Culture eats checklists for lunch

Last month, I made a day trip to Regina on a small, local airline. While I waited for my return flight in their Regina airport lounge, a Canadian Forces aircrew was also waiting. There were about a dozen of them, getting ready to fly out in their huge transport plane. The lounge was small, and the aircrew were quite boisterous, joking and clowning around. What happened next has been on my mind since then. But before I tell you about that...


Pre-op checklists garnered the limelight recently and briefly with the publication of the WHO international study that showed improvement in morbidity and mortality after the checklists were implemented. Just over a year ago, I blogged about WHO's checklist in beta version, and some responses I'd seen in the OR.

Not much has changed since then.

Recently, I was called into an OR room because the staff had difficulty inserting a catheter in a patient anaesthetized for abdominal surgery. I had to do another minor procedure to get the catheter in, and before starting, I asked if we should stop to do the preop checklist. The surgeon, who was waiting in the room, piped up dismissively, "Oh, jeez, come on. I know this guy!", and then proceeded to rattle off the patient's name, planned procedure, general health and allergies, auctioneer-style. "That checklist is such a waste of time", he concluded. There were sour looks on the staff's faces, but I couldn't tell whether it was because they agreed that the checklist was a waste of time, or because they disagreed with his assessment. The charge nurse went through the checklist, despite the surgeon's contempt.

Bryce Taylor, chair of Toronto's Department of Surgery and an author of the WHO report, was recently in Saskatoon to present the report, and discuss how to implement the checklist. One of the OR nurses who had attended the lecture commented that it might be difficult to convince all surgeons to embrace the checklist. I suggested that we needed to come up with the right incentives, perhaps going as far as linking the surgeon's access to OR time to his/her performance on critical patient safety issues. If our administration is truly committed to universal use of a safety checklist, they need to be anticipate that there may be a few surgeons who will push the issue that far.

The nurse laughed. "Can you please let me know when you're going to tell Dr. X that he can't operate until he does the checklist," she snorted. "I want to be in the room for that!"

These are a couple of examples of how the OR culture can affect improvement efforts. "Culture eats strategy for lunch" applies here.

But, don't despair! There are other cultures from which we can learn. Back to the airport...

The military aircrew were horsing around in the airport lounge when one of the officers quietly called out.

"Gentlemen. Let's get ready to fly."

Immediately, the aircrew settled down and gathered round. The officer recited the flight duration, altitude, weather conditions and other details. He called for questions. I suspect the crew members already knew most of the details of the flight, yet were completely attentive for the 1 minute briefing. The officer didn't need to raise his voice, or repeat his call for their attention.

Now, that is a professional, safety-conscious culture.

In my first OR vignette, the surgeon insisted that he already knew all the critical information about the patient and the planned surgery. Well, I certainly hope he would. But he misses the point that the checklist is not just for the surgeon; it's for the whole OR team. Also, the purpose of the checklist goes beyond the recitation of critical safety information. The checklist should foster and be part of a culture of open communication and cooperation in the OR. Check out some of the comments at the end of this Wall Street Journal article about the WHO checklist. People are amazed that checklists aren't already standard in ORs.

I guess it comes down to the Golden Rule. If you were on the OR table (or an airplane!), would you want the team looking after you to be communicating openly with the single goal of providing the safest, most effective service of which they were capable? Or are you comfortable with letting someone hinder, under the banner of professional autonomy, everyone else's efforts on your behalf?