It’s now 10 years since the WHO surgical checklist was introduced to the NHS. Ara Darzi was one of the doctors involved in the implementation. He should be proud of the countless lives saved and impairments prevented through the use of such a simple tool. Similar checklists are now widespread across healthcare. Their associated actions are very familiar to countless doctors and other clinicians. So familiar, in fact, that they are often just part of the routine. It’s a bit like getting in the car or walking to get to work. It’s easy to go through the steps without really thinking. When we arrive at work we often can’t remember negotiating that busy junction. But we know we’re safe, don’t we? We know this because, thankfully, nothing happened and everyone is OK. Yet, unfortunately, NHS Improvement’s data shows that so-called ‘never events’ still happen every single day across the UK.
Ticking boxes
Lord Darzi recently described how,
“Some surgeons scoffed at the idea that such basic checks could make a difference. Some objected that it was a box-ticking exercise. Staff complained it was poorly worded, time-consuming, inappropriate or redundant.”
‘Ticking the box’ is a common human behaviour. We’re most guilty when we become over-familiar with a routine, where we don’t understand the reasons or when we don’t really believe in a task. There are plenty of other examples of where tick-box attitudes have become common for some doctors. One is with the appraisal/revalidation process. Another is the practice of shift-handovers.
A shift in handovers?
A few years back, the discussions at our Advanced Team Communication Skills Courses suggested shift handovers no longer needed attention. The problem had been identified. Royal Colleges had published guidance and toolkits. Organisations had created and launched processes. Sorted. Time to focus attention on other matters then.
In recent times, though, there are indications that this simple process is slipping in some quarters. I’m meeting course delegates who openly admit that they don’t turn up to handover meetings. Some are locums and some are not. No one challenges them about this. So it’s become acceptable that they are not there. Others admit that they don’t listen. They are there when the meeting happens – it’s the routine afterall – but their mind is elsewhere. They’re ticking the box. One doctor told me that, to his bemusement, the department he had just joined now conduct the process via recorded voice messages. A good solution to short attention spans and big time pressures? Or are these indications that the handover is at risk of losing its way? There was no way for him to ask questions about anything that was unclear. The risks should be obvious…
Compliance or Utilisation?
Let’s go back to Lord Darzi. Here are his thoughts on the purpose for the checklist processes which were derived from the approach taken in aviation.
“The object of the checklist is not to eliminate thought but to stimulate it, by assisting professionals with the myriad routine tasks they must carry out, freeing them to do what they are trained to do – deliver skilled care”.
During our Healthy Teams in Healthcare Study, we asked doctors how they communicated with others regarding team processes. We asked, “How clearly can you describe the reasons for working this way?” 28.7% of the 202 doctors who participated responded either “Not enough” or “Not at all”. Even more notable was the fact that 36.6% stated that they didn’t discuss improvement of team processes either enough or at all. Were they avoiding the processes, ignoring them or mechanically going through the motions?
There aren’t enough hours in the day to waste time on doing things that serve little or no purpose. So doctors should, indeed must, challenge any activities which waste time and effort. Such challenge, when done well, should lead directly to systems improvements. This may be due to the generation of new and fresh ideas. At other times, however, the improvement arises because the doctor raising the challenge discovers the true thinking behind the system. In doing so, they may realise that there is true value. They are then likely to move from the mechanical compliance of a tick-box mentality into genuine utilisation. The improvements arise because they take ownership for the system.
Where are the mechanical compliance and tick-box moments in your current practice? What are you doing about it?
Stephen McGuire – Director of Development
