The Problem with the VA Study: Surgery Checklists Saving Lives
- October 20th, 2010
- Posted in Systems Thinking and Healthcare
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The VA study: Surgery Checklists Saving Lives is the kind of stuff that toolheads stand up and say, “see how tools work.” It is a false premise that will have hospitals running around implementing checklists to save lives.
If only saving lives were that easy. It is the type of headline that leaves systems thinkers shaking their heads.
In as much as there may (or may not) be a place for checklists. The reduction from a 17/1000 to a 14/1000 death to surgery ratio (besides bringing up statistical questions) doesn’t set the thinking on how to eliminate the next 14 deaths. The copying of tools does not promote the next new thinking needed to solve new or other problems.
Improvement is a function of changing our thinking . . . not standardization as a place to begin improvement. The lack of understanding this creates an inability to achieve sustainable and continual improvement.
Checklists have been around for a long time. The VA hospitals are not the first to try them – believe it or not. Unless we change thinking we fall into a hazardous trap of thinking that improvement is just about tools and implementing things like checklists. This is dangerous as hospitals wait for the next discovery rather than seeking to solve problems from the minds of their own workers.
Implementing checklists may have a worse effect in a hospital that has a poor work design and command and control thinking. Then we will be reading about how checklists kill patients.
If hospitals are to improve the work the need to start with “check,” not checklists. Understanding their hospital as a system from customer purpose. A normative approach will help change the thinking that created the problem in the first place buy understanding the “what and why” of current performance.
A redesign of the work will follow and it may find a different and better approach than checklists. As improvement is emergent from the work, not from tools. The checklist tools will stifle innovation as copying usually does.
There is never a bad time to begin to change thinking and redesign a system. Today’s problems require more than checklist thinking . . . they require systems thinking.
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Tripp Babbitt is a columnist (Quality Digest and IQPC), speaker, and consultant to private and public service industry.
Who said checklists were not the product of thinking?
The original thinking that produced it was. The copiers aren’t thinking they are copying. Change thinking to produce innovation, copying will not produce innovation . . . just copying.
Thanks for raising the issue that it’s not the paper checklist that’s important — it’s the process for creating, managing, and improving the checklist that matters.
If you read Dr. Atul Gawande’s outstanding book “The Checklist Manifesto,” he makes it very clear that the checklist process AND having a team environment are the key (breaking the strict hierarchy of the command-and-control hospital – although MDs are usually not directly in command, they just act like it).
Checklists must be created by the teams who use them (ala Taiichi Ohno). They must be tested, validated, and continually improved.
Some checklist efforts (like those of Dr. Richard Shannon) are done under the Lean/Toyota banner. Many other efforts are not done under the Lean name, but it’s the same good thinking.
I have gone through patient safety / checklist training done by one of the aviation-based companies that teaches this to hospitals. They emphasized those exact same points that the team must create their own checklist locally, it’s not forced on them by management or copied from another hospital.
Alas, there are the equivalent of “tool heads” in that world — there are some competing consulting groups that will just sell you the checklist. That’s going to fail and, you’re right, that might be harmful.
But that doesn’t mean ALL checklist efforts are top-down or attempts to just copy tools. The checklists crowd – they’re trying to change the culture so it is team-based and patient-focused — just like lean people.
As to the statistical comparison — it’s not quite as large of a reduction as anybody would like. But to be fair, there WAS a statistical rigor presented to show that the change WAS statistically significant, as presented here:
http://www.medicalnewstoday.com/articles/205205.php
@Tripp Babbitt
Final point – you’re making an unfounded assumption there that all of the checklist people are copying, Tripp.
Mark-
Read the manifesto, but it doesn’t address the design or thinking problems in health care or any other industry.
You are making the assumption that people didn’t or won’t copy. We are agreed that copying doesn’t work. So on with the thinking and away from the tools.
This statement is problematic to the study:
“It should be noted, as already mentioned, that this study was a retrospective study, so the groups were not randomly assigned to receive the training program. This could have inadvertently allowed a number of things to bias the results, as the researchers themselves were first to admit when they discussed the limitations of their work.”
I am not debating the statistical significance for this blog post, but I am challenging the poor thinking that it can or possibly did promote.