What a 5-Step Checklist at Johns Hopkins Can Teach You About Life and Business

Often the simplest steps -- ones we repeat all the time -- are an opportunity to slip up and create costly errors.

The average adult makes 35,000 decisions every day -- covering everything from agreeing to a merger proposal to deciding whether to eat the last french fry at lunch. Many of those decisions are fairly mundane or repetitive: things we are confident we know by heart and can therefore devote less mental energy to. In reality, those simplest and most common processes can have seriously negative consequences if they aren't monitored. 

Johns Hopkins discovered just how costly forgetting steps in repetitive processes can be when they tested out a five-step checklist (with very simple steps like "wash your hands" and "place a sterile dressing over the patient") for doctors to use while replacing catheters in the ICU. The results shocked everyone: Infections went from 11 percent to zero -- and only two total line infections occurred in the 15 months that followed. Johns Hopkins estimated this simple checklist prevented 43 infections and 8 deaths, and saved $2 million.

I'm willing to bet every doctor and administrator in that hospital thought a simple checklist reminding doctors of the basic things they definitely know to do would be a waste of time. Well, we all know now how that turned out. So, my question for you is, where is status quo bias keeping you from finding your own checklist-worthy fixes?

You may not have lives on the line, but that doesn't mean a few reminders wouldn't significantly boost productivity or profits (or reduce expenses). So, here are tips from a behavioral economist to help you find your own simple fixes.

Look for important, repetitive processes.

Decision making in the human brain is dominated by the subconscious, which uses rules of thumb (heuristics) to decide what is best. When it gets overwhelmed and busy, simple things begin to slip through the cracks. The basic things we do 100 times a day blur together. A doctor remembers washing their hands and assumes it was on this line change--but was that with the last patient? The brain is too busy to confirm, and those most basic things quickly become a problem.

To use the checklist solution properly in your business, it needs to be boiled down to its key elements and easily followed by everyone involved.

As an example, I created a checklist for my marketing department to ensure we didn't forget media options when creating a campaign. This continued to be used throughout the project to ensure everything was completed on time, reducing rush fees and expensive errors.

Find an outsider to observe.

At Johns Hopkins, nurses watched the doctors to see what they did day in and day out for the first month to see if a problem existed. Once they knew there was a problem, those same nurses were tasked with reminding doctors of the process and not allowing them to miss steps. Observing without intervention can be difficult, but it is critical. Using an outsider is important to reduce bias.

Personally, after watching tellers at the credit union throw away more than 90 percent of printed receipts, I asked why. Apparently, checking the "don't print" box meant a few extra clicks, and it was easier to throw the receipts away. I continued to ask questions (IT, operations) and learned it was merely a default setting. We changed the default and saved thousands in wasted paper.  

Be curious and open minded.

Status quo bias is a clever trick the brain plays on us to keep from changing the rules it loves so much. The overarching problem for the doctors and hospitals is that line infections were assumed to be a cost of doing business for decades. It took one curious man, Peter Pronovost, asking nurses to watch the doctors for a month to see how often they did all the steps on the checklist to discover that at least one step was missed in more than one-third of patients.

When you start looking under rocks and questioning "known truths," you need to be prepared for the brain to rebel. Knowing in advance your brain (and people throughout the organization) will want to fight for the status quo means it is important to be prepared from the beginning.

The Johns Hopkins checklist changed the world because they had hard facts to back up the learnings: infections prevented, deaths avoided, dollars saved. Observation isn't enough. Begin your project like a researcher and it will be easier to defend if and when you find something worth fixing. 

And, remember, your checklist doesn't need to save millions in one go. Small fixes add up. Where will you start?