Depending on your source, between 100,000 and 300,000 patients die in US hospitals every year due to potentially preventable, in-hospital medical errors. Many more are wounded.
100,000-300,000 is a wide range. So, let’s be conservative and call it 100,000. Now, contrast that with the number of deaths that occur in all of U.S. industry per year—4,340 last year.
There’s nothing different about reducing employee injuries and deaths and patient injuries and deaths. The approach is identical. If you want different results, you need to change the system that’s causing the current results.
In the case of patient or employee deaths, two things need to change—the way work is done and the culture that establishes the underlying values of the organization.
Thanks to Johns Hopkins physician Dr. Peter Pronovost and others, the simple surgical checklist during major operations has been found to lower the incidence of deaths and complications by more than one third. The checklist is usually a single page that requires only a few minutes to complete at three critical junctures of operative care: before anesthesia is administered, before skin incision, and before the patient is removed from the operating room.
Checklists aren’t new. Airline pilots have been using them for years. Checklists have been part of what’s often referred to as standard work in many industries for a long time. They work and they’re easy to make work because all you have to do is follow the list. What’s not easy is shifting the culture of an organization from one where the surgeon is the master of the operating room universe to one where all OR occupants work as a fluid team.
This culture shift doesn’t start in the OR. It starts in the office of the CEO and it needs to include every leader in the hospital, whether it’s the chief of the medical staff, chief of surgery, chief resident or the “chief” of human resources.
Shifting the culture requires a re-clarification of roles and expectations of each person in the hospital. It means measurement, communication, learning and development, work processes, technology and rewards and recognition all need to be focused laser-like on becoming and remaining a zero accident institution and nothing less. Checklists are part of the hard, technical aspect of change. Shifting the underlying values within a hospital or any other organization is the soft side of change.
But checklists are easy. Culture is hard.