14 ms·

Hospital checklists are meant to save lives, so why do they often fail?

158 points by areoform 7y ago

adolph 7y ago
Key point is the last paragraph: Fortunately, Fixsen says, the lessons of implementation science are “completely generalizable”, and all programmes could benefit by noting the importance of engaged leadership, local adaptation and user buy-in. “It doesn't matter how good the innovation is, it doesn't matter how much has been invested,” says Fixsen. “If we don't have the implementation savvy, we're going to get the crummy outcomes that we have seen decade after decade.”
skybrian 7y ago
If something as seemingly straightforward as using checklists is difficult to implement in hospitals, maybe we shouldn't feel too bad about the slow, partial, and controversial adoption of programming methodologies?
- marcosdumay 7y ago
  Oh, our profession moves very quickly and very universally. It's unparalleled on that. The controversy is usually about wether the movement direction is any good.
monocasa 7y ago
I like what they do in the Japanese train system. You have to point at whatever you're doing and day aloud what it is before you check it off. That heavily reduces the amount of mindless checking via scanning the sheet that leads to items being checked off without being fully validated. https://en.wikipedia.org/wiki/Pointing_and_calling https://en.wikipedia.org/wiki/Pointing_and_calling
- jfries 7y ago
  Yes, I think it's frustrating that this is not widely adopted. The upsides are really obvious and the only downside (I guess?) is that it feels a bit awkward to do it before society has gotten used to it. Another thing with obvious benefits I wish we would adopt from east Asia is wearing a face mask when having a cold to prevent infection those around you.
- ChicagoBoy11 7y ago
  I fly private planes as a hobby and during my training that practice was kinda grilled in to me. After flying for a bit, you end up realizing how easy it is to "see" something incorrectly, or to skip an item, etc. Even when there's no one else in the plane with me, I say things out let, touch nobs to confirm their position even though I checked it earlier and didn't touch the nob at all at any portion in the flight. (Good) Pilot training will make you aware of just how much trouble your mind can get you into.
  - thrownblown 7y ago
    Both of you have fat fingers.
    - behringer 7y ago
      I hope the landing gear isn't next to the ejection trigger.
      - thrownblown 7y ago
        In my defense downvoters, they both had typos, "day aloud" and "say things out let" and we're talking about pointing and touching dials here.
        behringer 7y ago
        I got your back :)
- Terr_ 7y ago
  I imagine it also brings in a certain kind of kinesthetic memory into play, habits of movement rather than just habits of thinking.
hestipod 7y ago
They fail because of egos and arrogance. This is the root cause of a lot of life's problems. People think they are above it and too smart etc. They hate being "told what to do". An example, I have a family member who will complain about texting and driving from some position of superiority but who does it constantly himself. When challenged with that behavior he refuses to acknowledge it. He believes he is above it, better than those who cause accidents, and only those "lesser" people need to follow rules. It's an incredibly common behavior and doctors are no different...and in some cultures more likely to assert their status.
- stronglikedan 7y ago
  > He believes he is above it Honestly, he probably is. We need to have laws because most people do it carelessly. Not necessarily because all people do it carelessly. Naturally, those who know they do it safely aren't going to just lump themselves in with the majority that don't.
  - hestipod 7y ago
    He really isn't. He hits the rumble strips constantly when staring at his phone, and it only takes a second of inattention to kill someone. Being lucky so far isn't proof of competence. This attitude is the exact problem I was addressing in relation to the article...people thinking THEY are safe and others are the real problem and why we need checklists/rules.
  - vangelis 7y ago
    Most people who text and drive are doing it safely until they aren't. It only takes a second to fuck up.
  - 0kl 7y ago
    The problem is that it builds and establishes a habit that we will _accidentally_ engage in when we are tired, distracted, etc. This is where accidents happen, and why it is important to never consider yourself above the fray. It’s not that anyone is always careless, it’s that everyone eventually has an off day, and in those off days our careful habits become careless ones.
deleted 7y ago
[deleted]
OliverJones 7y ago
I wonder. Does the Hawthorne Effect (https://en.wikipedia.org/wiki/Hawthorne_effect https://en.wikipedia.org/wiki/Hawthorne_effect) contribute to the success of these checklist regimes? When surgical or emergency-department teams believe they're participating in an experiment to learn whether certain practices improve outcomes, do the outcomes improve? Airplane pilots use checklists. It's illegal to start the engines unless the approved checklist book is within reach of the pilot in command. In training it's drilled into us that the response to panic is: get out the checklist and follow it. It works. duh. It's all too easy under pressure to forget to lower the wheels or turn on the carburetor heat, or whatever. The drilling in training is what makes the difference. (Aviation gasoline cools as it vaporizes in carburetors. Under certain conditions that can make the carburetor fill up with ice. If that happens the airplane will land soon. Not good. So carburetors have heaters. ) Checklists have far less success in medicine. Heck, almost two centuries ago Dr. Ignatz Semmelweis (https://en.wikipedia.org/wiki/Ignaz_Semmelweis https://en.wikipedia.org/wiki/Ignaz_Semmelweis) found that patients lived a lot longer when doctors and nurses washed their hands. But, even in the 21st century, it's a struggle to get compliance with hand-washing rules in hospitals. Maybe something about medical training makes people resistant to fixed procedures. Maybe it's the age-old practice of eminence-based medicine rather than evidence-based medicine. It's a serious problem.
- sjg007 7y ago
  Gloves are another one.. blows my mind.
- perl4ever 7y ago
  Without any specific relevant experience in a hospital, isn't the most likely reason procedures fail that people are required to ignore/bypass parts of them constantly, rather than having them updated to match reality? It seems so very obvious to me that any time you start asking, from a 40,000 foot level, why people can't follow simple instructions, the answer is going to be, not that they are all idiots, but that they are trained and required to ignore them selectively based on complex ever shifting criteria. That is basically what makes any job require a human and not a computer in the first place. The more rigid you want people to be, the better the process has to be.
mhb 7y ago
If I saw both Mark the surgical site and Introduce yourself by name on the list, I would also be suspicious about which items were saving lives and which were wasting my time. Separately, maybe it would work better to give the checklist to the patient and have her check off the items. In light of some comments, it appears I wasn't clear. My point was that the problem is having BOTH those items on the list. Marking the surgical site is definitely worthwhile. Having it on the same checklist as introducing yourself dilutes the importance of it and the other important items on the list.
- TylerE 7y ago
  Don't laugh. Mistakes happen, especially with body parts that we have two of, and it's heartbreaking when it does. Amputating the wrong limb, removing the good kidney instead of the bad kidney...
- vangelis 7y ago
  Consciously marking the surgical site ensures we have the right surgical site. A wrong site surgery 'never event' happens nearly 100 times a year in the US. The introduce yourself by name item is less crucial, but ensures everyone knows who everyone is, especially in larger hospitals. In a stressful environment, it might be the difference between fumbling and not. Apparently it also increases the likelihood that someone will speak up if there is an issue noticed.
- tunesmith 7y ago
  I recently had a very minor surgery scheduled to have something removed, on the right side. The doctor was filling out the surgery form and checked the "left" box. It was because on the form, the "right" checkbox was on the left side, and the "left" checkbox was on the right. (He immediately caught it and corrected it.)
- FabHK 7y ago
  Presumably you consider Mark the surgical site to be saving lives, and Introduce yourself by name a waste of time. However, there is a reason for the latter item. There have been many plane crashes in which at least one cockpit crew member had some inkling that something was wrong [1], but their warnings were ignored, often when there was a big authority gap. Crew Resource Management [2] was developed to address this. Introducing yourself by name is designed to emphasise that the group is now a team with a common purpose, and everyone, from the lead surgeon to the nurse, can and should speak up if something looks awry. Quite some thought and research has gone into this. Obviously, this doesn't mean that the ideas can't be criticised, but a facile dismissal like yours is unwarranted and might be one reason the checklists don't live up to their potential. [1] Some examples: The Tenerife disaster, 583 fatalities: 'On hearing this, the KLM flight engineer expressed his concern about the Pan Am not being clear of the runway by asking the pilots in his own cockpit, "Is he not clear, that Pan American?" Veldhuyzen van Zanten emphatically replied "Oh, yes" and continued with the takeoff.' https://en.wikipedia.org/wiki/Tenerife_airport_disaster#Communication_misunderstandings https://en.wikipedia.org/wiki/Tenerife_airport_disaster#Comm... United Flight 172: 'The captain focused on the landing gear problem for an hour, ignoring repeated hints from the first officer and the flight engineer about their dwindling fuel supply. Only when the engines began flaming out did he realize their dire situation.' https://en.wikipedia.org/wiki/United_Airlines_Flight_173 https://en.wikipedia.org/wiki/United_Airlines_Flight_173 Korean Air 801: 'The crew noticed that the aircraft was descending very steeply, and noted several times that the airport "is not in sight." Despite protests from flight engineer Nam that the detected signal was not the glide-slope indicator, Park pressed on.' https://en.wikipedia.org/wiki/Korean_Air_Flight_801#Accident https://en.wikipedia.org/wiki/Korean_Air_Flight_801#Accident [2] https://en.wikipedia.org/wiki/Crew_resource_management https://en.wikipedia.org/wiki/Crew_resource_management
heymijo 7y ago
An ophthalmologist I know is an attending physician, which means she teachers new resident physicians. She described a few surgeries to me and her role in the room as the resident performs the surgery. Her brain is the checklist for the surgical procedure. The culture seemed to be, you should be good enough to memorize these complex procedures. Meanwhile I'm thinking, why not just have someone else in the room reading and confirming the next step to the surgeon? I suspect the culture of medicine, and especially the culture of surgeons does not jive well with checklist culture.
- iguy 7y ago
  I suspect that what made the culture of pilots change is that their own lives are on the line. That, and the fact that the guys flying the coolest fastest planes had commanding officers who could simply ground them if they didn't like it.
  - WalterBright 7y ago
    My father was an AF pilot for 20 years. I've never known a more conscientious and careful man. One day he was going through the landing checklist, and was interrupted by a radio call. He resumed the checklist, then was told by the tower that he was attempting to land with the gear up. The interruption had caused him to skip that step on the checklist. After that, whenever he was interrupted in a checklist, he started it over again.
    - tonyarkles 7y ago
      I've been flying a somewhat large UAV lately, and inspired by the "real" aviators and The Checklist Manifesto, I put together a series of checklists. One for packing, one for pre-flight, and a mission-specific one for the day. Early on I was pretty lax about following them, and inevitably something bad would happen. I'd forget to pack something and not realize it until I had driven an hour. I'd forget to check for loose bolts and lose one. Or I'd completely forget one of the objectives for the day and have to go back out. I've tightened up my process quite a bit, and do exactly what your father does: if I get interrupted, I start over. It's mentally hard to do when I'm already feeling late, but I've come to the conclusion that that's exactly when I need to be more disciplined about it; that's when you forget things!
conorh 7y ago
They fail because of severe checklist fatigue according to my wife (a surgeon). Checklists are great - so let's do them for everything, ALL the time. People start to tune them out because they do the same checklist hundreds and hundreds of times and they often have many irrelevant things on them. The people using the checklists have little ability to change them or to improve them and so they start to suffer from checklist fatigue. As they say in the article: > “There's no point in having an item that says, 'Have the antibiotics been given?' if there are no antibiotics in the hospital,” says Dixon-Woods. The checklists that my wife uses are apparently filled with these types of irrelevant checks. Not to say that they aren't useful, they are, but as this article points out the implementation of checklists often leaves a lot to be desired.
- y0ghur7_xxx 7y ago
  > They fail because of severe checklist fatigue > checklists often leaves a lot to be desired. You say yourself that checklists are great, and it is proven that they save lives. So if there is fatigue in using them over and over, and they are not perfect, well... get over it? Sure i can understand that it's boring to go through the same checklist 5 times a day, but come on, there are lives at stake here. If one of your wife patients gets an infection and dies because she forgot some important, simple, step because of "checklist fatigue" how would she feel?
  - fgonzag 7y ago
    You're not going to cure the human condition. If checklist fatigue is a real problem, telling people to suck it up and do their jobs is not going to work. The process needs to be improved to account for check list fatigue, it's that simple. Be it read aloud each item before checking it off, have a secondary scribe confirming and checking it off, or any other improvement that minimizes the effect of the fatigue.
  - Balgair 7y ago
    The Messiah/God complex is a very real thing with MDs. It's dependant upon the enviroment and training, but a lot of them really do think that they are 'special' and that they have 'proved' themselves via the rigours of school and residency. Their sense of self is tied up into their job preformance. Like in other professions, if you 'attack' their job and their work, you are attacking them personally.
mieseratte 7y ago
Does anyone here use point-and-call or something similar for more mundane activities than trains and planes? I started doing this while driving a few years ago. I've gotten a good bit of shit over the years for it from skeptical passengers. Hard to point at a clear-cut win when it is about prevention.
- deepspace 7y ago
  I am somewhat obsessed with improving my driving skills, particularly w.r.t. anticipation and accident avoidance. I also got into the habit of using checklists for important but repetitive tasks after reading Gawande's book, Now I am kicking myself that I never thoguht about applying point-and-call to driving. I can absolutely see the benefit, but would need to think about the details. Do you point out only traffic signs and signals, or things like potential threats too?
  - mieseratte 7y ago
    The biggest use for me is turning from a static position, e.g. left from a cross-street, having started this after I made a left turn but was t-boned, mind you I've always been religious about seatbelts, checking turns (left-right-left), etc. When doing a static turn I will point-and-call left, "Clear Left," point-and-call right, "Clear Right," point-and-call left again "Clear Left," then with both hands on the wheel say "Go." I will look-and-call for lane changes, pretty much as you would imagine look over the shoulder and "Clear Left," then "Turning." Same goes for right. For me it is more action oriented, to make sure I've assessed the area for issues. I haven't done anything like call outs for threats, but now I'm kicking myself for not thinking of that. I already do that religiously in FPS games, I could see how doing that would be good to get and stay in the habit of active scanning, "Pedestrian crossing, two o'clock." Might have to try that one out too, after all my friends will love that development :)
    - therealx 7y ago
      I can't imagine this with a straight face, but I do think you're a safer driver for it. I imagine an accident like that would rapidly change that. Even a small fender bender changes my driving rapidly for a good period of time. Too bad I can't get over myself :)
WalterBright 7y ago
Checklists have been incredibly effective in improving aviation safety. But just having checklists doesn't help much - there has to be a culture of following them and a ritual to following them.
- mjevans 7y ago
  When followed correctly it is my believe that checklists can raise the floor of the worst case outcomes. Said another way, actually following the checklist eliminates the low-hanging fruit of preventable mistakes.
  - justinmeiners 7y ago
    Which is what they are designed to do. Eliminate stupid absent minded mistakes.
  - noir_lord 7y ago
    Not a pilot but I follow mine rigorously when doing rote tasks I haven’t automated yet and they save me from a lot of head slapping moments. It’s a habit I had to work hard at, item one on my list is usually don’t skip any steps.
casion 7y ago
I read the article, but I don't see if/where there is responsibility given for the checklist(s). Most QA systems have a source of responsibility and multiple levels of review. I wonder what would happen if there was a QA team (with sufficient education) at a hospital that had complete control over checklists and associated procedures. Would that improve the outcome when utilizing checklists? --- Anecdote --- I've been in the hospital many times, and I've been present for pre-surgical checklists a few times. It was ALWAYS a nurse handling it, and it was never a nurse that I was familiar with during my care. All but once the interactions started with trying to figure out who I was... without asking me. I can recall a number of times where there was a question, such as "Which body part is being operated on?", except I was told the answer. The "question" turned into "Looks like your right kidney is being removed", with a slight pause for me to object. It always made me feel like the staff thought the purpose of the checklist was to complete the checklist, rather than to QA the system they're part of. --- Anecdote Extended --- I suffered an unpleasant complication from this during a procedure. I do not respond to anesthetics the same way as most people. It takes a MUCH larger dose to knock me out, and to keep me out. (years of desensitizing medications + big (very tall) person + MC1R gene). I know this. I can communicate my past procedures and the doses administered. USUALLY they are supposed to ask if you've had any prior procedures and potentially follow up with questions about allergies, anesthetics and other questions related to sedation. I was not asked. I didn't think to speak up because I was already being inundated with stimulus. The result? The first "count down from 10" resulted in me counting to 0 and asking "What next?". I vividly remember the abject horror on the face of the nurse. She fumbled around, whispered to the anesthesiologist, whispered to other nurses. People shuffled around and nobody said a word to me. I was scared. It felt like forever before I was asked to count down from 10 again. It worked that time... Until I woke up in the middle of the procedure! When I woke up in post-op, I asked the nurse about it and she told me that I wouldn't remember any of it. She told my wife that I wouldn't remember the couple hours after post-op. I remember every single nurse's and doctor's name involved and the discussions my wife had with the doctor in post-op (which she confirms my recollection). It could have all be avoided if someone just said, "Hey, have you had a procedure where you've been under general anesthesia before?" I bet that checkbox was ticked though.
iamleppert 7y ago
Sounds like a great opportunity for a digital checklist with a computer vision, audio analysis component and deep learning backend that could quantify, and eventually automate the adherence to such checklists. I wonder how many people would actually follow the checklist if they knew their compliance was being continually monitored and audited?
- scott_s 7y ago
  I think that misses one of the lessons of the study: people need to be invested in the checklist for it to help. In other words, they need to want to go through the process. The checklist itself is not magical. When it's effective, it's because it formalizes everyone's desire to adhere to agreed-upon protocols that everyone agrees are beneficial.
  - sergioj97 7y ago
    Even though it seems clear that the checklist itself has to be well designed, I don't think it's a bad idea to ensure they are followed. Strategies like the one the OP proposed are independent from checklist quality.
- marcosdumay 7y ago
  Well, you actually just need an Alexa there reciting the checklist and waiting from a yes before moving to the next item. Since it is intended to be in a hospital, that's a $40K Alexa that must be created by somebody with the right connections. But all that you need is an Alexa.
cortesoft 7y ago
I also wonder how much of an effect the prior conditions have... if a hospital is already doing a good job of following procedures without a checklist, it might not make as much a difference as for a place that wasn't doing so well before.
srikz 7y ago
I was just thinking about the comparison between the medical industry and airline industry. In medicine you can (or have to) pay a premium to get the best doctors and expertise [1]. In the airline industry, the safety aspect is standardised across the board. It doesn’t matter if you are flying economy or 1st class you get the best in class safety, which is collectively shared across the industry. We pay a premium for the service and not to have better chances of surviving. In an alternate universe, we could have had cheaper airline tickets which had not so great safety record and the good ones only in reach of the super wealthy. [1]: I’m aware it may not be the case in some countries with completely free healthcare, but this applies to the majority of the world. Even in those countries with free healthcare for all, it is not uncommon to see huge wait times for some important procedures and being able to skip it by going through a private hospital.
- L_Rahman 7y ago
  There are some interesting experiments with hospital operation models in India that try to make it more like flight. Every patient gets the same surgeon and treatment, but people who pay more get nicer facilities (private rooms, less crowding, separate waiting area for family). It's not an equal model, but it is more just than what we have in America today. https://www.bloomberg.com/news/features/2019-03-26/the-world-s-cheapest-hospital-has-to-get-even-cheaper https://www.bloomberg.com/news/features/2019-03-26/the-world...
  - srikz 7y ago
    Yes, most private hospitals have this model in India where the same surgeons treat the highest paying and the lowest paying patients. However, the price difference between the base pricing across these hospitals vary a lot and you tend to go looking for that famous surgeon who practices in a hospital where everything is more expensive (Narayana Health and a few others may be an exception). Also, the other aspect of the airline industry which we should get in hospitals is sharing of best practices. The protocols and procedures which can be effective in saving lives should not be a differentiator, instead it should be standardised and made mandatory. The differentiators should be non-medical as much as possible. Of course, only the wealthy hospitals may be able to afford the latest equipments but the expertise of the medical staff and best practices are easily transferrable in a cheap way and shouldn't be guarded like an individual's or the organisation's IP
rb808 7y ago
Checklists are way overrated. To all the fanboys out there, how many of you regularly have checklists for things you do several times a day? I know in the last ten years I've seen new processes with forms to fill out for mundane tasks and its PITA.
wisty 7y ago
A lot of people seem to be hung up on the fact that there must be something special about doctors. They're too skilled, they operate in a unique environment, or that they're awful egotists with god complexes. Pick almost any profession other than pilot, and checklists are something that most people will ignore, often for the same excuses doctors have. It seems like it should be comparable, as both medical errors and aircraft crashes are taken seriously, but there's a huge difference in magnitude.
cardiffspaceman 7y ago
In the documentaries about Apollo 11 that are rather easy to find these days, one of the things you hear over and over again is the "go"'s from various participants right before a launch or other milestone.
- gpm 7y ago
  If you watch a modern rocket launch (the vast majority of which are livestreamed and uploaded to youtube) you hear the same.
wysifnwyg 7y ago
Doing UX Design right now and the popular phrase is: "If only people would read instructions everything would be alright."
effnorwood 7y ago
Broken pencils.
rscho 7y ago
Official role for checklists in healthcare: save lives! True role of checklists in healthcare: save management in case of legal action. Consequence: the checklist becomes longer and longer, and is done more and more frequently. To the point of being quite impractical. Goal: in case of legal action, take refuge in checklists. At least one of the items is bound to be missing so you can divert responsibility to someone else. Source: I do checklists. That's my job.
- tonyarkles 7y ago
  I replied elsewhere in the thread with a bit more detail, but my UAV checklists contain 100% material learned from experience only. They've grown a little (especially the packing list) as I've gotten out to the field and realized I didn't have a tool that would be useful to have, but they've also shrunk as I've eliminated equipment I no longer need (e.g. a programming cable for an ESC that I no longer use). It's pretty disappointing to hear that that's how checklists work in your org. I feel like it's doubly negative: not only does it pretty much guarantee that they won't be followed because they're not particularly useful in that form; it also helps to ensure that the folks that have to use them will push back against checklists in general at their next job! [I suppose that's what happened with me and JIRA too... it might be a decent product, but every org I've used it in has done a very bad job with it]
  - baud147258 7y ago
    I think our boss has made a good job with our bug workflow, but she had the authority (and Jira access) to do what she (and the QA lead) wanted.
- lonelappde 7y ago
  This is like Agile vs micromanagement in software dev. The workaround for that is for the practicioners to have their own good checklists in addition.
justinmeiners 7y ago
As the article states, the issue is they are often poorly implemented or designed. If that's the case, what is surprising?
dctoedt 7y ago
In aviation and nuclear-reactor operation, the ethos is that 1) of course people are going to make mistakes, because we're human; 2) the point of systems such as checklists and second-checking is to try to make sure the mistakes get caught before they have any effect; so 3) if you harbor resentment toward checklists, try to give yourself an attitude adjustment — learn to embrace and even enjoy them.
dctoedt 7y ago
Atul Gawande's book, The Checklist Manifesto, said that WHO's surveys found significant resistance by surgeons to using checklists — but if they were going to be operated on, something like 93% of the surgeons said, in essence, you're damned right I want the surgeon to use a checklist.
neom 7y ago
I've tried to read The Checklist Manifesto twice now, and I couldn't because I'm too squeamish.
sopooneo 7y ago
I've never worked in a hospital, but I have plenty of experience with massive bureaucracies. And that gives me guesses, perhaps fanciful, about things that could go awry with surgical checklists. Anyone with relevant experience, please weigh in if these seem feasible. 1. Every prominent error that occurs prompts administration to decree a new checklist item be added to provent it in the future. But these added items will not be root-cause fixes so will proliferate to the point that there are now several dozen of negative checks to prevent these one-in-a-million mistakes. And so the lists will grow and grow, but no one will ever dare to take an item off. Because then if that mistake ever does reoccur, the admin that authorized its removal is up for a hearing in front of the firing squad. 2. Some administrator somewhere, noticing redundancy within a given checklist will reinvent control structures. You'll have lists with loops and conditionals. And since the people creating these lists don't know what is "considered harmful" they will almost certainly add GOTO's. In fact, I'd be very surprised if GOTO's don't already exist in surgical checklists somewhere. But then this addition of control structures could increase to the point that a surgeon could, potentially, be put into an infinite loop! So committees will be formed to ensure every path through a checklist actually can be completed. And someone, somewhere in a hospital conference room, when asked to PROVE the lists all terminate, will take a breath, sit back, and rediscover the halting problem.
- scarejunba 7y ago
  Well, they only have to discover that their program halts, not all arbitrary programs so that's not quite the Halting Problem.
- therealx 7y ago
  Some patient record programs already allow control structures in the digital forms. Basic stuff like if(X) then show options Y or page Y - you get the point. I think I saw a goto type item last I checked, which was a little bit ago. As offices go digital, some are doing it right and recreating the forms in the signing application. Other, lazier firms, have you fill out a scan (gag me with a spoon.) The idea of a loop is a funny one, I wonder if anything checks for it?
charles_f 7y ago
Article seems to identify main reasons as either poor implementation, or poor change management. Funny how much this reminds me of capital-A-gile, and Jeffries "we've tried baseball"[0] - we've implemented some simple changes that make things better! - everyone, let's all do this thing! - there! We've tried! It doesn't work - but you've bastardized the original idea beyond recognition - doesn't work! [0] https://ronjeffries.com/xprog/articles/jatbaseball/ https://ronjeffries.com/xprog/articles/jatbaseball/ edit: formatting

158 points by areoform 7y ago

Key point is the last paragraph: Fortunately, Fixsen says, the lessons of implementation science are “completely generalizable”, and all programmes could benefit by noting the importance of engaged leadership, local adaptation and user buy-in. “It doesn't matter how good the innovation is, it doesn't matter how much has been invested,” says Fixsen. “If we don't have the implementation savvy, we're going to get the crummy outcomes that we have seen decade after decade.”

skybrian 7y ago

If something as seemingly straightforward as using checklists is difficult to implement in hospitals, maybe we shouldn't feel too bad about the slow, partial, and controversial adoption of programming methodologies?

marcosdumay 7y ago
Oh, our profession moves very quickly and very universally. It's unparalleled on that. The controversy is usually about wether the movement direction is any good.

monocasa 7y ago

I like what they do in the Japanese train system. You have to point at whatever you're doing and day aloud what it is before you check it off. That heavily reduces the amount of mindless checking via scanning the sheet that leads to items being checked off without being fully validated. https://en.wikipedia.org/wiki/Pointing_and_calling https://en.wikipedia.org/wiki/Pointing_and_calling

jfries 7y ago
Yes, I think it's frustrating that this is not widely adopted. The upsides are really obvious and the only downside (I guess?) is that it feels a bit awkward to do it before society has gotten used to it. Another thing with obvious benefits I wish we would adopt from east Asia is wearing a face mask when having a cold to prevent infection those around you.
ChicagoBoy11 7y ago
I fly private planes as a hobby and during my training that practice was kinda grilled in to me. After flying for a bit, you end up realizing how easy it is to "see" something incorrectly, or to skip an item, etc. Even when there's no one else in the plane with me, I say things out let, touch nobs to confirm their position even though I checked it earlier and didn't touch the nob at all at any portion in the flight. (Good) Pilot training will make you aware of just how much trouble your mind can get you into.
- thrownblown 7y ago
  Both of you have fat fingers.
  - behringer 7y ago
    I hope the landing gear isn't next to the ejection trigger.
    - thrownblown 7y ago
      In my defense downvoters, they both had typos, "day aloud" and "say things out let" and we're talking about pointing and touching dials here.
      - behringer 7y ago
        I got your back :)
Terr_ 7y ago
I imagine it also brings in a certain kind of kinesthetic memory into play, habits of movement rather than just habits of thinking.

hestipod 7y ago

They fail because of egos and arrogance. This is the root cause of a lot of life's problems. People think they are above it and too smart etc. They hate being "told what to do". An example, I have a family member who will complain about texting and driving from some position of superiority but who does it constantly himself. When challenged with that behavior he refuses to acknowledge it. He believes he is above it, better than those who cause accidents, and only those "lesser" people need to follow rules. It's an incredibly common behavior and doctors are no different...and in some cultures more likely to assert their status.

stronglikedan 7y ago
> He believes he is above it Honestly, he probably is. We need to have laws because most people do it carelessly. Not necessarily because all people do it carelessly. Naturally, those who know they do it safely aren't going to just lump themselves in with the majority that don't.
- hestipod 7y ago
  He really isn't. He hits the rumble strips constantly when staring at his phone, and it only takes a second of inattention to kill someone. Being lucky so far isn't proof of competence. This attitude is the exact problem I was addressing in relation to the article...people thinking THEY are safe and others are the real problem and why we need checklists/rules.
- vangelis 7y ago
  Most people who text and drive are doing it safely until they aren't. It only takes a second to fuck up.
- 0kl 7y ago
  The problem is that it builds and establishes a habit that we will _accidentally_ engage in when we are tired, distracted, etc. This is where accidents happen, and why it is important to never consider yourself above the fray. It’s not that anyone is always careless, it’s that everyone eventually has an off day, and in those off days our careful habits become careless ones.

deleted 7y ago

[deleted]

OliverJones 7y ago

I wonder. Does the Hawthorne Effect (https://en.wikipedia.org/wiki/Hawthorne_effect https://en.wikipedia.org/wiki/Hawthorne_effect) contribute to the success of these checklist regimes? When surgical or emergency-department teams believe they're participating in an experiment to learn whether certain practices improve outcomes, do the outcomes improve? Airplane pilots use checklists. It's illegal to start the engines unless the approved checklist book is within reach of the pilot in command. In training it's drilled into us that the response to panic is: get out the checklist and follow it. It works. duh. It's all too easy under pressure to forget to lower the wheels or turn on the carburetor heat, or whatever. The drilling in training is what makes the difference. (Aviation gasoline cools as it vaporizes in carburetors. Under certain conditions that can make the carburetor fill up with ice. If that happens the airplane will land soon. Not good. So carburetors have heaters. ) Checklists have far less success in medicine. Heck, almost two centuries ago Dr. Ignatz Semmelweis (https://en.wikipedia.org/wiki/Ignaz_Semmelweis https://en.wikipedia.org/wiki/Ignaz_Semmelweis) found that patients lived a lot longer when doctors and nurses washed their hands. But, even in the 21st century, it's a struggle to get compliance with hand-washing rules in hospitals. Maybe something about medical training makes people resistant to fixed procedures. Maybe it's the age-old practice of eminence-based medicine rather than evidence-based medicine. It's a serious problem.

sjg007 7y ago
Gloves are another one.. blows my mind.
perl4ever 7y ago
Without any specific relevant experience in a hospital, isn't the most likely reason procedures fail that people are required to ignore/bypass parts of them constantly, rather than having them updated to match reality? It seems so very obvious to me that any time you start asking, from a 40,000 foot level, why people can't follow simple instructions, the answer is going to be, not that they are all idiots, but that they are trained and required to ignore them selectively based on complex ever shifting criteria. That is basically what makes any job require a human and not a computer in the first place. The more rigid you want people to be, the better the process has to be.

mhb 7y ago

If I saw both Mark the surgical site and Introduce yourself by name on the list, I would also be suspicious about which items were saving lives and which were wasting my time. Separately, maybe it would work better to give the checklist to the patient and have her check off the items. In light of some comments, it appears I wasn't clear. My point was that the problem is having BOTH those items on the list. Marking the surgical site is definitely worthwhile. Having it on the same checklist as introducing yourself dilutes the importance of it and the other important items on the list.

TylerE 7y ago
Don't laugh. Mistakes happen, especially with body parts that we have two of, and it's heartbreaking when it does. Amputating the wrong limb, removing the good kidney instead of the bad kidney...
vangelis 7y ago
Consciously marking the surgical site ensures we have the right surgical site. A wrong site surgery 'never event' happens nearly 100 times a year in the US. The introduce yourself by name item is less crucial, but ensures everyone knows who everyone is, especially in larger hospitals. In a stressful environment, it might be the difference between fumbling and not. Apparently it also increases the likelihood that someone will speak up if there is an issue noticed.
tunesmith 7y ago
I recently had a very minor surgery scheduled to have something removed, on the right side. The doctor was filling out the surgery form and checked the "left" box. It was because on the form, the "right" checkbox was on the left side, and the "left" checkbox was on the right. (He immediately caught it and corrected it.)
FabHK 7y ago
Presumably you consider Mark the surgical site to be saving lives, and Introduce yourself by name a waste of time. However, there is a reason for the latter item. There have been many plane crashes in which at least one cockpit crew member had some inkling that something was wrong [1], but their warnings were ignored, often when there was a big authority gap. Crew Resource Management [2] was developed to address this. Introducing yourself by name is designed to emphasise that the group is now a team with a common purpose, and everyone, from the lead surgeon to the nurse, can and should speak up if something looks awry. Quite some thought and research has gone into this. Obviously, this doesn't mean that the ideas can't be criticised, but a facile dismissal like yours is unwarranted and might be one reason the checklists don't live up to their potential. [1] Some examples: The Tenerife disaster, 583 fatalities: 'On hearing this, the KLM flight engineer expressed his concern about the Pan Am not being clear of the runway by asking the pilots in his own cockpit, "Is he not clear, that Pan American?" Veldhuyzen van Zanten emphatically replied "Oh, yes" and continued with the takeoff.' https://en.wikipedia.org/wiki/Tenerife_airport_disaster#Communication_misunderstandings https://en.wikipedia.org/wiki/Tenerife_airport_disaster#Comm... United Flight 172: 'The captain focused on the landing gear problem for an hour, ignoring repeated hints from the first officer and the flight engineer about their dwindling fuel supply. Only when the engines began flaming out did he realize their dire situation.' https://en.wikipedia.org/wiki/United_Airlines_Flight_173 https://en.wikipedia.org/wiki/United_Airlines_Flight_173 Korean Air 801: 'The crew noticed that the aircraft was descending very steeply, and noted several times that the airport "is not in sight." Despite protests from flight engineer Nam that the detected signal was not the glide-slope indicator, Park pressed on.' https://en.wikipedia.org/wiki/Korean_Air_Flight_801#Accident https://en.wikipedia.org/wiki/Korean_Air_Flight_801#Accident [2] https://en.wikipedia.org/wiki/Crew_resource_management https://en.wikipedia.org/wiki/Crew_resource_management

heymijo 7y ago

An ophthalmologist I know is an attending physician, which means she teachers new resident physicians. She described a few surgeries to me and her role in the room as the resident performs the surgery. Her brain is the checklist for the surgical procedure. The culture seemed to be, you should be good enough to memorize these complex procedures. Meanwhile I'm thinking, why not just have someone else in the room reading and confirming the next step to the surgeon? I suspect the culture of medicine, and especially the culture of surgeons does not jive well with checklist culture.

iguy 7y ago
I suspect that what made the culture of pilots change is that their own lives are on the line. That, and the fact that the guys flying the coolest fastest planes had commanding officers who could simply ground them if they didn't like it.
- WalterBright 7y ago
  My father was an AF pilot for 20 years. I've never known a more conscientious and careful man. One day he was going through the landing checklist, and was interrupted by a radio call. He resumed the checklist, then was told by the tower that he was attempting to land with the gear up. The interruption had caused him to skip that step on the checklist. After that, whenever he was interrupted in a checklist, he started it over again.
  - tonyarkles 7y ago
    I've been flying a somewhat large UAV lately, and inspired by the "real" aviators and The Checklist Manifesto, I put together a series of checklists. One for packing, one for pre-flight, and a mission-specific one for the day. Early on I was pretty lax about following them, and inevitably something bad would happen. I'd forget to pack something and not realize it until I had driven an hour. I'd forget to check for loose bolts and lose one. Or I'd completely forget one of the objectives for the day and have to go back out. I've tightened up my process quite a bit, and do exactly what your father does: if I get interrupted, I start over. It's mentally hard to do when I'm already feeling late, but I've come to the conclusion that that's exactly when I need to be more disciplined about it; that's when you forget things!

conorh 7y ago

They fail because of severe checklist fatigue according to my wife (a surgeon). Checklists are great - so let's do them for everything, ALL the time. People start to tune them out because they do the same checklist hundreds and hundreds of times and they often have many irrelevant things on them. The people using the checklists have little ability to change them or to improve them and so they start to suffer from checklist fatigue. As they say in the article: > “There's no point in having an item that says, 'Have the antibiotics been given?' if there are no antibiotics in the hospital,” says Dixon-Woods. The checklists that my wife uses are apparently filled with these types of irrelevant checks. Not to say that they aren't useful, they are, but as this article points out the implementation of checklists often leaves a lot to be desired.

y0ghur7_xxx 7y ago
> They fail because of severe checklist fatigue > checklists often leaves a lot to be desired. You say yourself that checklists are great, and it is proven that they save lives. So if there is fatigue in using them over and over, and they are not perfect, well... get over it? Sure i can understand that it's boring to go through the same checklist 5 times a day, but come on, there are lives at stake here. If one of your wife patients gets an infection and dies because she forgot some important, simple, step because of "checklist fatigue" how would she feel?
- fgonzag 7y ago
  You're not going to cure the human condition. If checklist fatigue is a real problem, telling people to suck it up and do their jobs is not going to work. The process needs to be improved to account for check list fatigue, it's that simple. Be it read aloud each item before checking it off, have a secondary scribe confirming and checking it off, or any other improvement that minimizes the effect of the fatigue.
- Balgair 7y ago
  The Messiah/God complex is a very real thing with MDs. It's dependant upon the enviroment and training, but a lot of them really do think that they are 'special' and that they have 'proved' themselves via the rigours of school and residency. Their sense of self is tied up into their job preformance. Like in other professions, if you 'attack' their job and their work, you are attacking them personally.

mieseratte 7y ago

Does anyone here use point-and-call or something similar for more mundane activities than trains and planes? I started doing this while driving a few years ago. I've gotten a good bit of shit over the years for it from skeptical passengers. Hard to point at a clear-cut win when it is about prevention.

deepspace 7y ago
I am somewhat obsessed with improving my driving skills, particularly w.r.t. anticipation and accident avoidance. I also got into the habit of using checklists for important but repetitive tasks after reading Gawande's book, Now I am kicking myself that I never thoguht about applying point-and-call to driving. I can absolutely see the benefit, but would need to think about the details. Do you point out only traffic signs and signals, or things like potential threats too?
- mieseratte 7y ago
  The biggest use for me is turning from a static position, e.g. left from a cross-street, having started this after I made a left turn but was t-boned, mind you I've always been religious about seatbelts, checking turns (left-right-left), etc. When doing a static turn I will point-and-call left, "Clear Left," point-and-call right, "Clear Right," point-and-call left again "Clear Left," then with both hands on the wheel say "Go." I will look-and-call for lane changes, pretty much as you would imagine look over the shoulder and "Clear Left," then "Turning." Same goes for right. For me it is more action oriented, to make sure I've assessed the area for issues. I haven't done anything like call outs for threats, but now I'm kicking myself for not thinking of that. I already do that religiously in FPS games, I could see how doing that would be good to get and stay in the habit of active scanning, "Pedestrian crossing, two o'clock." Might have to try that one out too, after all my friends will love that development :)
  - therealx 7y ago
    I can't imagine this with a straight face, but I do think you're a safer driver for it. I imagine an accident like that would rapidly change that. Even a small fender bender changes my driving rapidly for a good period of time. Too bad I can't get over myself :)

WalterBright 7y ago

Checklists have been incredibly effective in improving aviation safety. But just having checklists doesn't help much - there has to be a culture of following them and a ritual to following them.

mjevans 7y ago
When followed correctly it is my believe that checklists can raise the floor of the worst case outcomes. Said another way, actually following the checklist eliminates the low-hanging fruit of preventable mistakes.
- justinmeiners 7y ago
  Which is what they are designed to do. Eliminate stupid absent minded mistakes.
- noir_lord 7y ago
  Not a pilot but I follow mine rigorously when doing rote tasks I haven’t automated yet and they save me from a lot of head slapping moments. It’s a habit I had to work hard at, item one on my list is usually don’t skip any steps.

casion 7y ago

I read the article, but I don't see if/where there is responsibility given for the checklist(s). Most QA systems have a source of responsibility and multiple levels of review. I wonder what would happen if there was a QA team (with sufficient education) at a hospital that had complete control over checklists and associated procedures. Would that improve the outcome when utilizing checklists? --- Anecdote --- I've been in the hospital many times, and I've been present for pre-surgical checklists a few times. It was ALWAYS a nurse handling it, and it was never a nurse that I was familiar with during my care. All but once the interactions started with trying to figure out who I was... without asking me. I can recall a number of times where there was a question, such as "Which body part is being operated on?", except I was told the answer. The "question" turned into "Looks like your right kidney is being removed", with a slight pause for me to object. It always made me feel like the staff thought the purpose of the checklist was to complete the checklist, rather than to QA the system they're part of. --- Anecdote Extended --- I suffered an unpleasant complication from this during a procedure. I do not respond to anesthetics the same way as most people. It takes a MUCH larger dose to knock me out, and to keep me out. (years of desensitizing medications + big (very tall) person + MC1R gene). I know this. I can communicate my past procedures and the doses administered. USUALLY they are supposed to ask if you've had any prior procedures and potentially follow up with questions about allergies, anesthetics and other questions related to sedation. I was not asked. I didn't think to speak up because I was already being inundated with stimulus. The result? The first "count down from 10" resulted in me counting to 0 and asking "What next?". I vividly remember the abject horror on the face of the nurse. She fumbled around, whispered to the anesthesiologist, whispered to other nurses. People shuffled around and nobody said a word to me. I was scared. It felt like forever before I was asked to count down from 10 again. It worked that time... Until I woke up in the middle of the procedure! When I woke up in post-op, I asked the nurse about it and she told me that I wouldn't remember any of it. She told my wife that I wouldn't remember the couple hours after post-op. I remember every single nurse's and doctor's name involved and the discussions my wife had with the doctor in post-op (which she confirms my recollection). It could have all be avoided if someone just said, "Hey, have you had a procedure where you've been under general anesthesia before?" I bet that checkbox was ticked though.

iamleppert 7y ago

Sounds like a great opportunity for a digital checklist with a computer vision, audio analysis component and deep learning backend that could quantify, and eventually automate the adherence to such checklists. I wonder how many people would actually follow the checklist if they knew their compliance was being continually monitored and audited?

scott_s 7y ago
I think that misses one of the lessons of the study: people need to be invested in the checklist for it to help. In other words, they need to want to go through the process. The checklist itself is not magical. When it's effective, it's because it formalizes everyone's desire to adhere to agreed-upon protocols that everyone agrees are beneficial.
- sergioj97 7y ago
  Even though it seems clear that the checklist itself has to be well designed, I don't think it's a bad idea to ensure they are followed. Strategies like the one the OP proposed are independent from checklist quality.
marcosdumay 7y ago
Well, you actually just need an Alexa there reciting the checklist and waiting from a yes before moving to the next item. Since it is intended to be in a hospital, that's a $40K Alexa that must be created by somebody with the right connections. But all that you need is an Alexa.

cortesoft 7y ago

I also wonder how much of an effect the prior conditions have... if a hospital is already doing a good job of following procedures without a checklist, it might not make as much a difference as for a place that wasn't doing so well before.

srikz 7y ago

I was just thinking about the comparison between the medical industry and airline industry. In medicine you can (or have to) pay a premium to get the best doctors and expertise [1]. In the airline industry, the safety aspect is standardised across the board. It doesn’t matter if you are flying economy or 1st class you get the best in class safety, which is collectively shared across the industry. We pay a premium for the service and not to have better chances of surviving. In an alternate universe, we could have had cheaper airline tickets which had not so great safety record and the good ones only in reach of the super wealthy. [1]: I’m aware it may not be the case in some countries with completely free healthcare, but this applies to the majority of the world. Even in those countries with free healthcare for all, it is not uncommon to see huge wait times for some important procedures and being able to skip it by going through a private hospital.

L_Rahman 7y ago
There are some interesting experiments with hospital operation models in India that try to make it more like flight. Every patient gets the same surgeon and treatment, but people who pay more get nicer facilities (private rooms, less crowding, separate waiting area for family). It's not an equal model, but it is more just than what we have in America today. https://www.bloomberg.com/news/features/2019-03-26/the-world-s-cheapest-hospital-has-to-get-even-cheaper https://www.bloomberg.com/news/features/2019-03-26/the-world...
- srikz 7y ago
  Yes, most private hospitals have this model in India where the same surgeons treat the highest paying and the lowest paying patients. However, the price difference between the base pricing across these hospitals vary a lot and you tend to go looking for that famous surgeon who practices in a hospital where everything is more expensive (Narayana Health and a few others may be an exception). Also, the other aspect of the airline industry which we should get in hospitals is sharing of best practices. The protocols and procedures which can be effective in saving lives should not be a differentiator, instead it should be standardised and made mandatory. The differentiators should be non-medical as much as possible. Of course, only the wealthy hospitals may be able to afford the latest equipments but the expertise of the medical staff and best practices are easily transferrable in a cheap way and shouldn't be guarded like an individual's or the organisation's IP

rb808 7y ago

Checklists are way overrated. To all the fanboys out there, how many of you regularly have checklists for things you do several times a day? I know in the last ten years I've seen new processes with forms to fill out for mundane tasks and its PITA.

wisty 7y ago

A lot of people seem to be hung up on the fact that there must be something special about doctors. They're too skilled, they operate in a unique environment, or that they're awful egotists with god complexes. Pick almost any profession other than pilot, and checklists are something that most people will ignore, often for the same excuses doctors have. It seems like it should be comparable, as both medical errors and aircraft crashes are taken seriously, but there's a huge difference in magnitude.

cardiffspaceman 7y ago

In the documentaries about Apollo 11 that are rather easy to find these days, one of the things you hear over and over again is the "go"'s from various participants right before a launch or other milestone.

gpm 7y ago
If you watch a modern rocket launch (the vast majority of which are livestreamed and uploaded to youtube) you hear the same.

wysifnwyg 7y ago

Doing UX Design right now and the popular phrase is: "If only people would read instructions everything would be alright."

effnorwood 7y ago

Broken pencils.

rscho 7y ago

Official role for checklists in healthcare: save lives! True role of checklists in healthcare: save management in case of legal action. Consequence: the checklist becomes longer and longer, and is done more and more frequently. To the point of being quite impractical. Goal: in case of legal action, take refuge in checklists. At least one of the items is bound to be missing so you can divert responsibility to someone else. Source: I do checklists. That's my job.

tonyarkles 7y ago
I replied elsewhere in the thread with a bit more detail, but my UAV checklists contain 100% material learned from experience only. They've grown a little (especially the packing list) as I've gotten out to the field and realized I didn't have a tool that would be useful to have, but they've also shrunk as I've eliminated equipment I no longer need (e.g. a programming cable for an ESC that I no longer use). It's pretty disappointing to hear that that's how checklists work in your org. I feel like it's doubly negative: not only does it pretty much guarantee that they won't be followed because they're not particularly useful in that form; it also helps to ensure that the folks that have to use them will push back against checklists in general at their next job! [I suppose that's what happened with me and JIRA too... it might be a decent product, but every org I've used it in has done a very bad job with it]
- baud147258 7y ago
  I think our boss has made a good job with our bug workflow, but she had the authority (and Jira access) to do what she (and the QA lead) wanted.
lonelappde 7y ago
This is like Agile vs micromanagement in software dev. The workaround for that is for the practicioners to have their own good checklists in addition.

justinmeiners 7y ago

As the article states, the issue is they are often poorly implemented or designed. If that's the case, what is surprising?

dctoedt 7y ago

In aviation and nuclear-reactor operation, the ethos is that 1) of course people are going to make mistakes, because we're human; 2) the point of systems such as checklists and second-checking is to try to make sure the mistakes get caught before they have any effect; so 3) if you harbor resentment toward checklists, try to give yourself an attitude adjustment — learn to embrace and even enjoy them.

dctoedt 7y ago

Atul Gawande's book, The Checklist Manifesto, said that WHO's surveys found significant resistance by surgeons to using checklists — but if they were going to be operated on, something like 93% of the surgeons said, in essence, you're damned right I want the surgeon to use a checklist.

neom 7y ago

I've tried to read The Checklist Manifesto twice now, and I couldn't because I'm too squeamish.

sopooneo 7y ago

I've never worked in a hospital, but I have plenty of experience with massive bureaucracies. And that gives me guesses, perhaps fanciful, about things that could go awry with surgical checklists. Anyone with relevant experience, please weigh in if these seem feasible. 1. Every prominent error that occurs prompts administration to decree a new checklist item be added to provent it in the future. But these added items will not be root-cause fixes so will proliferate to the point that there are now several dozen of negative checks to prevent these one-in-a-million mistakes. And so the lists will grow and grow, but no one will ever dare to take an item off. Because then if that mistake ever does reoccur, the admin that authorized its removal is up for a hearing in front of the firing squad. 2. Some administrator somewhere, noticing redundancy within a given checklist will reinvent control structures. You'll have lists with loops and conditionals. And since the people creating these lists don't know what is "considered harmful" they will almost certainly add GOTO's. In fact, I'd be very surprised if GOTO's don't already exist in surgical checklists somewhere. But then this addition of control structures could increase to the point that a surgeon could, potentially, be put into an infinite loop! So committees will be formed to ensure every path through a checklist actually can be completed. And someone, somewhere in a hospital conference room, when asked to PROVE the lists all terminate, will take a breath, sit back, and rediscover the halting problem.

scarejunba 7y ago
Well, they only have to discover that their program halts, not all arbitrary programs so that's not quite the Halting Problem.
therealx 7y ago
Some patient record programs already allow control structures in the digital forms. Basic stuff like if(X) then show options Y or page Y - you get the point. I think I saw a goto type item last I checked, which was a little bit ago. As offices go digital, some are doing it right and recreating the forms in the signing application. Other, lazier firms, have you fill out a scan (gag me with a spoon.) The idea of a loop is a funny one, I wonder if anything checks for it?

charles_f 7y ago

Article seems to identify main reasons as either poor implementation, or poor change management. Funny how much this reminds me of capital-A-gile, and Jeffries "we've tried baseball"[0] - we've implemented some simple changes that make things better! - everyone, let's all do this thing! - there! We've tried! It doesn't work - but you've bastardized the original idea beyond recognition - doesn't work! [0] https://ronjeffries.com/xprog/articles/jatbaseball/ https://ronjeffries.com/xprog/articles/jatbaseball/ edit: formatting