Speaking of checklists and routine, Atul Gawande and colleagues put out an excellent example of a mindless execution of a surgical checklist on You Tube. As they say, a picture is worth a 1,000 words–in this case, a video of “how not to do it” eloquently makes the case for ‘how to do it’ correctly. Thanks Atul, for providing yet another example of true north to patient centered care.
And a more mindful, creative method of performing a surgical checklist follows. If you have a few minutes, it’s well worth it to watch this one–at least until the Remix portion:
In Gawande’s piece, The Velluvial Matrix, for the New Yorker in July of 2010, he writes:
…Doctors and scientists are now being asked to accept a new understanding of what great medicine requires. It is not just the focus of an individual artisan-specialist, however skilled and caring. And it is not just the discovery of a new drug or operation, however effective it may seem in an isolated trial. Great medicine requires the innovation of entire packages of care—with medicines and technologies and clinicians designed to fit together seamlessly, monitored carefully, adjusted perpetually, and shown to produce ever better service and results for people at the lowest possible cost for society…
Without mindfulness applied to daily practice, including routines that may seem to have little effect on outcomes, health systems will fail to reach the high reliability that will deliver the Triple Aim–better care, better population health at the lowest possible cost. It is imperative we start teaching these newer concepts of high reliability, mindfulness, teamwork, human factors and transparency to our students and residents. Our future caregivers should not have to struggle trying to provide care that is safe and low risk.
Throughout our series on High Reliability Organizations (HROs), we have been discussing the five defining principles Weick & Sutcliffe have described HROs to possess: 1) Sensitivity to Operations; 2) Preoccupation with Failure; 3) Deference to Expertise; 4) Resilience; and 5) Reluctance to Simplify. The five principles are interrelated and do not exist unless they are built upon an organizational “collective mindfulness,” which describes the way in which the scarce commodity of individual attention is applied to the health of the overall organization. They use Langer’s model of a mindful state at the individual level and then apply it to the group based on its application and interplay within the five principles above. According to Langer:
“…a mindful state is expressed at the individual level in at least three ways: active differentiation and refinement of existing categories and distinctions; creation of new discontinuous categories out of the continuous streams of events that flow through activities; and a more nuanced appreciation of context and of alternative ways to deal with it…”
But mindfulness for the sake of mindfulness will not transform an organization into a HRO. Awareness and vigilance without action will not keep patients safe in our hospitals. It is the ability of all within an organization to consistently focus awareness to that which has the potential to cause harm without losing the forest through the trees as they say, and then effectively act upon the data taken in that will effectively transform an organization. As Weick, et al share:
“…To grasp the role of collective mindfulness in HROs, it is important to recognize that awareness is more than simply an issue of “the way in which scarce attention is allocated” (March, 1994, p. 10). Mindfulness is as much about the quality of attention as it is about the conservation of attention. It is as much about what people do with what they notice as it is about the activity of noticing itself…”
Mindfulness empowers action that prevents potential harm, and can be appreciated with the high reliability mindset of crews on aircraft carriers. Stephen Muething, MD, Vice President of Safety at Cincinnati Children’s Hospital illustrated one such example of action in his post, Lessons From An Aircraft Carrier:
“A piece a paper floated up onto the deck. A young trainee raised his hand immediately, dozens of other hands went up on deck when they saw his, and the landing was aborted. During the commanding officer’s daily address that evening he called out the sailor by name and thanked him.“
The chart at the top of this post is adapted from Weick, Sutcliffe & Obstfeld, 1999 and was found in the AHRQ publication “Becoming a High Reliability Organization: Operational Advice for Hospital Leaders.” The visual further reinforces that without a constant state of mindfulness, an organization will not achieve high reliability, or if they do so, the accomplishment will be fleeting. How can organizations develop and institute a state of collective mindfulness within their organization? With practice, intention and a culture steeped in transparency and an openness to learning. More on mindfulness to follow. Please share your thoughts–
Weick KE, Sutcliffe KM, Obstfeld D. Organizing for high reliability: Processes of collective mindfulness. Research in Organizational Behavior. 1999;21:81-123.
Weick KE & Sutcliffe KM. (2007). Managing the Unexpected: Resilient Performance in an Age of Uncertainty. San Francisco: Jossey-Bass.