Do Checklists Work in Healthcare? Patient Safety, Behaviors and Organizational Culture

The following content is sponsored by Select International.

The task can seem monumental: Improve patient outcomes. Improve patient safety. Improve the patient experience. Accomplish all of this while reducing costs. Re-design a delivery system that evolved around the traditional practice of medicine, a hospital structure designed decades ago, and payment methodologies built on volume, rather than quality and efficiency.

Sometimes the response feels like a shotgun approach of every solution we can think of: new technology, new data systems, new organizational structures, new delivery models and processes. Not surprisingly, this approach doesn't always work. Hospitals learned this when they tried to mandate the use of surgical checklists without understanding why these tools were successful in other industries.

Companies over-emphasize process tools, ignoring half the equation
Mike Hoseus, co-author of the best-selling book, "Toyota Culture: Heart and Soul of the Toyota Way" recently spoke at the Rice University Jones Graduate School of Business on this topic. He noted that many organizations, especially hospitals, miss an entire half of the lean equation: the value that Toyota places on employees and their behaviors.  

With his permission, we'll borrow liberally from Hoseus' Rice University presentation. Most lean (and other continuous quality improvement) consultants and their clients focus almost exclusively on lean process tools. Hoseus may be one of the only speakers who consistently points out a flaw in the approach. The ability to identify and solve problems depends on three, equally important components:

  1. Vision and goals — Clearly defining organizational purpose, your "true north;"
  2. Process — Workplace management through standardization and visualization, including relentless elimination of waste; and
  3. People — Engaging, challenging and coaching employees. Developing teamwork and putting people before products.

The third component is no less important but consistently neglected. Leaders, focused on the potential cost savings of lean, don't ignore a core principle of the Toyota Production System: Organization and employee goals must complement each other to ensure long-term mutual prosperity. An organization has goals relating to profit and financial performance, long-term success, quality and contribution to the community. Employees want a secure paycheck, personal and company growth, a safe workplace and meaningful work. Both organizational prosperity and employee satisfaction are built around, and achieved through, the continuous improvement process. The goals on both sides of the relationship depend upon, and contribute to, long-term mutual prosperity.

An example: Do operating room checklists improve patient safety?
Hospitals have been investing time and money into improving patient safety for over a decade.  Lean and other continuous quality approaches are ideally suited to improve patient care processes and safety but we find, time and again, that "process" alone does not suffice. The results have been inconsistent. The other speaker at the Rice event was Michael Rose, MD, vice president of surgical services for McLeod Health in Florence, S.C. and chairman of the South Carolina Safe Surgery 2015 leadership team. Dr. Rose was recently named as one of the top 50 Experts Leading the Field of Patient Safety by Becker's Hospital Review. He spoke about his experience implementing surgical checklists and, with his permission, we borrow from his presentation:

The Joint Commission Universal Surgical Protocol is checklist endorsed by 50 national groups and mandated for use in every hospital in 2004. The goal was to use checklists to ensure standardized processes and eliminate errors in the operating room. It was identified as an innovation that would change medicine. Mandating this change made perfect sense, and you'd expect near immediate performance improvements. Over the initial two year period after adoption of the protocol, however, many hospitals actually saw an increase in reportable events! Merely mandating that surgical teams implement the protocol clearly didn't work.

Many hospitals have re-grouped and "re-implemented" surgical checklists with much better success. What is different this time around? A different approach to the process, itself, to team work and team relationships, and to the staff care experience.    

1. Process. It's not just a checklist. It's the thoughtful implementation of a deliberate process. This includes a three step process: Brief, Time-Out and Debrief. Team members complete pre-procedure safety briefs. Then, everyone, including the surgeon, verbally confirms the procedure steps before the first incision is made. The entire team participates in a quality de-brief before the patient leaves the operating room. This includes a "lessons learned" document that identifies even the smallest opportunity to improve efficiency, standardization or safety.

It's a consistent process that reveals deviations from best practices. These deviations reveal stories — stories staff can relate to, stories that change behaviors. These events drive the team's educational and training plan. Initially, nearly 50 percent of cases give rise to learning events. Over time, process improvements drop this to 5 percent of cases. In addition to safety, the approach improves operational efficiency. Surgical volume increases while labor hours per case decline. You can start to see the path to "value" — improved patient safety and reduced costs.

2. Relationships. This laser focus on process improvement requires an extraordinary level of teamwork and collaboration among a diverse surgical team of technicians, anesthesiologists, surgeons, support personnel, surgical assistants, nurses and nurse anesthetists. Team dynamics and culture are critical. It requires an interactive and complex leadership style and an "every patient, every time, mentality" that permeates the entire team. There is heightened culture of accountability. Peer-to-peer performance observation checklists are valuable and accepted. Behavioral expectations are built into the employee performance management system.  Everyone on the team holds everyone on the team accountable, and is accountable to the organization with regard to the behaviors required for success. Yes, this includes the anesthesiologists and surgeons. No, this is not the traditional operational room culture.

3. Care experience. We speak often about the patient "care experience," but what about staff? The experience of the operating room team impacts not only their degree of job satisfaction, but their job performance, the organization's performance and patient outcomes. Staff struggle to adopt mandated approaches when they question the organization's commitment to patient safety. Even in strong organizations, operating room culture can be problematic. Employee engagement surveys often reveal that staff don't see a positive safety climate, hospital administrative support or overall positive department morale. On top of this, they don't feel valued or see physicians (the purported leader in the room) actively creating a positive workplace environment. Is it any surprise that merely mandating a checklist, failed to create meaningful change?

Culture, behaviors and talent strategies
Checklists can work, but mandates are insufficient. They work when a cohesive team actively participates in the implementation and when the efforts contribute to achievement of individual team member goals. Using a checklist, correctly, every time is a behavioral choice, predicated on a shared purpose and understanding.

There appear to be a few "cultural prerequisites" to the successful implementation of processes like an operating room checklist:   

  • Hospital and staff need to accept "value" as their shared purpose
  • The behaviors that contribute to "value" need to be built into the approach to talent
  • Physicians need to be receptive to these concepts
  • A willingness and ability to develop the "human" resource

Organizations struggle with the concept of developing a particular culture. This is most often because "culture" remains a vague and elusive concept. In the operating room example discussed here, the necessary culture grew out of specific processes and behavioral reinforcement. If we think about culture as nothing more than the collective behaviors of the workforce, we can begin to "operationalize"culture. These behaviors are what matter and what drive outcomes.  

How do these cultural prerequisites relate to the approach to talent?

  1. Identifying value as the shared purpose is the lean "true north" your talent strategies must support the organization's move toward value.
  2. Define with specificity, the behaviors that support that goal. In the case of the operating room checklist, for instance, a flexible leadership style, high levels of accountability, a sense of ownership and the ability to collaborate are critical.
  3. Build talent strategies around these behaviors. What are you doing, everyday to ensure that the people you bring on to the team have the behavioral competency to perform? Build these same competencies into your performance management approach and hold people accountable for these behaviors.
  4. Needless to say, a similar approach needs to be taken with physicians. What it means to be a successful physician has changed and we need to provide physicians with the tools to understand, and develop, behavioral skills.

Healthcare, more than any other industry, is about people. The service being provided impacts patients in intimate and profound ways. The service is provided by staff and professionals who are deeply invested in their jobs. The initial failure, and subsequent success of, surgical checklists, is the perfect example of what Mike Hoseus spoke of: Process is only half of the equation and will fail to yield the desired results if you don't put people before products.

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