The Playbook Archives - Page 2 of 3

Five Steps in Michigan

In 2001 Peter Pronovost of Johns Hopkins created “a simple checklist designed to reduce line infections” in intensive care units. It had five steps: wash hands, clean the skin with chlorhexidine, cover the patient with a full sterile drape, wear full sterile gear, and put a sterile dressing over the site.

The list was then used across Michigan, in the Keystone Initiative. In three months, “the infection rate in Michigan’s I.C.U.s decreased by sixty-six per cent.” In eighteen months it saved “more than fifteen hundred lives.” The results were published in the New England Journal of Medicine in December 2006.

Too Much Airplane

On October 30, 1935, Boeing’s Model 299 bomber crashed at Wright Field, Ohio. The board blamed “the elevator control being locked.” Two crew members died. According to the surgeon and writer Atul Gawande, a newspaper called the plane “too much airplane for one man to fly.”

After the crash, “Air Corps personnel developed checklists” for takeoff, flight and landing. The Model 299 became the B-17, and 12,730 B-17s followed. Gawande retold the story in The New Yorker and in his book The Checklist Manifesto (2009).

One Word Changed

Alcoholics Anonymous was founded in 1935 in Akron, Ohio, by Bill Wilson and Dr. Robert Holbrook Smith. Its Twelve Steps were first published in 1939. Step One reads: “We admitted we were powerless over alcohol—that our lives had become unmanageable.”

More than 200 self-help organizations now use the twelve-step model. Many keep the sentence and change one word. Narcotics Anonymous is powerless over “our addiction,” Overeaters Anonymous over “food,” Gamblers Anonymous over “gambling” and Debtors Anonymous over “debt.”

After HealthCare.gov

In October 2013 the federal health insurance website, HealthCare.gov, failed at its launch. On August 11, 2014, the White House launched the U.S. Digital Service. It was led by Mikey Dickerson, who had helped fix the site.

The White House also released a Digital Services Playbook of 13 “plays” for government projects. Play 4 reads: “Build the service using agile and iterative practices.” Its text says: “We should use an incremental, fast-paced style of software development to reduce the risk of failure.”

A Single Courageous State

In 1932 the Supreme Court struck down an Oklahoma law that required a license to sell ice. Justice Louis Brandeis dissented. “It is one of the happy incidents of the federal system that a single courageous State may, if its citizens choose, serve as a laboratory; and try novel social and economic experiments without risk to the rest of the country.”

Americans now speak of the states as “laboratories of democracy,” an idea that takes its name from this dissent. One example is the health care law Massachusetts passed in 2006. It became the model for the federal Affordable Care Act.

SBAR

Situation, Background, Assessment, Recommendation. A four-part script for handing a patient from one American clinician to another, taught in nursing schools and used in hospitals nationwide. Borrowed from the US Navy, where it standardized reporting to a commanding officer, and adopted in medicine because unstructured handoffs were losing information at every shift change.

The Incident Command System

Developed after the California wildfires of the 1970s, when agencies arriving at the same fire could not talk to each other, and now the national standard for every kind of US emergency response. Its core is a defined communications structure: who reports to whom, on what channel, in what format, before anyone arrives.

The Center for Army Lessons Learned

The US Army maintains a permanent organization at Fort Leavenworth whose function is to collect what units learned in operations and push it back out to units who have not yet deployed. The Army also runs the after-action review as standard practice after any significant event.

The counter-example is instructive. Where the cost of forgetting is measured in lives, the American institution builds the archive deliberately — which suggests the corporate habit is a choice rather than an incapacity.

The SOP written afterwards

American standard operating procedures are frequently documented after the work has been done successfully several times, by the person who did it. The document records a practice rather than prescribing one, and everybody involved knows which came first.

The pilot program

American organizations run a small version first, in one region, one store, one department — and write the procedure afterwards from what happened. The rollout follows the pilot. The rule follows the rollout.