Constructing routines to better support teams – Health Policy Today, 20 January 2009

Tom Smith's Health Policy Today looks at how a form can help organisational function follow a better path.

One of the most interesting reports from last week involved the World Health Organisation checklist for surgeons, which has resulted in a 40 per cent reduction in inpatient deaths.  Though some headlines were slightly mocking, 'Right patient? Right leg?', the study has an important point that was missed by many.  It reminds us of the critical importance of supporting teams, and how management can do this by supporting organisational routines.

THE HARVARD CHECKLIST
Inspired by similar routines in the airline industry, the trial of the surgical checklist has been so successful that it will be introduced in every hospital in the UK by next February.

The study of the pilot scheme was published online in the New England Journal of Medicine, authored by Atul Gawande, a general surgeon and professor at the Harvard School of Public Health, who says the findings are “startling”.  They were produced by researchers who 'collected data for 3,733 patients who were operated on before the checklist was introduced and compared this with data for 3,955 patients operated on after the checklist was brought in', finding improvements across the piece, in different countries and contexts.

THE IMPLICATIONS FOR THE NHS
The findings certainly started a couple of Times readers who couldn't believe this didn't happen already (comments on www.TimesOnline.co.uk).

'Neil' commented on TimesOnline, 'I have just read the article, and I'm absolutely horrified that such basic procedures have never been implemented. I reckon this is only the tip of the iceberg.'  Similarly, Sarah wrote, 'I'd always assumed a checklist of this type was standard practice and had been for decades.'  

The annual number of safety incidents, nearly 130,000 for surgery along were reported to the NHS National Patient Safety Agency (NPSA) in 2007, will draw attention to the need for more safety checks like the WHO checklist.  

There is a tendency, however, to misinterpret the findings.

An article on Conservative Home says the findings show professionals cannot be trusted.  And so the the lesson is, 'when formulating policy for our health service, we must not make the assumption that the caring professions can be automatically be relied on to do what's right.'

The real point of the story, however, is not that individual surgeons should go through a checklist to ensure they avoid mistakes, it is that the checklist is an organisational intervention to support   the team of people in surgery.

SUPPORTING TEAMS
As the  Times   report explains, 'Procedures will begin with a roll call, where all team members confirm their name and role. The senior nurses, surgeon and anaesthetist then confirm the patient, site and procedure. Nursing teams will also provide a sterility report and highlight any potential concerns about equipment. '

'The surgical checklist is a tool that supports the gelling process.'
Within my own PhD, I explored the nature of teams in the NHS, and I found they were very complex things with individual professionals simultaneously members of several teams.  Some teams are role-based rather than relying on specific members.  In emergency medicine, for example, these teams need to gel in an instant, even if individual member do not know each other very well.

The surgical checklist is a tool that supports the gelling process.  

ORGANISATIONAL ROUTINES
What the study shows is the importance of the team dynamic and the checklist, though it doesn't take long, allows the team to tune into their co-dependence and collective task.

There is academic support for this view.  

On November 29th 2008, the BMJ published an analysis piece by Trisha Greenhalgh on  the role of routines in collaborative work .  She argues that routines are critically important in maintaining and improving the quality of care, precisely because they provide a mechanism for autonomous professionals to engage with one another.  She says that poor co-ordination and collaboration is a major weakness of care.  

Routines reinforce that people work to a common task.  Drawing on research from organisational sociology, Greenhalgh suggests a routine is best understood as 'a repetitive, recognisable pattern of interdependent actions, involving multiple actors'.

QUALITY IMPROVEMENT: GETTING THE UNIT OF ANAYSIS RIGHT

'a key weaknesses of policy in recent years is that associated initiatives are often based on the wrong unit of analysis'
The analysis of organisational routines has a very important consequence for quality, as a key  weakness of policy in recent years is that associated initiatives  are often based on the wrong unit of analysis.

It should not be the whole organisation, which is too large and for which the measures chosen are often too broad, bearing little relevance to the patient wondering which gynaecology department to choose.

Neither should it be the individual clinician whose activity is shaped and determined by the context in which they work – they are dependent on others.

The right unit of analysis is the team - which is defined variously for different tasks: for surgery; for outpatients; for the management of chronic disease.  

What is really interesting about the surgical checklist is in reinforcing the importance of collective and coordinated action for individuals working together to care for patients.

The implication for managers is that they should explore ways to support professional standards for how individuals should work together in their local service.  

Trisha Greenhalgh's BMJ article touches on the subject of 'organisational learning', the subject of my PhD.  We are both interested in the ways that groups of professionals are able to gather data about their service, analyse the results and amend practice accordingly.  Her analysis suggests that organisational routines play an important part in this.  'Routines allow for the input of others'.  

Managers should not assert any particular routines on a group, but they should ensure that the organisation supports a local negotiation of these processes.