Paper: Surgical Safety Checklist - more than checking a box

Fabulous - the authors have published a study where the results show there's a problem. I've been harping on about the lack of negative studies for years. So well done to the authors.

Basically, they've done some follow up work to see how well used the surgical safety checklist is. No surprises to discover that is most cases only 4 of the 13 items were checked. They suggest there is a problem with the fidelity of implementation, and a poor dissemination strategy and implementation.

Fidelity really is key. There's no point in shouting from the rooftops that 100 hospitals are using a checklist, for example, if it is not being used as intended. The results will not be as good as the pilot study. The return on investment for the project will not be as good. And, who knows, in some programs, the results may actually be worse than if the program hadn't been disseminated.

Fidelity. Important.

Surgery. 2012 Jul 6. [Epub ahead of print]
Implementing a surgical checklist: More than checking a box.
Levy SM, Senter CE, Hawkins RB, Zhao JY, Doody K, Kao LS, Lally KP, Tsao K.

Airlines & Healthcare; what can we learn

We consider airlines safe so in healthcare we adopt some (and only some) of the techniques they use to be safe - like checklists used by pilots and engineers. I say @some@ because we often forgot some of the more basic and fundamental safety aspects employed by arilines - the often more complex human resources, financial aspects, organisational learning, training etc.

Putting safety aside I read the report by the USA Bureau of Transportation on the statistics for 2009. In 2009 of the 19 airlines who reported they had an average on-time arrival performance of 79.5%. Hmmm. What I like about this figure is it represents the complexity of different airlines, operating in different ways, to different airports - and all affected in some way by the things out of their control, like the weather. This sounds to me like the healthcare system - in public sector systems anyway. So the airline travel system in 2009 was designed for 1 late arrival in every 5 flights. This makes me feel a lot better about the flow of patients around the National Health Service in England. A way higher percentage experiences experiences on time care. I also feel that the NHS is able to work well in a crisis like bad weather.

Ever lost your baggage? Well in the USA in 2009 3.91 bags were mishandled (isn't that a lovely term!) in every 1000 handled. This was an improvement from the 5.26 in 2008 - well done. As rates go these mishandlings are very few. Of course, if it is your bag lost, then the amount of year on year improvement and the overall rate is of no interest. A failure is a failure. This reminds me of the way most healthcare projects adopt goals that are less than perfect. For instance, 95% of patients to be treated xxx. What this tells me is that the improvement project team and the organisation are opting to design for a certain amount of failure. And I am not sure I am happy with this. Mistakes I can forgive. Designed in failure rate, often large ones, are to me a sign of lack of confidence in the people and processes. And as a patient I am less confident being treated there.

We have a great deal to learn about and adopt from other sectors as part of improving healthcare. What have you adopted from another industry and how has it worked for you?

Large Scale Change: Theory & Practice - March news

I try to keep a close eye and ear on what gets published on the topic of large scale change. It seems the last few weeks have thrown up a peak in activity. My interest is LSC is a variety of contexts and while the majority used to be climate change related, I am seeing more and more comments and publications on issues touching organisations and wider systems, including healthcare.

Sir John Oldham, who calls himself a jobbing GP yet his impact on the healthcare systems is much more than that, published a Commentary in JAMA (4th March 2009 Vol 301, No.9 p965) on "Achieving large scale change in healthcare". http://jama.ama-assn.org/cgi/content/short/301/9/965 The healdines are:

• Status quo is not an option
• Optimism is necessary to overcome obstacles
• Everyone can make a difference
• Take calculated risks

Kate Goonan and colleagues published in ASQ in January "Journey to Excellence: Healthcare Baldridge Leaders Speak Out". They've done some excellent case study work on how organisations taking on the quality mantle can be successful. I like their 5 step model of transformation (Status Quo, False Starts, Traction, Integration and Sustaining). Which, after getting over the shock of this sort of deep and broad large scale change taking 3 to 8 years, is reassuring common sense. This paper is a precursor to a book on the topic http://www.asq.org/quality-press/display-item/index.pl?item=H1327 The context for this paper is the US and it is also quite organisational specific. Much of the large scale change I know people are working on is perhaps a little more systems based.

From the e-Government 2009 Awards we have a case study from Avon, Gloucestershire & Wiltshire Communities on how they have improved a child health system across a geographic region. For me this is large scale because it involved multiple types of organisations, with different perspectives, implementing changes with far reaching impact on an identified population. http://www.publictechnology.net/modules.php?op=modload&name=News&file=article&sid=19235

I'm watching a large scale change in process by following, and where I can also supporting, the IHI Surgical Safety Checklist "Sprint". With an aim of encouraging 4000 hospitals to test out the checklist wihtin a short period of time, this is large in geographic scale and in the numbers of teams and organisations involved. You can join in too: http://www.ihi.org/IHI/Programs/ImprovementMap/WHOSurgicalSafetyChecklist.htm I love the map mashup on the IHI website which puts your commitment on the map - literally.

"The Science of Large Scale Change in Global Health" is an other JAMA paper, this time published in Feb 2009 http://jama.ama-assn.org/cgi/reprint/298/16/1937.pdf by Joe McCannon, Don Berwick and Rashad Massoud. There are some great internationally focused examples in there. It is good to know large scale change can happen and is happening. though I have a few queries on some of the Roger's based theories as to whether they are the best lens through which to view what they are writing up. It's interesting work and their piece on how leaders can support large scale change is pertinent. I would like to see more from the leaders themselves on how they are doing it.

If leadership is your thing then a good blog post touching on leadership for large scale change can be found here: http://www.fastcompany.com/blog/seth-kahan/leading-change/creating-authentic-engagement-change "Creating authentic engagement for change" cover hints and tips that seem obvious on the page yet in practice are often much more difficult. It seems that what I'm finding about leadership is there are two camps about leadership for LSC (a) the hierarchical, structural approach, (b) the personal, emotional connection type approach. I suspect there is a continuum.

A new page on Wiki Answers looks at the topic "How can the process of small scale change differ from that of large scale change". The advantage of a Wiki is you can get in there and improve the answer! So feel free: http://wiki.answers.com/Q/How_could_the_process_of_implementation_for_a_small-scale_change_differ_from_that_of_a_large-scale_change

One thought I am left with after doing this month's catch up is how easy it is to describe what has happened and to make inferences from that as to how we can make something happen in the future. Much research and management consultancy wealth is based on the development of frameworks and models using this descriptive approach. These are, of course, very helpful. However, I am wondering where the research and practice is on developing and using more predictive models? For instance, I know and have used some of the predictive diffusion models which in my mind are more helpful than the Roger's work, though less easy to get to grips with. Similarly perhaps the shift to a more personal and behavioural approach to leading LSC is on the "predictive" side of the coin.

Maybe the seduction of the easy-to-understand model is getting in the way of the really tough work. Namely, finding our own meaning in our own piece of large scale change.

Your thoughts?

Surgical Safety Checklist Sprint 10th March 2009

The IHI www.ihi.org are leading a "sprint" to have every hospital in the USA test the World Health Organization (WHO) Surgical Safety Checklist at least one time with one operating room team. Sprint Day is 10th March 2009. The version in England is more marathon-like with a target set for February 2010 for all hospitals and teams to be using the checklist. So, we have two different approaches to getting this life-saving tool implemented.

If I had to place a bet as to the effectiveness of each strategy I would go for the sprint. Yes, the aim here is only for one team in each hospital to test it out. This strategy is going for coverage by having every hospital participate. The marathon version is going for both coverage as well as completeness - wanting every team to be using it. I expect the Sprint version will migrate into a marathon so completeness is developed in each of the hospitals that tested the checklist.

I'm placing my bet on the Sprint because I would rather the checklist got tested soon. If a team finds it helps and is not too onerous then they'll gossip about it in the surgeon's coffee lounge. To me that is preferable to planning sessions and meetings about how to implement marathon-style. Better to get on and test it.

As a patient, there is no choice - the sooner the better.

The IHI has all the tools you need to get started http://www.ihi.org/IHI/Programs/ImprovementMap/WHOSurgicalSafetyChecklistSprint.htm. So what are you doing? Sprinting, doing a short jog or planning for a marathon?