I recently read The Checklist Manifesto: How to Get Things Right by Atul Gawande, a surgeon with a strong interest in process improvement. It’s a great book about the value of multi-disciplinary reviews at certain stages of a project and the use of checklists. This book comes from a major WHO project he was involved with, which led to testing & validating the fact that having the habit and discipline of using appropriate checklists does help a lot in preventing mistakes in surgical operations.
Read on for my thoughts about this interesting book and some examples I suggest about how its approaches might help improve NPI and routine manufacturing.
Examining how commercial construction projects were managed
Gawande was curious about the way commercial construction projects were managed. A new shopping mall or a new skyscraper is a project too complex for one person, from a central location, to plan and control. Every project comes with its own specific difficulties and not all can be pre-planned. (Same as new electro-mechanical product development — more on that below.)
In commercial construction, the different contractors from different specialities, from structural engineering to plumbing and electricity, have to communicate about certain topics. Without that communication and what they often call “submissions”, major risks cannot be uncovered and managed as needed.
Best practices from aviation
The author also looked for best practices from aviation. The pre-flight checklist was introduced after a B17 crash (the investigation mentioned it was “too much plane to fly for 1 pilot” and, rather than more training, one corrective action was the use of a simple checklist. There are now checklists for many possible situations, such as engine failure, non-responsive landing gear, and so on.A Boeing expert who develops checklists was interviewed. Here are the good practices he suggests:
- Decide on the appropriate moments when to force people to pause and go through a checklist
- Decide if it should be a “do, confirm” checklist (people do the tasks and then check if they forgot something) or a “read, do” one (people have to read the points one by one and take action at the same time — that’s safer but more constraining)
- Keep it, ideally, to 5-9 items, and it should not take more than 2 or 3 minutes to go through (otherwise, people become much more likely to skip some points)
- The wording needs to be simple and adapted to what people are used to saying
- In every case, the checklist’s first draft must be tested in the real world and then tweaked as needed
The topic, of course, is deep and could not be covered entirely in such a short book. For example, the practice of “pointing & calling” is quite powerful in some settings, for example for train drivers. However, it may be too “theatrical” for surgeons and nurses to accept it easily.The author noted that few people are interested in the discipline of building checklists and using them systematically, and there is usually some resistance. Nearly everybody underestimates the power of a simple checklist in reducing omissions & mistakes.
How this also plays out in New Product Introduction and Routine Manufacturing
Here are some examples of where checklists could be adopted to improve new product introduction and routine manufacturing:
- Having an engineer who represents the manufacturing department look at the way the R&D team builds a prototype can lead to a lot of good suggestions to make the product easier and cheaper to manufacture. Having that engineer fill out a simple form with questions such as “any operation that seems unlikely to be replicated consistently?” or “any operation where operators will struggle if they don’t have proper tooling?” is quite useful.
- The bill of materials, and the drawings of custom-designed components, need to be reviewed formally at certain stages of the development process. Suppliers need to confirm tolerances, the quality team needs to confirm the suppliers of critical components, and so on.
- The process FMEA is a tool to force people from different teams to look at what might go wrong in manufacturing and what could be done to minimize the highest sources of risk.
- Pre-production pilot runs are a non-intuitive but extremely effective step. It is often skipped by inexperienced teams. In our own checklists at our contract manufacturer Agilian, the pilot run can never be skipped for a new product.
- The MRB (Material Review Board) is a way to force people from different disciplines (purchasing, quality, R&D, production…) to come together and make a decision based on a structured analysis.
- Ongoing reliability testing (to be done on each mass production run, as a routine test operation) is often not even planned. However, it is critical for most complex products. If a component is made in a different way during a given batch, and if that discrepancy is capable of leading to serious failures in the hands of customers/users after a few weeks/months, this testing will be likely to catch the issue. In most cases, end-of-the-line product inspections cannot catch such issues.