KM Is Alive

Pilots have been using checklists forever (well since World War II) and surgical teams are now starting to use them routinely.  Why…because they codify good practices.  In the words of the World Health Organization (in the downloadable speakers kit)

Currently, hospitals do MOST of the right things, on MOST patients, MOST of the time.

The Checklist helps us do ALL the right things, on ALL patients, ALL the time

I’d like to make the case that checklists should be a vital part of a KM program… they are one of the simple things that we as KM practitioners/advocates can help develop and implement in organizations that will have a profound impact on business outcomes.  If they are so important to pilots and surgical teams…is there a case to be made for their use in other professions as well?

What do checklists have to do with KM?  Can something as simple as a checklist help apply good practices across an organization? And if they can is there a role for the KM practitioner or advocate to help develop and apply checklists across an organization?

Aren’t checklists kind of like a grocery list…something you use so you don’t forget the simple things…like picking up the milk…or in the case of an airline pilot, putting down the landing gear (or not…if you are going to do a water landing)?

Yeah—that is what they are – they are lists so that you don’t forget the simple things – things that in the case of airline pilots and surgeons save lives.  Or in the case of construction superintends insure that no major steps or critical pieces are missed in a construction project.

It turns out that check lists are vital in a number of professions…helping everyone from the novice to the expert make sure they don’t skip the simple things…that can make a huge difference in the final outcome. But it also turns out that they are not used nearly as often as they could or should be.

Dr Atul Gawande,  a surgeon, associate professor at Harvard and a staff writer for the New Yorker, may have never heard of KM – or be able to define KM – but in his recent book The Checklist Manifesto – how to get things right, he lays out a very effective case for using checklists (and in effect KM) to ensure that what an organization knows is both captured and applied.  But…what he taking about is not the expertise of a neurosurgeon …or the expertise of a pilot of an airliner…but the routine things that if done consistently make a big difference in the outcomes.

In the book Gawande, who is one of best story tellers I have encountered in some time (a good trait for a KM type person), sites numerous statistics and tells great stories that demonstrate the value of using checklists for the simple things – the things that should be done routinely at the start of every procedure – such as making sure you are removing the right (and not the left) kidney (there are between 1500 and 2500 wrong side surgery incidents every year in the US) or the patient has been given the right anesthetic at the right time (giving antibiotics within one hour before incision can cut risk of surgical site infection by 50% – but in eight evaluation sites around the world nearly half the patients did not get the antibiotics timely) or the surgical team is communicating with each other (communication is the root cause of nearly 70% of the events reported to the Joint Commission…an accrediting agency associated with quality care initiatives).

So how can checklists make a difference?

In one hospital where they instituted a check list to reduce the incidence of central line infection, simply introducing (and using) a check list in the ICU reduce the infections  from 11% of the patient population to 0%.

In a World Health Organization (WHO) pilot study a surgery check list was instituted in eight hospitals around the world, four in high income countries (US, Canada, UK, New Zealand) and four in low to middle income countries (Philippines, India, Jordan and Tanzania.; The check list was simple…divided into three parts, before anesthesia, before incision and before patient leaves operating room.  In total only the check list has only 16 questions…and takes only a couple of minutes to complete.

After the study, which involved over 4000 patients, major complications for surgical patients fell by 36 percent and deaths fell 47%.  Without the check list 435 patients (just over 10%) would have been expected to develop serious complications – but just 277 did.  The check list “spared more than 150 people from harm…and 27 from death.”  And then there is the dollars that were saved…

But not only does Gawande look at the value of checklists in the operating room –he also looks at a variety of other professions.  For example….why do pilots…with 10’s of thousands of hours of flight time go through a checklist before every flight?  Why did the copilot on US Airways 1549 (Sullenberger and the Landing on the Hudson) immediately start going through the check list for engine restart, then for a water landing when the pilots realized there was a problem less than 90 seconds after takeoff?  Why do construction superintendents of major projects have massive checklists (also known as master project schedules)?  It is because they make a difference.  It is because they help even the experts make sure they apply good practices that have been learned over time.  And it frees up your mind from thinking about the routine stuff and lets you focus on the more complex….

But what does this have to do with KM?

A checklist is a simple way to codified practices (hopefully a good practices) and make them easily accessible, and if done properly easily usable by others.  Isn’t this one of the fundamental things that we do as KM practitioners – allowing the effective sharing and use of knowledge across an organization.

Near the end of the book Gawande talks about how we are all “plagued by overlooked knowledge (one of the domains of KM practitioners and advocates) and how checklists can help overcome this syndrome.

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 by 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 that human beings could fly it. (this was the first multi engine bomber – and it crashed the first time it was flown…the pilots got together and said…okay…it’s complicated…so let’s create a list of the key things we need to do before and during flight.  This was apparently the origin of the pilots check list.)

They to 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 check list.

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 patters. We see the costs.  It’s time to try something else.

Try a check list.

How to create the check list

But how are checklists actually created?  How many people have the expertise to create an effective checklist?  In the case of Gawande, he clearly has the inclination and the ability to create and help others apply good practices.  I think that if you read some of his writings you will see that in fact he is a very natural practitioner of KM….even though he and his colleagues may not think of it in those terms.  But how many people are like Dr. Gawande?  How many people have the expertise, the time or the inclination to help an organization use and apply the checklist?  Isn’t this a key role for KM practitioners?

In some cases creating a check list is easy…we have a mountain cabin and every time we leave there are a few things we want to make sure we do.  We created a list based on what we routinely did when we left.  At first we created a “winter list” (we really didn’t want the pipes to freeze if the heat went out), but then discovered that we needed a summer list as well.  Ok…that was easy—think about what you actually do and what you should do, write it down and put it someplace easy to find.  Now the last thing we do as we walk out the door is check the list.

In talking to David Allen – well known management consultant and author of Getting Things Done, it turns out that David routinely uses lists (one of his mantras is….you can only remember a few things…so get them out of your head by writing them down…that way you free up your mind to think about the important things).  One example of a list he uses is his packing list for travel. Several people have seen the list and asked if they could have a copy.  When asked how he created such a great list, he said…”every time I forgot to pack something, I just added it to the list…”  So creating checklists can be easy.

But they are not always that easy…

In many cases it’s necessary to do more than have a person or two compose a list.  It’s valuable to say…what do we know about a particular process…or what are the issues we are facing in a particular process.

In the case of the WHO they know that approximately 234 million people are operated on each year, and that over 1 million of these individuals die from complications.  And they know that at least half are avoidable with the checklist.  But as you read Dr Gawande’s story you will see, not surprisingly…it wasn’t possible for one person to sit down and put together a check list – no matter how good they are.  What was happening in US operating rooms was different from what happened in the UK, or in India or in Tanzania.  It took a team coming together…and then piloting both the check list and the procedures for implanting it to come up with something that was effective in hospitals around the world.  And still if you look at the WHO material…you will see the statement “The WHO’s checklist is not intended to be comprehensive, and additions and modifications to fit local practice are encouraged. Click here to see how others have done just this.”

In some organizations you may already have processes that can help you create checklists. For example, when I was at Unocal and then working for an Aerospace company we routinely ran retrospects for projects.  The retrospects were facilitated meetings conducted with a team that had just completed a project or phase of a project.  The intent of the retrospect was to capture advice from the team based on what they had just done.  The retrospects generated great advice that was based on the experience of the team that just did the work.

Initially, we captured this advice in document that summarized the recommendations and discussed what actually happened that generated the advice.  And for the most part the documents sat in a folder – largely unused.  Then we decided to start creating checklists.  The checklists were simple and actionable.  We put the check list on the web…and indexed to make it easy to find.  And…we then linked it back to the more complete document in the event people wanted more information…or wanted to contact the people that had created the document and the check list.

Other organizations such as the Army routinely use AAR’s (After Action Reviews) that may similarly be used as starting points for checklists and for information that can be used to update the checklists.

What makes a good check list?

Gawande talks at length about what makes a good check list.  And we have some experience of our own.

The checklist of what makes a good checklist

1. Keep it simple…this is not about reminding the neurosurgeon how to do neurosurgery or the pilot how to fly the plane.  It’s about making sure that the fundamentals are taken care of.
2. Keep it short…if it takes more than a few minutes to complete, people won’t do it
3. Use events such as After Action Reviews (AAR’s) or retropects to help create the checklist…as well as to periodically update it.
4. If possible establish metrics to assess the effectiveness of the checklists.  In a hospital…where everything is tracked this is much easier to do than in other organizations,  but it is still worth trying.  If you can’t get metrics, collect stories, as Gawande has done, about the effectiveness of checklists
5. Finally – it gets used in the organization.  This is a matter of culture – and of sharing the stories about the difference using check lists make.

I’d love to hear stories about how KM people are fostering the use of checklists in their organizations and their practices…what’s working and not working.

CT Scans can increase cancer risk – as many as 29,000 new cases of cancer will be caused each year due to the use of CT Scans.  Many hospitals don’t use the proper level of radiation…and even within hospitals dosages are not consistent.  And it would appear that many of these scans aren’t necessary.

So what does this have to do with KM?

A recent story on NPR talked about the increased risk of cancer due to the use of CT Scans along with the perceived need for these scans by both doctors and patients.

That study looked at actual radiation doses for 11 common types of CT scans in more than 1,100 patients. For the same body part, the doses varied enormously from one hospital to another and even within the same hospital. The researchers found a 13-fold range between the highest and lowest radiation dose.

That means many unsuspecting patients are getting considerably more radiation than they need for an adequate CT image.

”For the same body part, the same patient with abdominal pain being evaluated for possible cancer, there can be a profoundly different radiation dose,”

They then go on to talk about how Mass General has cut down the use of these scans… How did Mass General do it?  Several years ago Mass General put together a simple questionnaire that was designed to determine the need for a CT Scan.  A low score indicated the Scan was probably necessary…a high score that the Scan was needed.  Before Mass General instituted this procedure there was a 12% increase per year in the use of CT scans. Today, 4 years later, the growth rate is only 1%, which is slower than the rate of growth of the number of patients in the hospital.

So what did they do?  They took something that many may have considered an art…determining whether or not a CT Scan was required, codified a procedure for evaluating the need for the test…then applied it routinely (hummm…is this an example of taking what some would consider a complicated problem in the Cynefin framework…and reducing it to a simple problem?).

The role of KM

To me there are two aspects where KM plays (or can play) a role here.  The first is in recognizing the value in codifying what you know and then making it part of the routine procedure.  Looking at it from the outside it appears that the Doctors and staff at Mass General were able to devise a series of questions that let them routinely assess the need for the Scan (assessing and capturing what you know) and then institute a policy (and software) that allowed them to apply what they knew across the organization.  This would appear to be KM 1.0.  Was this recognized as KM?  I don’t know…but  regardless they have applied what KM practitioners would consider KM practices.

The second aspect of KM is how to share this across the medical community.  If Mass General has been doing this for 5 years why haven’t most other hospitals picked it up?  What can we do as a KM community to help address this issue?  Some organizations – such as Mass General, Geisinger Hospitals in Pennsylvania (see previous post and article in Time magazine) and Kaiser Permanente appear to do this on a routine basis.  It’s part of how they operate.

The beauty of what is being done in the medical field is that much of it is quantifiable.  Doctors can document the medical condition as they see it, treat it then observe the outcomes.  And with today’s ability to track all of this…they can see statistical trends. As KM practitioners we can help provide the tools and the processes that will allow others to take advantage of what they have learned and done in order to improve our health care system.

To me this appears to be one of the largest KM opportunities facing us today…one where KM can make a big difference in terms of both quality and cost.

Thoughts?

Over the past few months as the US House and Senate have been debating the health care bill I’ve been thinking about the role that KM can play in helping reduce health care costs as well as increase the health outcomes.

As I’ve read articles on the topic and listened to reports from news organizations such as NPR several examples of hospitals using what I would term effective KM have stood out for me  - although in none of the cases do they actually refer to KM…instead they talk about sharing and use of good or best practices.

• The first is Geisinger Medical Group in Pennsylvania
• The second is Mass General
• The third is a Surgeon, Dr Gawande, and his team at Harvard

In each of these cases what the hospital and staff have done is (1) examine what they are doing, (2) codify their process and (3) create a check list based on their current processes and what they perceive as good practices.  They are then able to observe the results from both medical outcome and a cost perspective.  In all cases this simple KM process…of taking tacit knowledge, making it explicit and then using it as a check list…has resulted in positive outcomes.

What I’d like to do is to take a brief look at each of these and ask…as KM practitioners what can we learn from what they are doing…and can we help extend these practices in order to help improve our healthcare system?

The first example – Geisinger…

In an issue of Time Magazine this past fall Geisinger Medical Group was highlighted in an article titled “A healthy way to pay doctors.”

The article talks about how Geisinger Medical Group in Pennsylvania has significantly reduced costs, improved patient health outcomes, and attracted and retained top quality doctor’s through the use of some fairly straight forward KM practices. An example of what they have done is in surgery.

The first thing he and his team did was take 20 general steps all surgeons follow throughout a bypass episode and try to sharpen them in a way that would remove as much chance and variability as possible, going so far as to spell out the specific drugs and dosages doctors would use. The result was an expanded 40-step list that some surgeons balked at initially, deriding what they called “cookbook medicine.” Once doctors began following the expanded checklist, however, they grew to like it. After the first 200 operations — a total of 8,000 steps — there had been just four steps not followed precisely, for a 99.95% compliance rate. A total of 320 bypasses have now been performed under the new rules. “There are fewer complications. Patients are going home sooner. There’s less post-op bleeding and less intubation in the operating room,” says Casale. What’s more, the reduced complication rate has cut the per-patient cost by about $2,000.

The article goes on to talk about how Geisinger Doctors have done similar things for hip-replacements, bariatric and cataract surgeries and kidney treatment. And the results from both a cost perspective…and a health outcome perspective.

As I read the article and thought about what the teams had done it was apparent that they are applying some very simple KM techniques – what many KM practitioners would probably consider KM 1.0.  But these simple techniques were having a powerful impact.

I’ll look at a couple other examples from Mass General and Dr Gawande and his team at Harvard in the next part of the blog.

At this year’s KM World conference I had a chance to talk to several of the participants and ask them the question “what stood out for you from this year’s conference.

Listen to what  stood out for Carla O’Dell, Jim McGee, Patrick Lambe, Stan Garfield and others.

Here are a few of the responses:

Carla O’Dell (APQC): Video will make a big difference in how we share knowledge…”YouTube has changed the world of KM”

Jim McGee: The return to the organizational dimension of KM and the shift away from being enamored with technology

Bob Wimpfheimer (Dr Pepper): It has shifted how I think about KM.  Previously it has been storing documents and making them available… I’ve come to see it’s much more important to connect people with people

Jon Husband:  After years of taking about how to reuse knowledge, optimize it and classify it, people are beginning to understand that it’s really not very useful if people can’t access it, share it and build upon it — and that involves learning.  We are going to see blending of the disciplines we now know as learning, KM, personal development, organizational change…

Eric Mack (ICA): The talk about social tools and social media…the primary value of these social tools is in the connection they provide between other peoples knowledge and the work we do…social networking tools allow us to bridge the connection between our experience and knowledge and that of others.

Patrick Lambe (Straits Knowledge): KM is in a long pause.  It has reached the limits of what it can do based on how we currently understand how knowledge is use in organizations.  It is still focused on individual transactions and individual pieces of knowledge….it needs to get to grips more with how organizations work as organisms…as thinking organisms.  It is touching that with the collective intelligence and wisdom of crowds stuff but it is nowhere near sophisticated enough to show results…and I think that is where it needs to go.

Stan Garfield (Deloitte): KM is definitely not dead…it’s alive.  But we still have a lot of things to do…the things that I think are more important than the technology is the leadership…the things we need to do to get people to behave in a certain way to get communities to take off.  These are leadership issues…not technical challenges.

The consistent themes appear to be that KM is about connecting people to people…KM is social… and success is dependant upon behaviors.  Even with the emergence of E2.0…techology is an important enablor for the connections (“YouTube has changed KM”)…but is not the center of KM.

If you were at the conference…what stood out for you?

As I talked to people at KM World this year and as I’ve worked with students in the CSUN KM program I’ve come to a greater realization that what KM means to me…is not what KM means to others.

I’m sure everyone is familiar with the story of the blind man and the elephant. In the story, a group of blind men touch an elephant to learn what it is like. Each one touches a different part such as the side, the ear, the trunk or the tusk. They then compare notes on what they felt, and learn they are in complete disagreement.

In many ways this is an apt metaphor for KM.  I suspect that all of  us  have been exposed to or “touched” some version of KM.

As I have talked to people I’ve realized that to many…KM is that “part of the elephant” they have touched.  For some who were initially exposed to KM in the form of lessons learned and best practices – in other words documenting what you know so others can access it….KM is “lessons learned and best practices.”  For others who were initially exposed to KM through a lens of content management and search…they see KM as a variant of document and information management or perhaps semantic search, taxonomy and metadata.  Some see KM as communities of practice.  Some see KM as a very sophisticated search algorithm that allows you to find anything any time you need it.  And recently some see KM as what is termed Enterprise 2.0…or using social media tools such as wikis, blogs and Facebook type applications to tap into what the organization knows.

I was originally exposed to KM through the mentorship of Kent Greenes who left me with the view that KM is about… tapping into what others know so I can build on what they have done in order to do my job better.  This may involve talking to Subject Matter Experts, it may involve conducting a peer assist, an action review or a retrospect,  it may involve exploring lessons learned and documents, it may involve being engaged in a community of practice.  In other words…KM is no one thing…or one process…it is a system or perhaps more aptly termed an approach to understanding what we know so that we can build on in order to improve our overall performance.

What I want to do in this blog is to explore these various aspects of KM and see how they are adding value to organizations.  I also want to ask….is there potential for more value from KM if it is viewed as a system or an overall approach aimed at providing an organization the ability to leverage what it collectively knows in order to improve overall performance and to compete in this hyper-competitive knowledge based world.

What is your view – what is KM to you and to your organization?  And what are the tools and processes that you have found to be most effective to help you and your organization leverage what is known in order to improve overall performance?

The purpose of this blog is to discuss how KM is being applied and making a difference in organizations around the world. This includes private enterprise, government, military, non profit and education.  If you have a success story…please let me know.  We will make sure others hear about the successes.  In addition…if you have lessons learned from successes for failures, we would also like to make those available for others to learn from.