Surgical Checklists in the News!
Thanks to long-time readers Chet and Andrew for pointing out these similar stories, one from NPR in the U.S. and one from The Independent newspaper in the U.K. (front-page news!)
As a Lean thinker, I love the idea of checklists. They are the Lean concept of “standardized work” in a different wrapper. Standardized work helps ensure quality and consistency of processes – whether in a factory, an airplane cockpit, or a medical setting.
Checklists, when done properly, are written by the people who do the work (just as we would do with standardized work). This isn't about consultants, mangers, or a single expert dictating the process to others.
Checklists aren't intended to “turn people into robots.” Checklists and standardized work are a foundation, they cover typical situations, but can't cover everything. When a truly unique situation comes up, people are expected to utilize their professional judgment – to use their brains. There's a Toyota expression that says standardized work allows you to avoid hundreds of little decisions so you can make the one major decision that matters.
Checklists aren't “carved in stone” practices that can never change. As new evidence or practices emerge, checklists and standardized work can be improved – that's the Lean concept of “kaizen.”
All of these principles were seen back in the story of the cardiac surgeons at Geisinger Health System in Pennsylvania. The surgeons themselves credited the checklists and standardized process for elective bypass surgeries – before, during, and after. The surgeons were able to deviate from the standardized work IF they had a reason they could justify to their peers (not just “because I didn't want to follow it today”). They improved upon their standard over time… and outcomes for patients improved dramatically.
As I've also written about, the work of Dr. Peter Pronovost and Dr. Atul Gawande has proven that checklists are incredibly powerful – preventing infections another preventable patient harm. This probably should be a surprise to Lean thinkers.
So now the World Health Organization is looking to spread these simple, yet powerful, practices around the world.
Since the 1930s, airplane pilots have run through checklists before taking off. Now the World Health Organization wants surgeons all over the globe to use them, too.
Dr. E. Patchen Dellinger, a surgeon at the University of Washington Medical Center in Seattle, says people are surprised when he tells them about the project.
“One of the common reactions is, ‘You mean you weren't doing that before? Good heavens!'” he says.
Yes, I can understand that reaction! For all of the medical and clinical brilliance in our hospitals, they often have a great deal of opportunity for operational improvements.
Of course there will be resistance to this – as with any change. Again, from NPR:
Gawande says there's been some resistance to the list. One London surgeon thought it was demeaning “Mickey Mouse stuff” until one day in the operating room.
“Right before the incision [the medical team] took a timeout,” Gawande says, “and when it came to the nurse's turn to raise any concerns, the nurse asked: ‘Are we really sure we have the right size knee replacement for this patient?'”
Turns out, they didn't â€” not anywhere in the hospital. That surgeon now swears by the surgical checklist.
The surgeon now sees the benefit of the checklists – to the patient and to themselves (avoiding a lawsuit — although I don't know how the legal system treats that in the U.K., compared to here in the U.S.). We have to sell people on the benefits of checklists — not just forcing the method on them and saying “here, do this.” It's one of my truisms that “people don't like to be told what to do.” That's true not only for doctors… but for practically any time of person or role.
From The Independent:
More than eight million operations were carried out in the UK last year, equivalent to one for every eight people in the population, and there were 129,000 reported incidents in which patients were put at risk, according to the National Patient Safety Agency.
An estimated 2,000 NHS patients die each year as a result of errors in treatment, and an inquiry by the National Audit Office in 2005 concluded that half of all incidents could have been avoided if staff had learnt the lessons of previous mistakes.
And more quotes from Gawande:
Atul Gawande, the US surgeon and columnist for the New Yorker who is leading the initiative for the World Health Organisation, said: “The complexity of medicine has increased to the point where no one person can ensure it is delivered reliably and accurately. We have been struggling for a tool that can help people reliably deliver safe care. The checklist is turning out to be as important to successful care as the stethoscope. I think you could make the case that it is the biggest innovation since the stethoscope.”
Dr Gawande said: “At the start of the pilot in the eight hospitals, 64 per cent of patients missed at least one check. Putting in the checklist cut the failure rate by half and has reduced deaths and complications, though it is too early to put a figure on it. The remarkable thing was we couldn't tell the first world countries from the developing world countries. This has shown we can do something we have never seen before – improve the safety of surgery on a population basis.”
I'm surprised that the error rate was only cut in half. Having the checklist is one thing — we need a management system and culture that ensures that the checklist is used the right way. Zero errors needs to be the goal with checklists.
Worldwide, the WHO aims to have the checklist operating in 2,500 hospitals in the most populous countries (with 75 per cent of the world's population) by the end of next year.
If you're reading this and you're not a hospital employee or leader — if you're a patient — it's time to push your local community hospitals to implement this proven method. If not before YOUR surgery, then before the surgery of a neighbor or a loved one. As Pronovost said before, the only thing stopping us from spreading the use of checklists is a lack of desire to do so.
The method is cheap, it's relatively easy, and it works!