Dziś o prostym i ważnym, ale niedocenianym narzędziu kontroli jakości złożonych procesów. Szczególnie interesującym, ponieważ autor jest praktykującym chirurgiem.
„In a complex environment, experts are up against two main difficulties. The first is the fallibility of human memory and attention, especially when it comes to mundane, routine matters that are easily overlooked under the strain of more pressing events. [...] Faulty memory and distraction are a particular danger in what engineers call allor-none processes: whether running to the store to buy ingredients for a cake, preparing an airplane for takeoff, or evaluating a sick person in the hospital, if you miss just one key thing, you might as well not have made the effort at all.
A further difficulty, just as insidious, is that people can lull themselves into skipping steps even when they remember them. In complex processes, after all, certain steps don’t always matter. Perhaps the elevator controls on airplanes are usually unlocked and a check is pointless most of the time. Perhaps measuring all four vital signs uncovers a worrisome issue in only one out of fifty patients. „This has never been a problem before,” people say. Until one day it is. Checklists seem to provide protection against such failures. They remind us of the minimum necessary steps and make them explicit. They not only offer the possibility of verification but also instill a kind of discipline of higher performance. Which is precisely what happened with vital signs – though it was not doctors who deserved the credit.”
„The routine recording of the four vital signs did not become the norm in Western hospitals until the 1960s, when nurses embraced the idea. They designed their patient charts and forms to include the signs, essentially creating a checklist for themselves. With all the things nurses had to do for their patients over the course of a day or night – dispense their medications, dress their wounds, troubleshoot problems – the „vitals chart” provided a way of ensuring that every six hours, or more often when nurses judged necessary, they didn’t forget to check their patient’s pulse, blood pressure, temperature, and respiration and assess exactly how the patient was doing. In most hospitals, nurses have since added a fifth vital sign: pain, as rated by patients on a scale of one to ten. And nurses have developed yet further such bedside innovations – for example, medication timing charts and brief written care plans for every patient. No one calls these checklists but, really, that’s what they are.”
„In what became known as the Keystone Initiative, each hospital assigned a project manager to roll out the checklist and participate in twice-monthly conference calls with Pronovost for troubleshooting. Pronovost also insisted that the participating hospitals assign to each unit a senior hospital executive who would visit at least once a month, hear the staff’s complaints, and help them solve problems.
The executives were reluctant. They normally lived in meetings, worrying about strategy and bud gets. They weren’t used to venturing into patient territory and didn’t feel they belonged there. In some places, they encountered hostility, but their involvement proved crucial. In the first month, the executives discovered that chlorhexidine soap, shown to reduce line infections, was available in less than a third of the ICUs. This was a problem only an executive could solve. Within weeks, every ICU in Michigan had a supply of the soap. Teams also complained to the hospital officials that, although the checklist required patients be fully covered with a sterile drape when lines were being put in, full-size drapes were often unavailable. So the officials made sure that drapes were stocked. Then they persuaded Arrow International, one of the largest manufacturers of central lines, to produce a new kit that had both the drape and chlorhexidine in it.
In December 2006, the Keystone Initiative published its findings in a landmark article in the New England Journal of Medicine. Within the first three months of the project, the central line infection rate in Michigan’s ICUs decreased by 66 percent. [...] In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated $175 million in costs and more than fifteen hundred lives. The successes have been sustained for several years now – all because of a stupid little checklist.”
„Four generations after the first aviation checklists went into use, a lesson is emerging: checklists seem able to defend anyone, even the experienced, against failure in many more tasks than we realized. They provide a kind of cognitive net. They catch mental flaws inherent in all of us – flaws of memory and attention and thoroughness. And because they do, they raise wide, unexpected possibilities.
But they presumably have limits, as well. So a key step is to identify which kinds of situations checklists can help with and which ones they can’t. Two professors who study the science of complexity – Brenda Zimmerman of York University and Sholom Glouberman of the University of Toronto – have proposed a distinction among three different kinds of problems in the world: the simple, the complicated, and the complex.
• Simple problems, they note, are ones like baking a cake from a mix. There is a recipe. Sometimes there are a few basic techniques to learn. But once these are mastered, following the recipe brings a high likelihood of success.
• Complicated problems are ones like sending a rocket to the moon. They can sometimes be broken down into a series of simple problems. But there is no straightforward recipe. Success frequently requires multiple people, often multiple teams, and specialized expertise. Unanticipated difficulties are frequent. Timing and coordination become serious concerns.
• Complex problems are ones like raising a child. Once you learn how to send a rocket to the moon, you can repeat the process with other rockets and perfect it. One rocket is like another rocket. But not so with raising a child, the professors point out. Every child is unique. Although raising one child may provide experience, it does not guarantee success with the next child. Expertise is valuable but most certainly not sufficient. Indeed, the next child may require an entirely different approach from the previous one. And this brings up another feature of complex problems: their outcomes remain highly uncertain. Yet we all know that it is possible to raise a child well. It’s complex, that’s all.
[...] We are besieged by simple problems. In medicine, these are the failures to don a mask when putting in a central line or to recall that one of the ten causes of a flat-line cardiac arrest is a potassium overdose. In legal practice, these are the failures to remember all the critical avenues of defense in a tax fraud case or simply the various court deadlines. In police work, these are the failures to conduct an eyewitness lineup properly, forgetting to tell the witness that the perpetrator of the crime may not be in the lineup, for instance, or having someone present who knows which one the suspect is. Checklists can provide protection against such elementary errors.”
Submittal schedule & checklist
„The experts could make their individual judgments, but they had to do so as part of a team that took one another’s concerns into account, discussed unplanned developments, and agreed on the way forward. While no one could anticipate all the problems, they could foresee where and when they might occur. The checklist therefore detailed who had to talk to whom, by which date, and about what aspect of construction – who had to share (or „submit”) particular kinds of information before the next steps could proceed.”
„In the face of the unknown – the always nagging uncertainty about whether, under complex circumstances, things will really be okay – [they] trusted in the power of communication. They didn’t believe in the wisdom of the single individual, of even an experienced engineer. They believed in the wisdom of the group, the wisdom of making sure that multiple pairs of eyes were on a problem and then letting the watchers decide what to do.
Man is fallible, but maybe men are less so.”
„Listening to the radio, I heard the story behind rocker David Lee Roth’s notorious insistence that Van Halen’s contracts with concert promoters contain a clause specifying that a bowl of M&M’s has to be provided backstage, but with every single brown candy removed, upon pain of forfeiture of the show, with full compensation to the band. And at least once, Van Halen followed through, peremptorily canceling a show in Colorado when Roth found some brown M&M’s in his dressing room. This turned out to be, however, not another example of the insane demands of power-mad celebrities but an ingenious ruse.
As Roth explained in his memoir, Crazy from the Heat, „Van Halen was the first band to take huge productions into tertiary, third-level markets. We’d pull up with nine eighteen-wheeler trucks, full of gear, where the standard was three trucks, max. And there were many, many technical errors – whether it was the girders couldn’t support the weight, or the flooring would sink in, or the doors weren’t big enough to move the gear through. The contract rider read like a version of the Chinese Yellow Pages because there was so much equipment, and so many human beings to make it function.” So just as a little test, buried somewhere in the middle of the rider, would be article 126, the no-brown-M&M’s clause. „When I would walk backstage, if I saw a brown M&M in that bowl,” he wrote, „well, we’d line-check the entire production. Guaranteed you’re going to arrive at a technical error... Guaranteed you’d run into a problem.” These weren’t trifles, the radio story pointed out. The mistakes could be life-threatening.
In Colorado, the band found the local promoters had failed to read the weight requirements and the staging would have fallen through the arena floor. „David Lee Roth had a checklist!” I yelled at the radio.”
„points at which the team must stop to run through a set of checks before proceeding.”
„Who [...] was supposed to bring things to a halt and kick off the checklist? [...] Perhaps, I suggested, the surgeon should get things started. I got booed for this idea. [...] dispersing the responsibility sends the message that everyone – not just the captain – is responsible for the overall well-being of the flight and should have the power to question the process. If a surgery checklist was to make a difference, my colleagues argued, it needed to do likewise – to spread responsibility and the power to question. So we had the circulating nurse call the start.
Must nurses make written check marks? No, we decided, they didn’t have to. This wasn’t a recordkeeping procedure. We were aiming for a team conversation to ensure that everyone had reviewed what was needed for the case to go as well as possible.
Every line of the checklist needed tweaking. We timed each successive version by a clock on the wall. We wanted the checks at each of the three pause points – before anesthesia, before incision, and before leaving the OR – to take no more than about sixty seconds, and we weren’t there yet. If we wanted acceptance in the high-pressure environment of operating rooms, the checklist had to be swift to use. We would have to cut some lines, we realized – the non-killer items.
This proved the most difficult part of the exercise. An inherent tension exists between brevity and effectiveness. Cut too much and you won’t have enough checks to improve care. Leave too much in and the list becomes too long to use.”
„The baseline rate of surgical complications was indeed lower in the four hospitals in high-income countries, but introducing the checklist had produced a one-third decrease in major complications for the patients in those hospitals, as well – also a highly significant reduction. [...] In every site, introduction of the checklist had been accompanied by a substantial reduction in complications. In seven out of eight, it was a double-digit percentage drop.
This thing was real.”
„More than 250 staff members – surgeons, anesthesiologists, nurses, and others – filled out an anonymous survey after three months of using the checklist. In the beginning, most had been skeptical. But by the end, 80 percent reported that the checklist was easy to use, did not take a long time to complete, and had improved the safety of care. And 78 percent actually observed the checklist to have prevented an error in the operating room.
Nonetheless, some skepticism persisted. After all, 20 percent did not find it easy to use, thought it took too long, and felt it had not improved the safety of care. Then we asked the staff one more question. „If you were having an operation,” we asked, „would you want the checklist to be used?” A full 93 percent said yes.”
„Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is.”
„We don’t like checklists. They can be painstaking. They’re not much fun. But I don’t think the issue here is mere laziness. There’s something deeper, more visceral going on when people walk away not only from saving lives but from making money. It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us – those we aspire to be – handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists.
Maybe our idea of heroism needs updating.”
„All learned occupations have a definition of professionalism, a code of conduct. It is where they spell out their ideals and duties. The codes are sometimes stated, sometimes just understood. But they all have at least three common elements.
• First is an expectation of selflessness: that we who accept responsibility for others – whether we are doctors, lawyers, teachers, public authorities, soldiers, or pilots – will place the needs and concerns of those who depend on us above our own.
• Second is an expectation of skill: that we will aim for excellence in our knowledge and expertise.
• Third is an expectation of trustworthiness: that we will be responsible in our personal behavior toward our charges.
Aviators, however, add a fourth expectation, discipline: discipline in following prudent procedure and in functioning with others. This is a concept almost entirely outside the lexicon of most professions, including my own.”
„Without question, technology can increase our capabilities. But there is much that technology cannot do: deal with the unpredictable, manage uncertainty, construct a soaring building, perform a lifesaving operation. In many ways, technology has complicated these matters. It has added yet another element of complexity to the systems we depend on and given us entirely new kinds of failure to contend with.”