OR Checklists Reveal Real Time Problems and Save Lives
Posted by steven_spear | Under health care, organizational learning, process excellence Wednesday Jan 21, 2009Chasing the Rabbit asserts that the marked differences in performance among organizations that do much the same work are directly due how complex work processes are managed. Great organizations specify in advance how work is expected to be done to capture the approach most likely to lead to success with tests built into the work indicating when something is going wrong while work is being done.
This is a critical. Without a stable base from which to start reliability is hard to achieve and without rapid recognition of when improvement and innovation are needed, it is impossible to get better. This leaves people mired in the same frustrations and aggravations, subject to occasional catastrophe. Take this first step, and you can use the other capabilities of high speed, disciplined problem solving to build new knowledge and expertise, and knowledge sharing to make sure it has wide impact.
Liz Kowalczyk (”Safety List Cuts Surgery Deaths: Measure tied to fewer errors, complications,” Boston Globe, January 15, 2009) provides a powerful example of this principle. She reports on an international study showing that when operating room teams completed safety checklists before, during, and after surgery, complications fell from 11% to 7% of patients and deaths fell from 1.5% of patients to 0.8%! What an incredible ratio of reduced human suffering (and reduced financial burden of follow up treatment) relative to the cost of implementing checklists which have already been developed!
One can only hope that more hospitals see the specific value of similar check lists to increase the chance of success and reduce the chance of failure in surgery and also take away the more general lesson defining how work is expected to proceed before it is begun is a powerful tool for raising the base level of performance and creating the potential for ever more gain.
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