Lessons on Performance from the Hospital

Posted earlier this week at LeaderTalk

We had a surprise on Saturday – our baby girl arrived nearly 5 weeks early and was breech, so we had to have an emergency C-section. The baby is in NICU right now and making steady progress. We’re in one of the best hospitals on earth in which to have a baby, and I feel profoundly grateful for the care we’re receiving. We’ll be here for a while, and for a hospital, it’s not a bad place to be.

While we’re here, there’s plenty of waiting to do, and I can’t help but draw some lessons from our hospital experience, and make some comparisons with the world of education. Richard Elmore and colleagues make such a comparison into their central metaphor in Instructional Rounds, and the past day has given me insight into a few instructive similarities and differences between hospitals and schools.

1. Treatment plans are highly directive
In hospitals, there are extremely specific procedures for virtually any set of circumstances, to ensure that the desired outcomes (healthy patients) can be achieved with a high degree of consistency. There is no pretense that “whatever you want is fine” – there is a well-defined best practice for virtually every circumstance. While the patient still has some degree of say in his or her care, hospital staff have no qualms about being very directive and even downright bossy.

In education, we tend to “try” things and make suggestions to parents, rather than insist on a specific plan of action. Of course, people go to hospitals when they’re in crisis, which places clients and professionals into different roles.

2. Failure is not an option
The NICU devotes an incredible level of support to high-needs patients. Whatever the baby needs, the baby gets, regardless of cost or hassle. We would consider anything less morally unacceptable, assuming we have the resources. If the situation worsens, the interventions intensify.

In education, resource constraints (such as access to tutors, teacher:student ratios, and learning time) are generally considered a given, and the results are allowed to vary. In schools with a well-developed RTI model, the most intensive levels of support are given to the students who need support the most. However, schools are not designed (or funded) around a “failure is not an option” mission.

3. The division of labor is…interesting
Most of the people we’ve interacted with so far are nurses, and it’s clear that the nurses do the vast majority of the work. They use their own professional judgment in the day-to-day choices about patient care, but are always bound by the doctor’s care orders. Doctors make decisions about all aspects of the treatment regimen, but carry out very little of it themselves. In addition (as Elmore emphasizes in Instructional Rounds), doctors consult with nurses and each other in developing and adapting treatment plans.

In education, most decisions about what students need (by way of instruction, supports, accommodations, and interventions) are made and carried out by teachers in isolation. We don’t have a doctors-and-nurses division of labor; if anything, teachers are both doctors and nurses, and principals are most like hospital administrators – responsible for everything that goes on, but not involved in direct service to clients.

This has me wondering: What might it look like to have, say, two or more teachers (perhaps with complementary areas of expertise) and a large number of tutors working with a large number of students? Many of the things teachers do could easily be done by people with less training. Teachers could check in and revise the plans – the care orders – as they go on rounds.

How Similar Are Education and Medicine?
Education has a lot to teach medicine, too, so I’m not suggesting that the solution to educational improvement is becoming more like the medical field. Schools and hospitals are both complex organizations working for the public good, but the economic, human resources, and professional practice realities are drastically different.

If you’re interested in learning more about improvement in medicine, I highly recommend Dr. Atul Gawande‘s books and New Yorker articles, which are rife with potential analogies for how we can improve education. Thanks to my mentor, Carolyn Gellermann, who works in both education and medicine, for introducing me to Dr. Gawande’s work.

Depending on how long we’re in the hospital, I may have more to say about what the medical profession can teach the education profession about how to improve. What lessons for performance improvement in education would you draw from the medical field?

Gawande on Checklists vs. Heroism

We don’t like checklists. They can be painstaking. They’re not much fun. But I don’t think the issue here is mere laziness. There’s something deeper, more visceral going on when people walk away not only from saving lives but from making money. It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us – those we aspire to be – handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists.

Maybe our idea of heroism needs updating.

-p. 173

The fear people have about the idea of adherence to protocol is rigidity. They imagine mindless automatons, heads down in a checklist, incapable of looking out their windshield and coping with the real world in front of them. But what you find, when a checklist is well made, is exactly the opposite. The checklist gets the dumb stuff out of the way, the routines your brain shouldn’t have to occupy itself with (Are the elevator controls set? Did the patient get her antibiotics on time? Did the managers sell all their shares? Is everyone on the same page here?), and lets it rise above to focus on the hard stuff (Where should we land?).

Here are the details for one of the sharpest checklists I’ve seen, a checklist for engine failure during flight in a single-engine Cessna airplane. … It is slimmed down to six key steps not to miss for restarting the engine, steps like making sure the fuel shutoff valve is in the OPEN position and putting the backup fuel pump switch ON. Bus step one on the list is the most fascinating. It is simply: FLY THE AIRPLANE. Because pilots sometimes become so desperate trying to restart their engine, so crushed by the cognitive overload of thinking through what could have gone wrong, they forget this most basic task: FLY THE AIRPLANE. This isn’t rigidity. This is making sure everyone has their best shot at survival.

-p. 177, The Checklist Manifesto: How to Get Things Right

Gawande on Learning from Patterns of Failure

We don’t study routine failures in teaching, in law, in government programs, in the financial industry, or elsewhere. We don’t look for the patterns of our recurrent mistakes or devise and refine potential solutions for them.

But we could, and that is the ultimate point. We are all plagued by failures – by missed subtleties, overlooked knowledge, and outright errors. For the most part, we have imagined that little can be done beyond working harder and harder to catch the problems and clean up after them. We are not in the habit of thinking the way army pilots did as they looked upon their shiny new Model 299 bomber – a machine so complex no one was sure human beings could fly it. They too could have decided just to “try harder” or to dismiss a crash as the failings of a “weak” pilot. Instead they chose to accept their fallibilities. They recognized the simplicity and power of using a checklist.

And so can we. Indeed, against the complexity of the world, we must. There is no other choice. When we look closely, we recognize the same balls being dropped over and over, even by those of great ability and determination. We know the patterns. We see the costs. It’s time to try something new.

Try a checklist.

The Checklist Manifesto: How to Get Things Right, p. 185-186

Gawande on Discipline as a Professional Responsibility

From Atul Gawande’s book The Checklist Manifesto:

All learned occupations have a definition of professionalism [that includes]…selflessness..skill…[and] trustworthiness… Aviators, however, add a fourth expectation, discipline: discipline in following prudent procedure and in functioning with others.

This is a concept almost entirely outside the lexicon of most professions, including my own. In medicine, we hold up “autonomy” as a professional lodestar, a principle that stands in direct opposition to discipline.

But 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. It has the ring more of protectionism than of excellence. The closest our professional codes come to articulating the goal is an occasional plea for “collegiality.” What is needed, however, isn’t just that people working together be nice to each other. It 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 not built for discipline. We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at.

That’s why aviation has required institutions to make discipline a norm…we have national regulations to ensure that those recommendations are incorporated into usable checklists that are reliably adopted in ways that actually reduce harm.

The Checklist Manifesto: How to Get Things Right, p. 182-183

Book Review: The Checklist Manifesto

One of my strategies for professional growth is to read widely – both within and beyond the field of education. I hope to regularly review book here from a school leadership perspective; here’s my recent review of Results Without Authority, a book on project management.

Atul Gawande‘s The Checklist Manifesto: How to Get Things Right is my latest favorite. Gawande is a surgeon and a staff writer for The New Yorker, as well as a project leader for the World Health Organization and a recipient of the MacArthur “Genius Award” Fellowship. Here’s a bit more perspective on Gawande as an “educator.”

Checklist Manifesto Gawande photo

Gawande’s thesis is that checklists can be used to facilitate decision-making and reduce errors in situations of high complexity.

Obviously, checklists can be used to make sure essential tasks are completed in any arena, but we tend to think that they’re trumped by professional judgment in situations encountered by professionals such as doctors and educators. Gawande says we’re wrong.

Rather than replace expert judgment, he says, checklists can “get the dumb stuff out of the way” so we can spend our mental energy exercising judgment, not worrying about whether we remembered to cross every t and dot every i. The prime example from other industries is airline pilots, who use checklists extensively to manage situations of enormous complexity that require expert-level skill.

Checklists can ensure that we not only do certain things, but that we communicate with our colleagues at critical points.

It’s an excellent book, and I found many applications to my work as a school leader. The quotes and valuable insights I noted from the book are too numerous to include in one post, so I’ll share them in separate posts over the next few weeks.

The Checklist Manifesto: How to Get Things Right

Introducing Atul Gawande, Educator

One of my favorite authors on improvement and performance today is Atul Gawande. His insights have profound implications for educational leaders, and he may be one of the most influential reformers to come along in a long time.

But you won’t find him at Teachers College or ASCD. Atul Gawande is a surgeon.

In Better, he writes about numerous aspects of improvement in healthcare. In The Checklist Manifesto, he explores the power of checklists to reduce errors in complex fields such as aviation (where checklists are ubiquitous) and medicine (where he hopes to make checklists part of standard practice). I finished these two books in a day or two each, and am working on his first book, Complications, now.

Complications Better Checklist Manifesto New Yorker

In addition, Gawande writes regularly for The New Yorker.

Here’s Gawande in a recent appearance on The Daily Show with Jon Stewart, in which he talks about The Checklist Manifesto:

Clearly, there are many parallels between the challenges in healthcare and those faced by educators. I will soon have more to say on The Checklist Manifesto and Better from an educator’s perspective (you can subscribe to email updates using the form in the sidebar of this site).

Gawande will be in Seattle on May 3 if you’d like to hear him live.

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