Horizontals & Vertical - healthcare has to get it right

Medical/technical knowledge is vertical. Leadership knowledge is horizontal. Healthcare, especially doctors, need to understand this.


Clinical and medical knowledge i.e. technical knowledge – is vertical. It always starts with wide basic foundations and over time doctors knowledge becomes deeper and narrower. As a first year medical student you need to know about everything about a human body. But, say someone like a anal sphincter repair specialist or a paediatric neuro oncologist, who are very highly defined sub-specialists deliberately move away from their broad knowledge to knowing everything about their narrow scope of work. Such knowledge can mainly be learned from senior, mostly older more experienced persons, who have a higher technical knowledge. The process is pyramidal. Quite rightly so.


Leadership (and many aspects especially non-technical aspects of management) i.e. non-technical knowledge is horizontal. Leadership starts small and expands widely around us mostly in a flat transverse plane with amorphous blobby edges not necessarily circular. Leadership is where anyone and everyone has something to offer/teach/show anyone and everyone else irrespective of age, sex, colour, nationality, hierarchy, wealth, etc. The process is similar to an amoeboid motion expanding and ending up with varying end dimensions, yet no well defined end points for learning and development (though leaders themselves do have goals and aims).


Pilots learn flying (technical) mainly from other older, more experienced pilots – vertical; but crew resource management techniques (non-technical) is learned together with all staff who will be in an aircraft - horizontal.


What may be happening is that we are learning clinical, medical and technical stuff in multi-disciplinary, multi-professional combined learning atmosphere (some of the learning using this approach especially for procedural skills may be valid)


and


Leadership learning is being offered in situations and by organisations mainly or solely consisting of, designed for and responsible for doctors (such as deaneries, FMLM and many others).


I do not think there should be doctor leaders or nurse leaders which is what we find now; at least within organisations such as the NHS there should be leaders who happen to be doctors and leaders who happen to be nurses. Courses, teaching systems, learning atmospheres, pathways, about leadership in healthcare that are exclusive to any profession does a disservice to the whole cause by pre-defining a narrow mental perspective. The hierarchy in the professions are based on narrowing similarity (vertical) whereas leadership is based on broadening equality (horizontal).


It is possible that healthcare is now confused between horizontals and verticals. The quicker we resolve it the more successful we will be.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Generalists

GENERALISTS FOR UK HEALTHCARE - WILL IT WORK?

A rethink of training is happening. We debate that here.

In the USA most doctors undergo four or five years training depending on whether they are medical or surgical fields and become 'generalists' (family practitioner, internal medicine physician or general surgeon). They provide the bulk of care in their areas. Some of course choose to sub-specialise into ever narrowing areas for which they undergo a further 2 to 3 years of 'fellowship' training. When it comes to care delivery the patients do have a choice (at least in theory) of seeing their Family Practioner, 'generalist' or sub-specialist; the family practitioner and/or the Emergency Department has the choice of referring patients to generalist or sub-specialist as the situation demands. Of course the generalists refer on to the specialists as needed.

Moving from the mature economy USA example to the advancing economy of India the situation is more or less the same. Doctors after their MBBS are allowed to practice as GPs and recently there is a trend of emerging opportunities to train further to become an advanced family practitioner. Many doctors obtain post-graduate training and become 'generalists' general physician, general surgeon, etc. Some obtain sub-specialty (though the Indians love the term 'super-speciality', they never call their narrow field as a 'sub-specialty') and become cardiologists, vascular surgeons, et al.

In the UK there has been in the guise of rather misguided and seemingly always wrong work force planning, the training system has, since Calman, delivered 'sub-specialists' to deliver care in the NHS. There are no more 'general physician' or 'general surgeon'. In theory a collaborative approach of all these good people is supposed to deliver high quality integrated care to the patient at the front line. In practice it falls and fails often and more. 

At the real front end where direct care is delivered by the trainees and sub-specialty doctors the sub-specialist attitude becomes a big problem. In these young doctors' minds they are very keen to learn their sub-specialty skills and they are not interested or do not have have the time to learn or deliver 'general care'. What it translates into are junior doctors who are unable or unwilling to do 'general' care. I have heard from many about numerous instances of junior doctors and non-consultant doctors being unable to do things like supra-pubic catheterisation, torsion testis, embolectomy, etc despite being on call for their relevant generality in DGHs (or even teaching hospitals). The 'sub-specialist' has to be called out to deliver what is essentially general care.

There are strong arguments for the UK sub-specialist model, mostly emotional. An example such as 'would you like to obtain the best care from the most highly trained person or be messed up by a generalist?' However since we do not train generalists in the UK we do not know what kind of care a generalist might deliver; since there are other countries training generalists, we know that generalists do deliver a high standard of care. What we also know is that care can slip between sub-specialists, care can slip due to non availability 24/7 of sub-specialists in every hospital, care can slip due to difficulty of access to sub-specialists (in the version of centralised care in major hubs) and sub-specialist based care is costly. 

Of course my favourite argument is costly care is generally not beneficial at a system level.

The UK is now at the closing stages of the 'Shape of Training' consultation to explore potential future models of training that would suit UK requirements. No favoured models have been decided yet, no decisions have been made. The consultation includes a model where more generalists would be trained to deliver the bulk of care across locations. Even within this model, UK would obviously still train sub-specialists but their numbers and the location of work could be limited.

There are many reasons why the idea of generalists would not work. First and foremost is the culture in UK where the current sub-specialist model is seen as inherently superior and in those circumstances change becomes frustratingly difficult. Sub-specialists seem to carry more glamour, power, earning opportunities and even respect; hence it is a natural aspiration for most doctors; even many general practitioners in UK want to be 'GPwSI'. Broad knowledge seems not be valued as much as deep knowledge (and by the way, broad does not equate to superficial).

However, it is important to question whether in a small country (at least relatively in terms of population and geography) with current economic difficulties it is possible or reasonable to train and maintain sub-specialists 24/7/365 in every location that care is provided; which we will have to do if we have to deliver high quality of healthcare to our population. With care being delivered outside conventional settings closer to the patient and community with concepts such as tele-health, virtual consults, hospital at home, becoming real; with technology enabling remote diagnosis to be made (smart phone ECGs and blood tests at super-store car parks); with Dr Google and crowd sourcing having the potential to be more accurate/knowledgeable than individual specialists we do need to think if the training of doctors in UK needs to move to a 'generalist' model.

I am in support of training generalists who would have in the hierarchy of NHS appointments have a higher or equal level as specialists. They should be charged with the specifics of designing and delivering high quality of care (including management responsibilities). A generalist would be far more likely to interact closely with the patients, general practitioners and specialists than now - that would be a boon and a refreshing change to the passing-the-parcel that is currently played with patients due to a system that is divided into very narrow specialties. There will of course be the rare generalist who is blind to her/his limitations who can be very dealt with proper systems in place.

What do you think will work for UK/NHS? Are generalists a good idea?

©M HEMADRI 

Follow me on twitter @HemadriTweets

Info:

Shape of Training: http://www.shapeoftraining.co.uk/

I provided oral evidence to the Shape of Training consultation as a part of BAPIO team and hence we had a specific remit to support the interests of IMG and BME doctors apart from providing general views on the various proposals and our own views as individuals. This blog does not discuss contents of BAPIO's evidence to the consultation; the above are my personal views.

Some thoughts on future healthcare

BMJ's doc2doc social media website's Matthew Billingsley recorded my interview at the 2013 International Forum for Quality and Safety in Healthcare at London for a podcast.

We discussed crowd sourcing healthcare, learning from other healthcare systems, the gate keeper role of UK general practitioners, etc. I hope you enjoy the podcast.








The future of healthcare is changing and could be unrecognisably different. How willing or ready or you to cope with it?

©M HEMADRI 

Follow me on twitter @HemadriTweets

PS: This podcast was originally posted on the doc2doc website and is reposted here.

My Conversation with Dr Ravindran, Chairman of Aravind Eye Care

I had the privilege of meeting Dr Ravindran, Ophthalmologist and Chairman of Aravind Eye Hospitals, India, at the International Forum for Quality and Safety in Healthcare London 2013. I had a general informal conversation but it was of course an eye opener - you bet he has experience in that!

I share some of the conversation here. 

Clinicians' Selection processes at Aravind

Doctors

It is well known that Aravind has processes that are followed really well by the staff, especially doctors who work there. Protocols and processes are very important for their pathways and systems to work. It is also well known in healthcare that it is very difficult to get doctors to follow organisational protocols. I asked Dr Ravindran on how they do that.

Aravind appoints doctors after a 3 day selection process. Applicant to appointment ratio is a minimum of 3:1. Fellows and residents work and spend time with staff on those three days. Doctors then provide feedback to the appointments panel on the suitability of applicants. Anyone blackballed by existing staff are not selected. The main if not the only criteria for appointment is if the doctor is 'suitable for our culture and basic values'.

They obviously get people who are already high flyers with research credentials, publications, etc but Aravind's attitude seems to be that they want only normal average people to work with them and their system and culture will then make them do good work. (This sounds very similar to Toyota Chairman Cho's statement that they get brilliant results from average/normal people when other car manufacturers get average results from brilliant people). These high flyers, if they are not suitable for the Aravind culture are told that they are likely to be very successful outside the Aravind systems.

Chairman Ravindran says 'we want everyone to be pleasant and professional to each other. If we detect even a small amount of arrogance during the selection process, we will not appoint the person. Arrogant people can offend and upset others which will disrupt team work and increase staff turnover - we cannot have that'.

Nurses

Student Nurses are selected after a written test and an interview. The test is a hand written test where they answer a question on a social concept. Hand writing is thought to be important (if you cannot read a person's writing the value of their documentation and written communication becomes a future problem). As for the content, it is thought that if a young aspiring nurse cannot write with genuine empathy about a socially important issue they would not fit in with Aravind's culture and communication.

Now comes the interesting part of the process. While interviewing the applicants is what everyone does anyway, Aravind interviews the parents of the applicants. They see this as very important. Attitudes of parents and aspects from home have an influence on how people behave and work. This is accounted for in the interview and selection process.

Once they are selected to be nursing students, Aravind pays for their training, accommodation etc. These students after graduation get to work for Aravind.

I probed their thinking - I said that the society will have many different types of people and their organisation will/should have different type of people; including and excluding some types will not reflect the society. Dr Ravindran was very clear with his answer, he said that of course the society  will have many types of people but in his organisation they only want the type of persons who can share their basic value.

Their basic value is compassion.
 

He also said that many in the organisation including the senior people continue to engage with the staff and their lives, he said 'I know a lot about many people who work with us, what they enjoy, what problems they have at work, what issues they have outside work and in general a lot about their lives. Due to this we are able to support them very early.'

Learning

I specifically asked him about where and whom he and his organisation learns from. He says that their main learning is from within their organisation, they try to improve everyday and share it with their internal colleagues -  mutual learning within the organisation. (This blog has in a previous post stated this as the fourth fundamental condition if healthcare is to be successful http://successinhealthcare.blogspot.co.uk/2012/01/hemadris-four-fundamental-questions-for.html )

No external consultant has even been contracted. No lean specialist, no management consultant. They get regular visitors trying to learn from the Aravind system. Aravind staff do visit hospitals around the world to explore what might be suitable for adaptation.

Attitudes

When asked about how they deal with the high volume of patients Dr Ravindran said 'If we have more patients we simply start early - all of us. We do not put patients on a waiting list, we do not turn patients away'.

I asked about being lean and quick and his response was 'It is not about being quick. It is the attitude of not wasting anything. So if we don't waste time it looks like we are quick. We do not throw away anything; if a bed sheet is torn you can be sure it will re-appear in some other form to help with some other function'.

I think my commentary is not really needed as the conversation is very illuminating and self-explanatory. Their website shows that eight out of ten directors of their board are doctors - does that say something? I think we can learn a great many things from Aravind Eye Care and their practices. I wonder what we can actually adapt and use for healthcare delivery in the western world?

©M HEMADRI 

Follow me on twitter @HemadriTweets

Links

Aravind Eye Care http://www.aravind.org/

Anonymity, Privacy, Whistle Blowing and the use of Internet

Please see disclaimer at the end of the write up - by accessing this page and reading this blog you agree to the disclaimer.


There are two major topics that are really exercising the healthcare fraternity in the UK these days. First is whistle blowing and the second is the GMC's new social media guidance for doctors. It is very frustrating that at a time when we should be encouraging whistle-blowing including anonymously if needed and the department of health seemed to have banned gagging orders, we are also presented with what might look to some, as one mass gagging order for all doctors. The message from the top is mixed and hence confusing.

Whistle blowing is to report wrong doing to someone who has authority to do something about it. UK government has advice for whistle blowers ( https://www.gov.uk/whistleblowing/overview )The NHS supports raising concerns ( http://www.nhsemployers.org/employmentpolicyandpractice/ukemploymentpractice/raisingconcerns/pages/whistleblowing.aspx ) The GMC obliges doctors to raise concerns ( http://www.gmc-uk.org/guidance/ethical_guidance/raising_concerns.asp )

Please do your very best not to post or whistle blow anonymously. Please develop the strength and courage to use your own name and then report the facts and evidence that concerns you. Anonymous whistle-blowers are generally not taken seriously ( http://www.sciencedaily.com/releases/2010/07/100712102810.htm ). The latest GMC guidance on social media says that ''If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name'' - so if you are a doctor and talking medicine in social media you must use your own name.

Having said that it is also possible that some may be in such a vulnerable position or the impact of whistle blowing or otherwise writing non-anonymously will have a permanent and disproportionate effect on your life, then it is obviously important to protect your privacy and anonymity. You may also want to take steps to ensure that you are not ignored.

I personally feel that anonymity gives a voice to the voiceless and the weak; I wish those who are reading this are not weak and hence do not have to follow any of the methods in this blog. But for those who are forced into anonymity, what follows are methods to increase your privacy and anonymity while using the web.

For a lay person this is a basic explanation of how the internet thing works.

Your computer uses a particular piece of hardware to connect to the internet. That hardware identifies itself to your internet provider using a MAC number and connects to the internet. Then you open a browser (e.g. Mozilla Firefox, Google Chrome) and you start searching or browsing. Your internet provider (ISP) will know which websites you are visiting and emails you are sending though they may not choose to find out the actual contents of what you do in those websites or what you write in your emails. Your ISP then routes your requests to the website that you want to visit and the website you visit could fairly simply find out a lot about you.

So, for anyone using the internet it is quite easy with the right resources to identify more or less precisely who you are, what you did and where you did that from.

If you wanted to make it difficult for people to identify you a few steps could enable that (though with huge governmental resources normally reserved for high impact criminal activity, anyone can be tracked down).

Step 1
Use an Open public wi-fi network such as in shopping malls, coffee shops, etc where no log-in was needed to access the internet. You can use your own internet connection (at home, etc) but your ISP will know that you are accessing a particular service regularly (the service being the Tor network described in Step 3)

Step 2
Use software that can change the MAC number by which your computer talks to your ISP or to the open public wi-fi provider. You can change this every time you access the internet. By doing this the ISP will not be able to identify your computer specifically.
MAC spoofer (http://www.online-tech-tips.com/computer-tips/how-to-change-mac-address/ or http://www.technitium.com/tmac/index.html )

Step 3
This is the most important step. Use the Tor browser bundle.

Using the Tor browser would mean that the information that you send from your computer into the internet is encrypted and thus cannot be read on the way. Tor system then routes your communication (emails, browser requests, etc) through at least three computers with encryption. The communication then exits the Tor network to your destination but at that point it is not encrypted and hence can be captured and read but that will not identify you as the sender by revealing your computer and net details if you have not explicitly identified yourself in the communication. So you could send communication from India to USA and it will be very very difficult to identify your specific computer.

Tor browser ( https://www.torproject.org/projects/torbrowser.html.en )

When using the Tor browser use do not open attachments, do not send attachments (unless you are an expert in internet anonymity), do not open additional programs within Tor browser or when Tor browser is in use. Find out more about Tor ( http://en.wikipedia.org/wiki/Tor_%28anonymity_network%29 )

Step 4

Even within the Tor browser if you are searching, use a search engine such as Duck Duck Go  https://duckduckgo.com/
who unlike conventional search engines do not track you or otherwise want to know too much about you.

So far it is about anonymity on the net.

You will still need to make sure that you do not reveal yourself. Hence you should not be using your own regular email id, if you want anonymity or privacy. So.....

Step 5

Open a new account using any of the regular email providers (e.g. Yahoo!, Hotmail, Gmail, etc - taking care to provide only the minimum legally required information) using a Tor browser to send emails with no personal or identifiable details in the content/body of the email, subject line or in the email id. Cancel the email account once the purpose is served.

Use a disposable email ids when possible (e.g. https://www.guerrillamail.com/ ; http://10minutemail.com/10MinuteMail/index.html ) for 'forms' in websites and forums

If you are whistle blowing: Copy a news organisation for evidence record that you have reported/whistleblown. 


Step 6

Steps 1 to 5 above are things that you must do. This Step 6 is about things that you should not do:
a) do not attach any thing or send anything as attachments with your email or posts
if you attach anything you risk losing exposing who you are
b) do not open any files, programmes, or other software when you are using Steps 1 to 5 above as that will risk revealing your identity.

Please remember that all these steps and what is written in this blog post are for amateurs. Please learn about all these steps and related items, get yourself very familiar and confident before you use them. Do dummy runs, trial runs etc before you actually use it for any worthy purpose. Remember that there is no (and probably never will be) complete privacy or anonymity in the internet.

Do not use these methods for anything illegal, please do not use these methods to harass, intimidate, spread falsehood or anything else that is offensive. Please remember that internet is never anonymous and illegality should never be attempted even under anonymity.

Whistle blowing is a frustrating but noble act. Please check your facts before you blow the whistle; please see if you can raise your concerns confidentially within the organisation using normal/regular channels before you consider using whistle-blowing methods. Please consider every opportunity to whistle blow without taking recourse to anonymity.

Please note that these tools above are not just for whistle-blowers; they exist for people who just want to be anonymous. All of us could use Tor to maintain and enhance our internet privacy. We could use disposable email ids to avoid spam. 

If you have used Tor then keep the Tor on and allow your connection to be used as one of the nodes so that you will contribute to increasing the privacy of the net.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Disclaimer: 
Please check if the above steps and everything else in this blog are legal for use in your location, country, area, etc

Please do not do anything illegal (anonymously or not) on the internet (or in any other area).

I am not an expert in internet security/anonymity/privacy; I am merely a normal user of some of the methods described above. The anonymity and/or privacy and/or security enabled by the methods described above have not been personally checked/validated/guaranteed by me; I only write due to an interest in these matters; I cannot therefore take or accept any responsibility for any loss of any sort including financial, lack of anonymity/privacy/security, embarrassment, or for any negative effects of following anything written in this blog post. It will be your/the reader's responsibility to ensure your own anonymity/privacy on the net and the consequences of any loss of anonymity/privacy or other negative effects.


No vested interests


PS: If there are any errors in the blog or if you have any ideas to enhance the topic please leave a comment below.

Breaking down monuments

Here are a few examples of monuments that we can break down.

Ultra-sound scan room

There is no real need for in-patient diagnostic USS to be done in a specific room. Put them on wheels and take them to the patient on-demand. Doctors get bleeped for opinions for in-patients and they go to the patient, no reason why diagnostic USS cannot be done by the bedside after drawing the curtains around. This spares physical space for more work do be done (I think the managers call it creating capacity).

USS for outpatients - could it not be done at patients' home? District nurses do dressings at home why not USS?

Flexible Sigmoidoscopy

For in-patients diagnostic flexible sigmoidoscopy can be done in their own beds during ward rounds. For outpatients it should be done during the consultation at which it was thought to be required and in that same consultation's examination room. Why do we think we have the right to ask the patient to come back for something that can be done then and there?

Gastroscopy

In-patient diagnostic gastroscopy could very easily be done at the bedside or in the relevant ward's treatment room. Outpatient gastroscopy should be done in the consultation room at the same time as the consultation at which the gastroscopy was thought to be needed. Have we not heard of ENT surgeons doing nasal endoscopy in OPD? Have we not heard of ultra-thin scopes? Have we not heard of oral sedation if it was indeed necessary?

Oh, by the way, we have not obviously heard of companies willing to provide clean scopes by motorcycle courier delivery wherever we want.

We have this rigid old-world belief that patients should be moved around to where the 'facility' is and when that is not possible clinicians and others should become runners to connect patients and a variety of facilities. We have to stop such thinking and move with the modern world. We used to run to telephones

Arterial Blood Gas analysis

Hand held ABG analysers are available and these ought to be used as POCT (point of care testing). It is well known that blood gas results have to be acted upon within minutes if it needs to make any difference to patients. ABG analysers are situated as some centralised monuments when they should be available near the bedside of any acute patient anywhere in the hospital. We call for a demolition of this monument.
This blog has already argued for improved ABG turn around times as an example of clinical lean  http://successinhealthcare.blogspot.co.uk/2012/03/arterial-blood-gas-turnaround-times.html

Bedside Hemoglobin, WBC and other testing

Hemocue POCT hemoglobin testing has been available for a few decades and has been used by many para-medical services but still not used routinely in many hospital operating theatres and other areas. There is really no reason why this should not be available anywhere in the hospital or be carried around by doctors and nurses. When we can provide treatment in life and death situations using POCT blood sugar testing, we could do these couldn't we?

General Practitioners as Gate Keepers

In the modern world where information is provided in plenty by Dr Google, where patients are far too knowledgeable than when the NHS was created 60 years ago, patients must have the liberty of seeing any specialists of their choice without having to go through a general practitioner. Seeing the specialist directly happens in other parts of the world especially with post service self-pay patients, in UK having pre-paid patients do not get the same liberties or choices. There are innumerable myths on the gate keeper role of UK GPs which need to be challenged if clinical practice is to be compatible with current expectations.

This in no way an attack on the role of GPs as clinicians providing an invaluable service and is essential; I am only questioning if any value is really provided by the gate keeper function and whether there is any sense in putting hurdles in a particular patient's chosen pathway.


There will always be a 'this is too risky and against the rules/regulations' brigade. I am looking at how we can innovate and improve safely. Yes, if we put it that way, risk and improvement do not make comfortable bedfellows. 

Please add your ideas on what monuments that you would seen broken down in your hospital/clinic by leaving a comment below.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Checklists in Healthcare - not easy

Checklists in healthcare is not the same as in other industries and is not easy

Checklists are the hot and happening thing in healthcare today, it is to improve the safety and quality of care delivery.

The WHO safe surgery checklist was evolved after good research showed its benefits across the world in reducing deaths and complications. It is a simple one page document. Prof Atul Gawande who pioneered this effort has described the background using construction, airline and other industries as examples.

The checklists as used in industry and by some eminent healthcare providers places seem to be different from the kind of checklists that we do, including the WHO surgical checklist.

In industry checklists are used to define what precisely the work is, in what order the work has to be done – the people who do the work look at it, do the work as it says (execute the work) and tick the box (checklist) to indicate that the work has been done according to the work specification. Often that is the main documentation to record the completion of the work. Here is an example of a construction checklist http://www.sustrans.org.uk/assets/files/guidelines/appendix.pdf I have no special knowledge or affinity to this particular checklist, it simply comes high up on a google search. I encourage you to look at the detail with which the work is specified. I am reliably informed that many construction checklists are even more detailed and project specific. Prof Gawande's book points that in construction work, checklists are done for every component with about 16 different specialities being involved.

In aviation the checklist is aircraft specific. Here is a checklist for a Piper PA28 which is a very small basic plane which is often used to train pilots and it runs to 11 sheets. It is both precise and detailed – it tells you what degree and what RPM to set and so on. The checklist is read out loud and followed every time. It is never 'tick'/'check' marked, never signed and never filed anywhere.

The ‘check’ in industry e.g. construction – is to indicate the tick, cross, ‘check mark’ other marking in the document – a one step process that documents that the defined work is done. In aviation it is a document that is followed but not filed.

The ‘check’ as used by us in healthcare in general and UK in particular – seems to indicate that we need to check (as in inspect/confirm/verify the correctness/hold back/restrain/stop); by the way this is the dictionary definition. This is a two step process – do the work document it and then confirm in a different document that the work is done. The WHO checklist is an additional document – i.e. the antibiotic is ordered and given elsewhere in the process, documented elsewhere and these are confirmed in the checklist; the checklist becomes a supplementary document. This also gains medicolegal importance and adds the bulk of the medical notes. The WHO checklist is allowed to be changed but is often not and where they change it, is still organisation specific and not specialty specific (and never ever patient specific).



When the industry and aviation use detailed and project/plane specific checklists why did healthcare choose to use a single page, generic, general checklist? Clinical medicine and healthcare delivery is obviously more complex than industry or aviation, yet the checklist is a simple single page. The beauty of the WHO checklist lies in its simplicity. It has proven itself under research conditions across the world. However, it is valid to ask whether it is proving itself in real time practice in the NHS. The evidence is not clear yet if there has been a year on year decrease in the incidence of various problems the WHO checklist is supposed to address. The consensus is that the checklist helps.



My personal view is that a one size fits all checklist that the WHO Surgical Checklist is will see its own limitation in time; after all there was a checklist even prior to the WHO one. Procedure specific checklists are the needed urgently - a good example is the matching Michigan checklist for the insertion of central lines. For surgical patients, each patient/procedure should have a customised detailed and specific checklist with an obligation for the surgeon, anaesthetist and their teams to modify the checklist prior to surgery to a patient specific checklist. This empowers the local team members and the process becomes directly relevant to the specific procedure that a specific patient is having on a given day. That is when the power of the checklist seen by Atul Gawande in aviation, construction and finance can truly be realised in healthcare.

©M HEMADRI 

Follow me on twitter @HemadriTweets