Monday, November 3, 2014
Checklists in Healthcare
Reading about the specificity with which the Toyota process demands that individual steps be singled out and grouped together (precisely 55 seconds to install this seat using these 7 steps) made me think of a paper I read during my undergraduate studies. Some quick googling turned up a New Yorker article (not quite the journal paper I remembered, but far easier to read) about Peter Pronovost, a M.D./PhD who pushed for the use of checklists as standard procedure in the medical care field, specifically in intensive care units.
The basic premise of using checklists in intensive care units is two-fold. First is that medical care in incredible complicated, with the average patient requiring 178 individual actions per day. While it is impossible to develop a checklist that covers every possible action, for most of the routine ones it is possible to develop a short checklist. One of the examples they use is for line changes. A simple 5-step checklist was able to significantly reduce the number of line infections in patients. The use of checklists to assist medical care professionals as they stay true to the specified process helps them avoid mistakes that are fairly common place in the chaotic hospital environment.
In addition to helping medical professionals remember every step in their healthcare processes, used effectively the checklists empower nurses to challenge doctors they see doing something wrong. The power dynamics in a hospital can be difficult to manage, as highly educated and highly paid doctors work along-side nurses without the same background and compensation. Using checklists allows nurses to challenge doctors that make mistakes, where-as previously doctors would just brush their complaints aside. The institutionalized use of checklists allow nurses to hold doctors to hold each other accountable, while previously half the individuals involved in delivering health care to patients were unable to effectively and efficiently point out flaws to the other half.
The use of these checklists for different areas of patient treatment find their parallels in some of the Toyota production systems’ four rules:
1. All work is highly specified in its content, sequence, timing, and outcome.
Using checklists that outline every step in the process for specific healthcare procedures helps ensure the content and sequence is uniform and done properly every time, helping to reduce variability in patient care.
2. Each worker knows who provides what to him and when.
The use of checklists doesn’t necessarily address this rule, though the reading provided about factory efficiency in hospitals does. http://www.nytimes.com/2010/07/11/business/11seattle.html?adxnnl=1&pagewanted=all&adxnnlx=1415030468-G3yDSTvYVG9Dhqc1+DFPqg
3. Every product and service flows along a simple, specified path
Assuming the product is healthcare for individual patients, the use of checklists helps ensure the process flows smoothly. By removing complications such as line infections the entire process is simplified (sick => treatment => healthy => sent home instead of sick => treatment => complications => treatment => healthy => sent home or even worse sick => treatment => complications => sent to morgue).
4. Any improvement to processes, worker/machine connections, or flow path must be made through the scientific method, under a teacher’s guidance, and at the lower possible organizational level.
This one is theoretically improved by the existence of checklists, however practically it is difficult for change to be made at the lowest level (nurses). In reality that change will come from a much higher level (hospital executives) which effectively removes the biggest advantage of this rule.
Personally I think there is no reason why checklists should not be a part of the standard operating procedure in all healthcare processes. While it is difficult to map out the entire healthcare process to a single checklist, individual actions/treatments/functions should be written down and followed. Like the article notes, house movers, wedding planners, and tax accountants have figured this out years ago, why should healthcare be so different? In the summer of 2011 I watched my grandfather die of pneumonia, following his fairly successful treatment of liver disease. While in reality his time in this world was not long due to a whole host of medical issues, part of me wonders if his pneumonia was a complication from his time in the hospital or one that could have been avoided through the stringent use of checklists to help prevent against in-hospital infections. I place no fault at all on the wonderful healthcare individuals who treated him as his life drew to a close, but like in any line of work there is the chance that one of them at some point made a mistake like failing to wash their hands between patients. Who knows.
Re-focusing on the topic of checklists, my question is what other industries could benefit from the use of checklists in codifying their processes? Automotive and aerospace manufacturing seem to be at the forefront, but just about every single business out there uses processes to deliver services and products to their customers. Making sure those processes are known and broken down on the smallest level could help them avoid errors (defects) and provide better service. From something as simple as how to make an omelette (at Pamela’s on Saturday my girlfriends omelette must have had 5 eggs in it while it seemed like mine only had 3!) to how to fill up a tank of gas (looking at you New Jersey with your gas pumping employees), having a standardized process can help avoid mistakes like an omelette with not enough eggs or forgetting to put the gas cap back on after fueling up.