During the recent snowstorms in the East, one of my friends told me about an arrangement that he has with a neighbor. The neighbor has a John Deere tractor, and ploughs the snow from their driveway. In return, my friend, who is a tool and die maker, fixes their tractor when needed. He said that he certainly gets the better of the deal, because a John Deere rarely breaks!
In the 2005 book, The John Deere Way, David Magee reports on Deere’s commitment to quality and customer service. Quality extends far beyond the John Deere product lines and dealerships. The total quality effort is what employees see…that quality in their daily work ultimately results in quality that the customer sees when they “get behind the wheel of a new yellow Deere 710 backhoe loader.”
Hospitals and tractors are certainly different animals, but the importance of quality processes is shared. In a recent blog (2/8/2010), Bob Wachter reviews Atul Gawande’s Checklist Manifesto. The insightful point that Wachter makes is that “the public is so unsettled by our patient safety and quality flaws… (because) they assume that we do know the right thing to do, but simply screwed it up.” Wachter quotes Gawande: “… under conditions of true complexity – where the knowledge required exceeds that of any individual and unpredictability reigns – efforts to dictate everything from the center will fail. People need room to act and adapt.”
Says Gawande: “In a world in which success now requires large enterprises, teams of clinicians, high-risk technologies, and knowledge that outstrips any one person’s abilities, individual autonomy hardly seems the ideal we should aim for. ..what is needed, however is discipline…discipline is hard – harder than trustworthiness and skill and perhaps even than selflessness. We are by nature flawed and inconstant creatures. We can’t even keep from snacking between meals. We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at.”
Despite demonstrating that checklists produce results, there is resistance to their use because of the (1) Master of Universe mentality (Rock Star; Fighter Pilot; Hero), (2) our jobs are too complex to reduce to a checklist, (3) checklists are too rigid and don’t force us to look up and see and think ahead of what’s in front of us.
Gawande finds two pitfalls in our resistance – the fallibility of human memory when it comes to mundane, routine matters that are easily overlooked under the strain of more pressing events and secondly, people can lull themselves into skipping steps even when they remember them – after all certain steps don’t always matter…until one day they do.
The similarity to a manufacture of a tractor is startling – Gawande is stating that the people need to see the quality that they are producing, and be aware that it is quality based on an established process (like through a check list). Gawande gave a great example of a cleanliness checklist used in intensive care units in all Michigan hospitals in 2003 to eliminate infections. Said Gawande (in his New Yorker article that inspired the book): “ In December, 2006, the Keystone Initiative published its findings in a landmark article in The New England Journal of Medicine. Within the first three months of the project, the infection rate in Michigan’s I.C.U.s decreased by sixty-six per cent. The typical I.C.U.—including the ones at Sinai-Grace Hospital—cut its quarterly infection rate to zero. Michigan’s infection rates fell so low that its average I.C.U. outperformed ninety per cent of I.C.U.s nationwide. In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated hundred and seventy-five million dollars in costs and more than fifteen hundred lives. The successes have been sustained for almost four years—all because of a stupid little checklist.”
Within hospital operations, I’ve seen how the successful application of a process called AIDET (Acknowledge, Introduce, Duration, Explanation and Thank You) when applied to support service workers creates a positive reaction within patients and leads to higher patient satisfaction scores. AIDET is a mnemonic device which really does serves as a checklist to support service workers when interfacing with patients. Click here to read Quint Studer’s application of AIDET.
Like Deere, quality impacts the cost structure at hospitals in every area of the business. Successful hospitals see quality as all pervasive, and instill the camaraderie, discipline and processes in place to create a culture of quality. “The promise of quality always comes first” is from Magee’s work about Deere. Gawande would add that in hospitals, the process that ensures quality (a checklist) is part of that promise.
