Checklists Promoted and Debated on “Grey’s Anatomy”
It's my second post about the TV show Grey's Anatomy, the first being “McDreamy” Fights the Blame Game on “Grey's Anatomy.” Each post makes it less believable that I don't watch the show religiously. Thanks go to my wife for detecting something Lean related and calling me into the room to watch.
Last week's episode had a subplot about Checklists and protocols. A number of blog readers also emailed or tweeted saying I needed to check it out. I've compiled about 3:30 of the Checklist-related clips into a video for this post – I hope it's educational and provides a way to talk in your hospital about the real-world issues related to Checklists.
In the video, you see a sequence of events from throughout the episode (yes, the love stories and other drama have been edited out):
- An eager resident, April, is telling the head of trauma surgery about checklists and how they're taken from aviation safety
- The checklist she is talking through is for the emergency department (we normally hear about checklists in operating rooms)
- Another resident, Cristina, purposefully violates “proper protocol” and refuses to page the attending (it is a very unusual case involving a small tree in a patient's lungs and Christina wants to do the procedure herself).
- April calls out Cristina for violating protocol, Cristina argues she “streamlined it.”
- During surgery, Cristina says she wants to keep the small tree. April argues that proper protocol is to send it to pathology for disposal. Cristina gives a speech, “Protocol accounts for whatever comes up. That's why we have protocol, so there are rules and steps that we can depend on. I know the rules seem fussy and annoying and the people who enforce them are fussy and annoying too, but they are there for a reason.” Cristina says, “I don't care how many boxes you check, you're not going to be chief resident.”
- In a final scene, April gives a little speech at the bar (as her colleagues roll their eyes), “You know the rules are there for a reason. I killed a woman when I first started here. I got fired for it because I missed a little step. One simple step. If you follow the protocol, you don't skip steps. People live. Simple as that. The checklists work. You can't tell me they don't.”
Here is the edited video:
Let's dig into a few details about the checklists as shown here.
Dr. Atul Gawande, in his outstanding book The Checklist Manifesto: How to Get Things Right, he emphasizes that checklists don't contain every single step, just the most important steps that are likely to be forgotten or skipped.
Is the checklist overly specific? It says, on the third line, “PLACE PATIENT IN ER GOWN.” Is that really a necessary thing for a checklist? Being overly specific like this is one reason some people react to checklists as being silly.
Below, we can see the boxes that Cristina just checked without really properly going through them. Page attending got checked, although she never planned on doing it.
It's often too easy to just check the list without really doing the steps. I've seen hospital departments where there was supposed to be a checklist done daily to verify that all needed emergency supplies were present. Doing spot checks, there was always at least one item missing, although somebody had checked the boxes everybody. In the UK, they'd warn against a “tick box” exercise, if I have the lingo right.
In cases like this, or in other standardized work, who is checking to make sure the checklist is being properly followed? In the Grey's Anatomy full episode, the attending DOES somehow find out that Cristina wasn't following protocol, but the patient said he wanted Cristina to do the procedure (hence the “hostile environment” comment and the stare from the attending from outside the O.R.). I think the implication was that April ratted Cristina out – that's not ideal management of standardized work, especially since April's motivation was probably more about currying favor to try to be chief resident (or maybe she was concerned about what was best for the patient too).
What are your reactions to the clips? How do you feel about the portrayal and the situations as a healthcare professional or as an outsider?
Dr. Gawande emphasizes, as we would with Lean standardized work, that the checklist isn't a substitute for thinking and judgment. But, here, we clearly see a doctor who thinks the protocol is interfering with what she wants to do (also, seemingly, for selfish motives). Are checklists overly fussy and annoying? How do we find the balance between helpful and not being annoying?