Over the years, I have spent much time in discussion over the use of checklists for equipment changeovers and startups in plants. I have explained, reasoned, rationalized, cajoled, appealed, beseeched, entreated, implored, pleaded, urged and even cried real tears in my efforts to get people to use checklists.
So it was great to see a recent study published in the New England Journal of Medicine that found (amazingly) that hospitals using checklists in their operating room procedures suffer a much lower death rate than those that don’t.
I was glad to see the study, but my very first reaction on reading it was outrage, along the lines of “Operating rooms don’t routinely use checklists? What?” Hopefully, the study will ratchet up awareness and perhaps drive some improvement.
But experience has absolutely convinced me that there is something in the human psyche that fights back desperately against using checklists.
“We need to get things done quickly. Checklists will slow us down. We know what we’re doing; we’ve done it a zillion times before.” Even with the best intentions in the world, these just are not correct statements.
Generally, we’ve found on packaging lines that any missed item on a changeover checklist cost us at least 10 minutes of lost time on startup. In several cases, it resulted in some significant equipment damage, and who knows how many other times there were damage- or safety-related near-misses. Settings that weren’t changed, bolts that weren’t tightened, clamps left loose – all completely unintentional, done by people who had done it many times before.
Human memory just isn’t reliable enough, especially if interrupted to briefly do something else … or perhaps someone has a question or needs a hand momentarily. Once the mind has changed focus, all bets are off on memory.
A weakening memory in our culture seems to be treated as a real indicator of diminished capability, a sign of oncoming senility, the dreaded “senior moments.” But human memory isn’t a reliable mechanism at any age. We all forget our keys or where we left them or “what did I come into this room to get?” I’ve seen even the smartest, most capable people I’ve worked with forget things when distracted.
I can understand why surgeons, renowned for the magnitude of their egos, would resist anything that seems to suggest a compensation for a failing capability. But why then have airline pilots (with at least comparable egos) accepted checklists for many years. (Well, yes, the regulations say they have to, but if you talk to them, they say they just wouldn’t even think of operating without them.)
Mike Thomas, an associate who was a Navy pilot and then a long-time trainer of Navy and airline pilots, explains it as just a part of flying. From their very first exposure to airplanes, pilots work from checklists, and a key part of the trainer’s job is training in how to use checklists, just as much as training in the actual functions of the airplane.
Similarly in plants, we’ve found when individuals are trained to perform tasks using checklists, they tend to continue using them. The difficulty comes when someone has been routinely performing a task before the checklist is developed. Even if they help develop the checklist, it’s still difficult for them to begin using it.
Of course, we always get the argument that for pilots it’s a life-and-death situation (surgeons, too), and the same rigorous practices are just not necessary (and not affordable) in industry. Yet, when we started using checklists, things always got better and faster.
The simple answer then is just to make it a requirement for people to use checklists, and if they don’t, then there are consequences. But if you absolutely insist that people turn in completed checklists, then you’ll absolutely get completed checklists, because that’s what you asked for. Nothing says the checklist was actually used like it should have been. Unfortunately, that’s the story behind much reported checklist use. The requirement was a completed checklist, so that’s what we got.
I have looked in many files and seen many pristine checklists and preventive maintenance (PM) work orders without any fingerprints, smudges or stains, and wondered how people could manage to keep them that clean out on the floor.
Americans historically are not good at mindless obedience, but we are quite excellent at mindful disobedience, particularly when someone tries to force us to do something for which we don’t hold much value. That’s the way people in this country are typically wired, and I’m sure it’s becoming the case in most other countries these days. We always push the limits, and we don’t take much for granted.
(You know just one thing wrong on that checklist, even a typo, negates completely the value of the entire thing.)
We also had to talk about different ways to use checklists. If someone has performed a task countless times, it’s not very efficient for them to go step by step through a detailed listing, checking off each item as they do it. In that case, it’s OK to perform a small group of related tasks and then check them off. But it is never OK to perform all the tasks and then check them off.
I have counseled people, “Why do you want to stress yourself, taking the risk of forgetting something? Why even try to remember? Use the checklist.” This is all about getting equipment started up and running well, as fast as possible, not completing mental improvement exercises.
Who deserves more respect – the person who uses the checklist, completes the changeover perfectly and the equipment starts up and just runs, or the person who manages to do almost all those steps completely from memory and then we burn time trying to get started?
If you want to win trivia games at home, maybe even compete on Jeopardy or otherwise exhibit incredible memory prowess, that’s great, but memory gymnastic demonstrations don’t help us with more effective, efficient equipment changeovers or startups.
I remember a plant where the qualification requirement for operating a piece of equipment was to be able to change it over completely from memory. This was a big piece of equipment with way more than 100 steps in the procedure. I got blank stares when I asked why?
So, what actually works?
- The use of checklists has to be mandatory, beyond debate. Just like safety glasses, ear protection, lockout safety, etc., they’re part of the job. But it takes much more than law-and-order enforcement to get successful ongoing use.
- You have to work with people and train them to do the job using the lists. Then it’s a routine, essential part of the process, and they get over the idea that it’s something extra, that it’s slowing them down.
- You have to actually be out there, making sure that everyone has his or her checklist and is really using it, and finding any issues with the lists.
- We found laminated plastic checklists and grease pencils worked best.
- Changeover follow-up meetings can help determine where people are struggling with the checklists. Identify time loss due to improper use. We’re looking for improvement, not blame. Blame tends to get you back again to mindful disobedience.
- You must have active, participative processes to continuously improve changeovers and startups that include keeping the checklists current and building ongoing ownership for them. It’s always amazing how ownership makes the whole process just so much easier.
This means constant work for team leaders, supervisors and managers, but it’s an essential part of their job. Most importantly, they themselves really have to believe that using checklists is the most effective, efficient approach.
About the Author
Currently working as a consultant, John Crossan retired after spending 30-plus years with the Clorox Company. His roles for much of the past 14 years were mainly focused on improving operations by fostering the installation and ongoing implementation of basic manufacturing and maintenance procedural mechanisms across 30 varied plants in the U.S. and Canada. Prior to Clorox, John also held operational and engineering roles with Johnson & Johnson and the Burndy Corporation. He can be reached via e-mail at john@johncrossan.com or online at www.johncrossan.com.
