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!

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One thought on “Why we all need to care about systems

  1. I really liked this article as it echoes my thoughts on this topic. I do like check-lists (a bit of autistic/ OCD trait in me) and it has been reinforced upon by this brilliant book called ‘The Checklist Manifesto: How to Get Things Right’ by Atul Gawande.

    (https://www.goodreads.com/book/show/6667514)

    As you rightly pointed out, checklists shouldn’t be a mere tick exercise but its meant to ensure thorough preparedness prior to a procedure/ documentation post procedure etc to augment patient safety.
    Thank you for writing this article.

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