Checklists for the Lean OR

In his recent book The Checklist Manifesto, Dr. Atul Gawande describes in great detail the creation of the World Health Organization's Safe Surgery Checklist. Checklists for healthcare were first discussed by Gawande in an article in the December 2007 issue of The New Yorker titled (what else?) The Checklist. The central point of this article is how the use of a 5-point checklist helped in dramatically reducing infection rates associated with the insertion of central lines. There you have it, one shining example of the power of the humble checklist. Why then are healthcare professionals so slow are at adopting standardization practices in their daily work?

Standard Work is not your enemy! There is a misconception among clinicians that by standardizing some of the repetitive tasks they do every day, they will lose the autonomy that characterizes their professions. Nothing could be farther from the truth. By making repetitive work predictable, you save your energies for the unpredictable. For example, by making sure that there is a clear and repeatable procedure to assemble case carts and deliver all the required supplies to the OR prior to the surgery, you can dedicate all your energies to the patient, and not to hunting for supplies or wondering if everything you need is there. Do not be afraid of standard work, just trust your judgment as to what processes should and should not be standardized in your clinical work.

Checklists are a tool to aid with standardized work. They aim at ensuring repeatability of certain critical elements of work. Wash hands with soap, check. Clean procedure area with chlorhexadine, check. We are all humans and we are bound to forget something, no matter how small, when we are immersed in the non-stop world of the OR. Observations of work in ICUs show a rate of error for around 1%, or an average of two mistakes per patient!

What checklists should we adapt? The WHO Safe Surgery Checklist is one of them, check. How about a checklist for the Pre-Surgery department to ensure that every patient receives all the necessary care and talks to every required clinician before being wheeled to the OR? What about a checklist to ensure that every patient has all the necessary documentation before the day of Surgery? How about a checklist for the OR Suite changeover? The opportunities are vast, once you put your mind to it.

Clinicians and OR Nurses are not opposed to checklists or other tools for standardizing work. They do, however, have a problem with being told what to do. Here is a recommendation: be pro-active. By being against something you are on the losing side of the issue. The next time something does not go as planned, you might be slapped with another checklist developed by some external expert that may have no knowledge of your processes and culture. Cross the road to the sunny side and embrace the Culture of Continuous Improvement that Lean brings to the OR.

Next time you see a process that has some weaknesses and potential failure points, organize an OR team for a Kaizen project. Outsiders and consultants are welcome, but this is your project, not somebody else's. Plan for a maximum of three days to complete the project and deliver a functional checklist. Evaluate the process and figure out the critical works elements that may lead to failure. Test the checklist with staff. Do a quick pilot run, make tweaks, implement it, observe the new process, gather performance data, and prepare a quick presentation to tell your success story. Here are a few pointers that may help you develop an effective checklist:

• Decide on the type of checklist. A Do-Confirm checklist assumes that team members work independently from memory until they stop to go over the checklist to confirm that the right steps were completed. With a Read-Do checklist one team member carries out the tasks while another one reads each task and checks them off as they are completed.

• Make it short. It is a checklist, not a training manual. The checklist is not there to tell you how to do the job. Think index card, rather than legal size paper.

• Keep wording precise and simple while avoiding unnecessary clutter and coloring.

• Turn the brain on. The checklist must help you turn your brain on when you are using it. A checklist is not a replacement for a brain.

• Test the checklist. There is a very good chance that your first draft will need revision. Do not be discouraged, but correct it and try again.

Healthcare around the world is at a crossroads, evolving from a craftsman-style delivery of care to the creation of an integrated healthcare delivery system. This change is necessary, both to improve patient outcomes and to reduce costs that are growing at an unsustainable rate. The use of checklists will be a powerful tool in this transformation. Being left behind is entirely up to you.

Gerard Leone, MSIE, MBA, is the Lean Hospital practice leader with the Leonardo Group Americas. The Leonardo Group is based in Munich, Germany and Denver, CO in the USA.
Gerard is has been a consultant to manufacturing companies for almost 20 years and to hospitals for 8 years. You can reach him at gleone@leonardo-group.com or visit the Lean Hospital Group website at http://www.leanhospitalgroup.com