Checklists and How You Manage Them
Thinking back to a letter-to-the-editor that I mentioned last week, this is such a critical point, I wanted to think and write about it again, especially since it was in the comments and not everyone sees that.
It's not the checklist itself that's important – what matters is how it is managed.
A checklist, or any form of standardized work, is useless if it is not followed consistently or, in some cases, 100% of the time. Errors might be rare in certain fields, but we don't want to be on that one plane where the pilot fails to go through the pre-flight checklist (because they are feeling rushed or out of arrogance), leading to catastrophic results (such as the Northwest Airlines Flight 255 crash that happened during my childhood in Detroit because the pilots didn't follow a checklist).
As hospitals are adopting checklists (or “standardized work” in the terminology of Lean), I'm sure much effort will be put into the writing of the checklists. Ideally, the checklists will be written by the people who actually do the work, rather than being copied from another site or being handed down from a manager or a single expert. Hopefully, people working in the process will be taught to understand the value of a checklist, rather than just being told to do it.
So if we have a checklist in place, how do we make sure it is followed 100% of the time? Again, creating “buy in” by involving people and selling the idea of the checklist is important. That is leadership's job. It is important for managers to “audit” the use of checklists, but we cannot watch people 100% of the time. Hence, the need to create that buy-in so people will do the right thing, in all circumstances, when not being watched.Leadership must make it clear that ANY team member can call a true “time out” if a surgical procedure, for example, is about to go forward without the checklist being used. Leadership must support and stand by staff members, particularly junior ones, who take what might be a courageous stand against, let's say, a powerful surgeon who doesn't want to do the checklist.
vWhile we don't want to “hound” people constantly, it is important that leaders check frequently to make sure the checklists are being used. We want to avoid a situation like one where a hospital leader, before Lean, explained (somewhat tongue in cheek) that “this process is so critical that nobody ever checks to make sure it's happening.”
As President Ronald Reagan famously said, “trust, but verify.” Leaders, or other designated observers, must check in to see that checklists are being followed (at the time they are supposed to be used), or we must verify the paperwork quickly after the fact to see if the checklists have been followed. Some direct observation is important to make sure that the checklists aren't just a “tick the box” exercise that is done without thinking. We have to make sure the “spirit of the law” is followed, not just the “letter of the law.”
Here is a recent story from the BBC about a hospital that has new rules requiring that physicians not wear long sleeves and that, if they wear ties, they be tucked back. These rules are in place to make it easier for physicians to wash their hands and to help them avoid touching a dirty tie during the day. Again, hopefully these rules were developed with the participation of the physicians and that they were sold on the idea, rather than having it dictated. At least one physician is helping lead the effort, apparently:
Consultant physician Dr Chris Uridge told BBC News: “We roll our sleeves up, take off any rings, bracelets and wrist watches.”If you've got cuffs and watches it inhibits good, effective cleansing – it's as simple as that.”
Good stuff – they are measuring the results (although there are other changes happening in parallel – how do you prove it was this change that reduced infection rates? It seems like it would help, though. It also sounds like they are explaining why, a good Lean practice that is in keeping with the “respect for people” principle.
Now my question for this scenario would be, “who is monitoring or verifying that these practices are being followed?” The reaction of administrative and clinical leaders when they see someone wearing long sleeves that first time will be critical. If they look the other way, then they effectively have no standardized work.Leaders must be strong enough to question people when they are not following standardized work. This doesn't mean they should yell at someone. Especially early on when a new method, it's good to gently reinforce the importance of the new standard, making sure people are aware and they understand why it's important. If you don't hold people accountable, the standardized work becomes discretionary and you'll lose the potential benefits that would come from everyone following the process.
Asking, rather than yelling, is key because there may be certain circumstances when it was best for the patient to NOT follow the standardized work. For example, a truly urgent situation in the emergency department might require swift action, where the risk of stopping to do a time out (time delay) is worse than the risk of a mixup that could occur from not following standardized work.
Even with standardized work, people need to be able to exercise professional judgment. But we have to be careful that someone isn't choosing to not follow standardized work “because I didn't feel like it.” There's a difference between having a legitimate reason or not, as explained in the case of Geisinger Health System and their cardiac surgeons' checklists.So as hospitals implement checklists and time out processes, the same question applies. Who is going to verify and hold people accountable?
Can leaders truly lead and sell people on ideas instead of being dictatorial and mandating?