training a veteran pilot still consults a checklist before making any major decision
- 39. Aviation Checklist: "Miracle on the Hudson" 2009 Crew saved Lives Decision to Use Engine Dual Failure Checklist
- 40. It is the builders and the pilots discipline to consult checklists no matter how familiar they are with their jobs is what makes them responsible professionals.
- 43. After 3 months of using checklists: Major complications dropped 36% Deaths dropped 47%
- 44. Surgery does not begin or goes onto the next step until the nurse goes through the checklist until all items are validated. “Verify that the correct patient is on the table”
- 45. ● Training ● Experience ● Intelligence Doctors started to see the benefits and the disasters it prevented, they embraced checklists. Despite:
- 46. ● Checklists are not just recipes ● They are reminders ● For teams to prepare for the unexpected
- 47. We don’t like checklists. They can be painstaking. They’re not much fun. The truly great are daring. They improvise. They do not have protocols and checklists. Maybe our idea of heroism needs updating.
Editor's Notes
- On October 30, 1935, at Wright Air Field in Dayton, Ohio, the U.S. Army Air Corps held a flight competition for airplane manufacturers vying to build the military’s next-generation long-range bomber. It wasn’t supposed to be much of a competition. In early evaluations, the Boeing Corporation’s gleaming aluminum-alloy Model 299 had trounced the designs of Martin and Douglas. Boeing’s plane could carry five times as many bombs as the army had requested; it could fly faster than previous bombers and almost twice as far. A Seattle newspaperman who had glimpsed the plane on a test flight over his city called it the “flying fortress,” and the name stuck. The flight “competition,” according to the military historian Phillip Meilinger, was regarded as a mere formality. The army planned to order at least sixty-five of the aircraft. A small crowd of army brass and manufacturing executives watched as the Model 299 test plane taxied onto the runway. It was sleek and impressive, with a 103-foot wingspan and four engines jutting out from the wings, rather than the usual two. The plane roared down the tarmac, lifted off smoothly, and climbed sharply to three hundred feet. Then it stalled, turned on one wing, and crashed in a fiery explosion. Two of the five crew members died, including the pilot, Major Ployer P. Hill.
- An investigation revealed that nothing mechanical had gone wrong. The crash had been due to “pilot error,” the report said. Substantially more complex than previous aircraft, the new plane required the pilot to attend to the four engines, each with its own oil-fuel mix, the retractable landing gear, the wing flaps, electric trim tabs that needed adjustment to maintain stability at different airspeeds, and constant-speed propellers whose pitch had to be regulated with hydraulic controls, among other features. While doing all this, Hill had forgotten to release a new locking mechanism on the elevator and rudder controls. The Boeing model was deemed, as a newspaper put it, “too much airplane for one man to fly.” The army air corps declared Douglas’s smaller design the winner. Boeing nearly went bankrupt.
- Still, the army purchased a few aircraft from Boeing as test planes, and some insiders remained convinced that the aircraft was flyable. So a group of test pilots got together and considered what to do. What they decided not to do was almost as interesting as what they actually did. They did not require Model 299 pilots to undergo longer training. It was hard to imagine having more experience and expertise than Major Hill, who had been the air corps’ chief of flight testing. Instead, they came up with an ingeniously simple approach: they created a pilot’s checklist. Its mere existence indicated how far aeronautics had advanced. In the early years of flight, getting an aircraft into the air might have been nerve-racking but it was hardly complex. Using a checklist for takeoff would no more have occurred to a pilot than to a driver backing a car out of the garage. But flying this new plane was too complicated to be left to the memory of any one person, however expert.
- From the ashes of 1935, four generations after the first aviation checklists went into use, a lesson is emerging. Checkless are our defence because they catch mental flaws inherent in all of us:
- A useful checklist has a clear pause point a particular point in time where you know to pause and complete the checklist before proceeding
- a useful checklist is speedy at each item of a checklist has to be less than 60 seconds to complete any longer and you'll resist doing it or you'll start ignoring it
- a useful checklist is a supplement to existing knowledge and expertise a checklist should not allow you to turn your brain off and execute a task like a robot each item should be a short and concise reminder a way of triggering a familiar routine
- A useful checklist is field tested and continually updated a checklist should be practical and based on actual experiences if it's not you won't trust it an ideal checklist is made up of past failures and lessons