It would be extremely useful for this topic to be discussed in light of Quality Management theory, especially of the form and 'philosophy' that originate from the teachings of W. Edwards Deming. In brief, through the application of Profound Knowledge - Systems, Variation, Psychology and the 'Theory of Knowledge' - people and resources are, among many other things, managed in alignment with [the intentions of] a defined aim - one that is understood and shared among all relevant stakeholders.
A checklist is simply a tool used to control a process with the intent of producing consistent results through adherence to defined procedures. An appropriate context of Quality Management theory would lead to redirecting the focus from the use of tools such as checklists to that of the underlying processes that they are designed to serve.
Many practitioners of traditional American management inherently foster elements of discord among internal and external stakeholders of their organizations. Such manifestations of disharmony, whatever forms they take, may be likened to cancers that exist in opposition to the composite health of organizations and their missions.
The governing body of an organization, typically a board of directors, establishes policy that effectively charts the course of an organization. Executive management, comprised of officers, is charged with the execution and administration of these policies. Collectively, the board of directors and executive management may be termed 'upper management.' It is this level that is ultimately responsible for all results that are produced under its leadership and supervision. It should be evident that upper management 'owns' the organizational culture and all of the systems employed within its scope of control.
Having laid this rather simple foundation, permit me to offer the following regarding the issues mentioned surrounding the use of medical checklists.
Any doctor that resists the use of checklists certainly has his or her reasons. Such a doctor may feel that requiring the use of checklists is 'managerial overcompensation' with associated implications that infer upon them some degree of incompetency. This perspective is an exemplary remnant of the demoralizing effects of certain traditional American management practices.
If a medical institution holds a viable intention of continually improving over time, it must likewise possess the will and means by which to do so. Quality Management theory is a proven means to accomplish these ends.
Were medical staff to be properly educated in Quality Management theory, a context would exist within which their beliefs, attitudes, emotions and behavior could be channeled together towards achieving the organization's express mission. This, accompanied by a new vision of the future and appreciation for a 'process orientation,' would naturally foster acceptance of the philosophy, methods and tools by which to do so.
In an organization that practices Quality Management, all stakeholders should be aware of the general 'core' intentions of the organization, thereby endowed with the basis upon which to think and act toward common ends. In a hospital, for instance, all stakeholders who are subject to a process may potentially participate in the definition of that process. Doctors, for example, may meet to discuss 'Best Practices' for the purpose of adapting and integrating them into a hospital's standard procdures. The benefits of this process could expand exponentially by enlisting the cooperation of other like-minded organizations - all of which could share results ona periodic basis.
Consider that if doctors and other medical staff are afforded the opportunity to meaningfully contribute, having influence upon the creation and revision of procedures that they will be expected to follow, there should be low resistance to their adoption. With a focus now upon processes and a new appreciation for the tools and personnel required to administer them (e.g., checklists), acceptance comes more readily.
Where a common purpose exists to perfect processes that are capable of producing consistent, high-quality results - such as reducing rates of infection and mortality - and these processes are the result of collaboration among stakeholders that share in this common purpose, any resistance by such a stakeholder in the active theater in which they apply may be perceived to be the result of ignorance or ineptitude. Ignorance can be cured. Ineptitude warrants 'a boot.'
It is worth noting that only upper management is capable of creating the organizational climate within which such an environment and its benefits may exist. Quality Management theory must permeate an entire organization, including its adoption by the highest ranks of its management. To derive the greatest benefits, Quality Management must be exercised throughout an entire organization - and beyond it. Potential benefits are greatly diminished when the practice of Quality Management is 'departmentalized.'
There is so much more that can and should be said. My hope is that this may serve to spawn further conversation.
A New England Journal of Medicine study of post-operative care finds that managing complications can be as important as avoiding them after an operation.
The University of Michigan study found that differences in post-surgical death rates were not due to the number of complications encountered, but how they were handled.
Said study author John Birkmeyer, “What distinguishes high quality hospitals and low quality hospitals is how proficient they are at rescuing people once a complication has happened.”
There are low-tech and high-tech ways of making these improvements.
- The low-tech method, pushed by MacArthur “genius” Peter Pronovost (right), is to have checklists covering procedures and follow them.
- The high-tech method is to not only have quick alerts on complications but data delivered at the point of care on what to do.
The problem with the checklist, as Pronovost himself learned, is that their use and control sets off a power struggle. He recommends nurses control the checklist, so doctors resist the process, because they don’t like taking orders from nurses.
The problem with relying on technology is that, sometimes, technology is the problem. Faulty setting of alarms is the biggest technology hazard hospitals face. Their setting, again, can be controlled through the use of a checklist.
Having correct procedures on hand, knowing them, and implementing them make the difference between patients surviving surgery and dying after it. If a low-tech checklist in the hands of a nurse can solve this problem, why are doctors continuing to resist?
Is their ego killing their patients? And might the difference between good and bad hospitals lie in how much authority nurses are given?
