When Process Precision Saves Children’s Lives

1343374839_gosh-logoIf your CEO is lukewarm on process excellence, invite her to watch How To Avoid Mistakes In Surgery, from the BBC Horizon team, in which consultant anaesthetist Kevin Fong explores what, in the corporate context, would be called performance improvement initiatives – within and beyond the operating theatre.

A collaboration between London’s Great Ormond Street Hospital For Children and the McLaren and Ferrari Formula One racing teams perfectly illustrates the power of process precision.

Relaxing in a staff room after completing a 12-hour emergency transplant operation, two doctors watched a Formula One race. What they saw led to a collaboration that has saved lives.

After open heart surgery, the patient must be transferred from the operating theatre to the Intensive Care Unit.  It is a huge and complex set of time-critical tasks. It can take 30 minutes after the surgeons have completed their work and left just to unplug all the wires and tubes from a patient, ready for transfer to the ICU.

Great Ormond Street’s head ICU doctor, Allan Goldman, and heart surgeon, Professor Martin Elliott, observed that when a Formula One car pulls into the pit stop, a 20-member crew can change the car’s tyres, fill it with fuel, clear the air intakes and send it off in seven seconds in a way that is coordinated, efficient and safe – in a perilous environment.

And so began a collaboration that resulted in a major restructuring of patient handover from theatre to the ICU.  It involved adopting a new protocol, better training and rehearsals.  It made clear who was the leader throughout the process (the anaesthetist); provided a step-by-step checklist covering each stage of the handover process; and included a diagram of the patient surrounded by the staff so that everyone knew their exact position as well as their precise task.

The result of precision and visualization in executing this handover was stunning (it’s reported here). It has reduced by 40% the human errors in this critical transfer, saving lives and complications.

In a sense, it’s nothing new.  Professor Atul Gawande has shown conclusively how simple checklists can reduce deaths and complications in surgery by around 30% (which is an even more extraordinary figure than it seems because it varied very little between hospitals, whether they were in the USA or Kenya or India).

Commenting on the improvements at Great Ormond Street, Nigel Stepney from Ferrari noted that:

“It’s not about having the best people and just putting them together. It’s about a group of people who can work as a team.”

Which echoes one of Professor Gawande’s themes in The Checklist Manifesto. It’s easy to think that precision and visualization are important just to compensate for human fallibility.  But, actually, process precision – which usually hinges upon process visualization – is even more valuable because it enables teams in complex situations to work together more effectively.  Process precision underpins effective collaboration.

Related Posts

22 Feb 2012   Hello Checklists, Goodbye Process?

© Text Michael Gammage 2013

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