Creating “Organizational Learning” – What could get in the way? #2

Example 2:  Health Care Improvement:

Checklists anyone?  You’ve probably heard of checklists by now, made famous by surgeon Atul Gawande,  author of “Checklist Manifesto”.  It is now accepted that surgeons  should use checklists to improve patient safety and outcomes of surgery. As you probably know, “wrong site surgery” sometimes occur, where surgeons operate on the wrong side of your body.   There are several steps in the checklist to prevent this from happening:

  • they mark your leg or arm with a special marker (which should not be erased when they cleanse the area during prep);
  • they check with others on the team, and they ask the patient “What side are you having surgery on?”

I recently heard a surgeon describe what happened when his hospital implemented this procedure – they ask the patient “which side?” so many times that the patient loses confidence in the clinical staff, and wonder whether they’re paying attention 😉  Ouch – unintended consequences!

So when we talk about introducing a new procedure such as this one, let’s remember to:

a.  Include the patient/customer/client in the conversation.  Ask them:  what could you imagine going wrong, if anything?

b.  Ask the staff:  What unintended consequences could you imagine when we implement this?    If we go to the other extreme, where we ask too many times, or do X too often, what do you think might happen?

What are our measures for evaluation of success?  When and how often will we evaluate if things are working?  What’s our plan for adjusting the procedure as we go forward?

What’s your experience implementing new procedures?  What checks do you put in place to make sure things are going well, or to make any necessary adjustments?

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