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.

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22 Feb 2012   Hello Checklists, Goodbye Process?

© Text Michael Gammage 2013

Hello Checklists, Goodbye Process?

The Checklist ManifestoMy little world wobbled as I read Atul Gawande’s bestseller The Checklist Manifesto.

It seemed to challenge head-on my conviction that process matters most because it provides the language that enables effective collaboration amidst complexity.

It’s superbly well written (Dr Gawande is an eminent surgeon but he’s also a staff writer on the New Yorker). It was ravishingly reviewed in the FT, the NY Times and The Economist, whose reviewer described it as ‘a meditation on the growing complexity of the world, and how to cope with it’.

The book sets out the evidence on the value of the humble checklist in saving lives (and much else – injuries, time and costs) in even the most highly complex activities – in the operating theater, on skyscraper construction sites, and on the flight deck. It is utterly compelling.

Why do checklists work? Firstly, because ‘they get people talking’, suggests Dr Gawande. They break down hierarchical barriers and encourage the teamwork that can ensure the best possible outcomes – in surgical teams, among construction engineers, even in due diligence teams working for private equity investors.

Checklists also encourage discipline. They recognize that, in a fast-paced world, we can all too easily forget the obvious. Kitchens in top restaurants use them. Checklists can ‘force reflection’ says Dr Gawande, even in complex and dire situations like the loss of an aircraft engine.

As I read the book, I feared I was hearing the distant rumble of a paradigm shift. It seemed entirely plausible that my approach had been turned upside down, that process had been a wasteful diversion – and that checklists were the new process.

The truth though seems to be more subtle and interesting. Checklists and process may overlap but they are essential, and complementary, in enabling us to deal with our enormously complex world.

Both enable collaboration and ensure compliance. ‘Checklists are not comprehensive how-to guides’, says Dr Gawande, ‘they are quick and simple tools to buttress the skills of expert professionals’. Sometimes a checklist could be easily substituted by an end-to-end process and a Storyboard. In other circumstances, only one of them will work. What’s appropriate will depend entirely upon the context.

Context is one of the exciting themes of the book. The best checklists work because their creators are painstaking in understanding the context in which they will be used. They care about the tiniest details because they know that it matters in effective communication. Those who have advocated ‘publishing’ business processes that are static, generic and described in technical gobbledeegook might want to read and ponder these sections.

It’s also, in an odd way, heartening to read of the widespread resistance to checklists, despite clear evidence of their value. Organizations and individuals, across all industries, often applaud the idea of checklists – but have some reason why they are ‘special’ and should be exempt. They have to be won over – even if they subsequently emerge as the strongest champions of the idea. Inviting us to re-think how we define heroism, Dr Gawande reflects on this inertia:

“…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 protocol and checklists. Maybe our idea of heroism needs updating.” [p.173]

Replace ‘checklist’ with ‘process’ and it’s the journey of most organizations towards process thinking, and towards a recognition of the process platform as an essential enabler for sustainable operational excellence.

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© Text Michael Gammage 2013