Relying on Memory Leads to Rework


    Biden Takes Shot at Roberts for Flubbing Presidential Oath – First 100 Days of Presidency – Politics

    On Tuesday, Chief Justice John Roberts appeared to flub his giving of the presidential oath of office, leaving out the word “faithfully” in the phrase “I will faithfully execute the office….” Roberts said “I will execute the office of President to the United States…” and then, in his second attempt, tacked on “faithfully” at the end of the phrase. I'm pretty sure “President to the United states” was wrong too.

    That's a pretty big stage upon which to have a “defect” in the process. Somewhat spoiled a historic moment.

    The cause of the error? Roberts chose not to use a notecard or a “checklist.” Is it confidence or arrogance to think, “I can memorize these 35 words” and not have a notecard as a backup if you get nervous or forgetful?

    …the Supreme Court chief, who a day earlier had to recite to Obama the 35-word oath of office, which Obama was to repeat back to him. Unlike his predecessor, Chief Justice William Rehnquist, Roberts — perhaps unwisely — chose to forego a note card with the oath.

    When he started to say the second portion of the quote “… that I will faithfully execute the office of president of the United States,” he instead put faithfully at the end of the sentence. Obama, who apparently had memorized the oath, looked at Roberts, who then realized his mistake and repeated that portion of the oath correctly.

    Because there was some confusion about the legality of the oath having been said incorrectly (President Obama repeated the defective oath as read by Roberts), the oath was re-administered.

    I think we have our first case of “inaugural rework” here? It certainly wasn't “done right the first time” as we would say in the Lean world.

    It's ironic that the failure to use a checklist tarnished the inauguration when, last week, the issue of surgical checklists made such big news. I will blog about that topic more, but it seems to tie into what happened Tuesday.

    New research published today in the New England Journal of Medicine found that when surgical teams heeded a simple checklist — as pilots do before takeoff — patient-mortality rates were cut nearly in half and complications fell by more than a third.

    The study — which included 7,688 patients in eight hospitals around the world — saw death rates drop from 1.5% before the checklist was instituted to 0.8% afterward. Serious complications fell from 11% to 7%. Study sites included Seattle, London, Toronto, New Delhi, and Ifakara, Tanzania.

    One major advantage of a checklist is that it makes it harder (or impossible) to “forget” a step in a process or to do steps in the wrong order. Some people get overconfident (or maybe cocky) and think “well I couldn't possibly make that mistake, I'm smarter than that” and they don't want to use the checklist.

    We need people in healthcare to take an oath maybe….

    “I will execute this checklist to the surgical process…. faithfully.”

    or “I will faithfully execute the checklists….” Either way :-)

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    Mark Graban
    Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


    1. Mark, looks like your mistake-proofing process for LeanBlog may also need a review? Look at the first paragraph:

      “I will faithfully executive the office….”


    2. I have read hand-washing checklist stories that show this same principle. Many medical professionals thought they were washing there hands but weren’t. Memory (or bad rote patterns) were not enough to keep hands washed. Checklists and other visual reminders have raised awareness and improved wand-washing compliance (and reduced infections).

    3. Mark, my understanding is that this isn’t the first case. It’s been done before I believe with Coolidge and one other president.

    4. How do you convince people to follow the checklist when they say they know it? There is a prevailing thought that reading over the list is overly time consuming and is far worse than the occasional rework. Sadly our numbers for rework are murky as well.


    5. Mark – I gotta admit I chuckled out loud at this. Funny thing is, I never even thought of it from the lean perspective until you brought it up. Jeez, don’t you ever turn off your “lean goggles?” Just kidding…

    6. Mark W. — apparently, I don’t ever turn off those goggles! :-)

      I love it when I’m training hospital people on Lean and we’re into a project… they often start seeing Lean principles (or waste) all around them. It really is a way of thinking, not just a tool set.

    7. Great comment always Mark.

      Unfortunately we live in the “Shortcut” world and healthcare professionals (and every one in business as well) just look for the shortcut or cut to the chase when tackling a task. What they fail to realize it that the “Shortcut” is the Procedural Checklist!!!

      In my consulting practice over the past year have stepped up the use of procedural maps/checklists and have found that it now takes my client project managers 60% less time in performing their respective studies with more detailed procedural maps/checklists. Oh and with much better and faster results on their Lean Value Analysis Studies (evaluations of supply chain products and services).

      Bob Yokl


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