Why we all need to care about systems

Do we really need more checklists?

The WHO Surgical Safety checklist is credited with improving the safety of operations across the world.  At its introduction, there was resistance.  Who needs a checklist to do what any good surgeon/team/department would do anyway?  But, gradually, this has become more accepted.  I’m not a surgeon (clearly! Definitely do not have the concentration or manual dexterity to do that) but I know about the checklist.  I know about it because almost* every time that I’m called into theatre to attend a delivery (paediatricians go to deliveries in theatre that are unexpected – Caesareans, trial of forceps… that kind of thing) somebody is running through the checklist.

If you’re not familiar with it (and bear with me if I get this wrong), the WHO checklist is a process where the team checks basic safety issues at 3 separate points: before anaesthesia; before skin incision; and before leaving the theatre.  It covers rather important things like  confirming the patient/procedure/site is what everyone expects; and whether the equipment is all working properly.  There are points where you can plan for possible problems: is there likely to be significant blood loss? Is this going to be a “difficult” airway?

All in all, this sounds like a good thing to me.  Compliance rates are recorded to be high, and the initial resistance seems to be fading.  It’s a systems change that works: Hurrah

All is well in the land of checklists…

Except nothing is ever that simple.

Because filling in a piece of paper is not the same as doing the checklist (just like filling in monitoring isn’t the same as working EWTD compliant hours, but that’s another blog and another rant…).  Two recent papers have pointed this out: compliance is not the same as meaningful compliance; checklists by themselves aren’t as useful as when they’re part of a culture that supports safety.

Using a checklist becomes a tick-box exercise unless you mean what you’re doing.  Tick-boxes are meaningless: worse than that, I find them dispiriting and disheartening.  Sometimes (if it’s a spectacularly bad day), then they seem like a personal criticism: of course I would remember to check the allergy status or the dosage of flucloxacillin.  Why do I need to double check this? Don’t you trust me as a professional?  Systems change that is meaningless or that happens in isolation is a problem, not a solution.

Now, this sounds like I’m against systems change, and believe me, I’m not.

I’ve gone from being a junior Dr who thought that as long as I worked harder and stayed longer and came in on my days off that things would be better.  That’s rubbish.  Individuals don’t make that much of a difference; not across whole departments or sectors. Or even across the NHS.

Or do they?

Maybe they do.  Kate Granger is one example of an individual who’s making a difference throughout the NHS.  #hellomynameis has become widespread across the NHS (it even gets referenced by Jeremy Hunt MP for what that’s worth).  So here is an individual; making a difference in a system without checklists or punitive measures; without funding; without celebrity endorsement (apart from Dr Granger herself!).

What works about #hellomynameis is that we care about it.

And that’s the message from the WHO surgical checklist as well.

If we care about patient safety then we’re going to care about how we fill the checklist in.  We’re going to take the time to do it as a team and work together.

If we care about delivering the best care to our patients then we’ll realise that there is a human being at the end of that tick-list; that this is someone’s health & life that’s involved.

And if we care about continually improving the NHS, then changing & and developing systems that support us that are only going to help.

If we don’t care, then it’s just a checklist…

*The exception is for “crash” Caesarean section – 15 minutes from decision time to delivery; a good reason for not filling in a piece of paper!

Why medicine isn’t like the driving test…

I failed my driving test the first time around.  It was 13 years ago, but I remember that day vividly.  Getting stuck in a traffic jam on a hill (repeated hill starts); being taken on the country road that absolutely petrified me (and insisting on driving at a comfortable 40m.p.h rather than the 60 that everyone else was doing); and the overwhelming sense throughout the whole thing that I was going to fail, that I couldn’t do it, that I couldn’t change anything about it.  I remember coming home, and the following morning, still wanting to through something through the window.  (A pyrex pepper pot, by the way.  My mother removed it from my hand, and made me a bowl of pasta…)

And I remember the second attempt a few months afterwards, where I passed.  It wasn’t a perfect run by any means: my 3-point turn became a 9-point turn; I abandoned my reverse park the first time, and had to pull out and start again; the emergency stop was a genuine stop because I hadn’t realised that the examiner would do that on the approach to a junction….  But I passed, and I was elated.

On neither of these attempts was I allowed to drive home.

Apparently, the emotional upheaval of sitting the driving test is so enormous that my instructor didn’t allow her students to drive afterwards, whether they’d passed or failed.  (This wasn’t just me being 18 and emotionally crumbly: a quick look on internet fora suggests this is quite common).  It makes sense: passing your driving test is a fairly major life event.  I wouldn’t have been safe on the roads after that!  Having to go back and do something that you know you’ve just failed to do is difficult because your confidence in your abilities has taken a massive hit; passing makes you confident, over-confident maybe.  Either way, mistakes happen. So, having a break to reflect and re-group before getting behind the wheel again makes sense.

Medicine doesn’t work like that: regardless of what happens, we still have to keep going.  I’m not 18 anymore, I’m (probably) not as volatile: but I don’t just sit a driving test anymore.  Work just isn’t like that: you can genuinely see life & death within moments of each other.  And at each point, you just have to keep going and do the best that you can.  I don’t mean the technical skills: although doing that is hard enough.  I mean the bits that count: explaining to families what’s going on; talking about stopping; knowing that we’ve done what we can, and it hasn’t been enough.  And then turning around and giving another family good news.

And being a brilliant health care professional is about doing it honestly.  The most amazing thing I’ve seen in the past few weeks is watching my absolutely fantastic team share the pain of losing a patient, and supporting their family; and then coming back and sharing the joy of the baby steps of progress for another family.  And they’ve been absolutely genuine whilst doing it.  Seeing the looks on their faces when they come into the coffee room; when they’re on their way home.  It’s exhausting, and draining.

Doing that is hard: it takes a huge chunk of emotional resilience.  Doing it whilst also leading a team, and allowing them to see that you’re vulnerable is astonishing, and I’m very lucky to work with seniors that I can look at and think “if I can be that for my families in the future, then I’ll be doing my job”.

But in order to do that, then we/I need to also care for myself.  It’s why I’ve missed being part of a team so much the past few months: we look out for each other.  That’s not selfish: it’s making sure that our families get the care that they deserve, and that we can give it to them for the duration of our careers.  Maybe that’s a sensible New Year’s resolution?

I know this is a rambling post, but I’m not sure this is something I can think of in a more detached way.  I don’t know what I’m doing with my career path really.  I hate the “where do you see yourself in 5 years time?” scenario.  One thing I know: if I can be that doctor for the families that I care for; if in 10 or 15 years time I can be that leader for my team, then everything else is just extra.