Guest Article: What the low-tech checklist can teach techies about medical business processes and proper system design

I’ve often said that if you can’t repeat something, you can’t automate it — meaning trying to jump into creating software or systems before you have identified and fixed your human processes is always prone to failure. One of the best ways to understand if your process is repeatable is to create checklists and see if people follow them. I recently ran across Jacob Ukelson, Chief Technology Officer of ActionBase, who is somewhat of an expert on human process management and action tracking solutions that enable organizations to manage business-critical processes. I invited Jacob to tell us how low-tech checklists can be useful in healthcare organizations and how as technicians we can use that knowledge in helping design systems. I’ve often wondered — if our users can’t follow simple checklists, can they really use complex systems? You can use Jacob’s advice in requirements gathering, process comprehension, usability analysis, and many other areas that have more to do with software success than the code we write. Here’s what Jacob had to say:

In his 2007 New Yorker article, “The Checklist,” writer Atul Gawande explores the work of a doctor at Johns Hopkins Hospital who wanted to bring a process model to the highly individualized, specialized work of physicians in intensive care units.  Medical personnel perform an average 178 tasks per day on the typical ICU patient, notes Gawande, raising the question of how to avoid errors in processes with so many steps.

The answer, according to a Johns Hopkins Hospital doctor at the center of the article, is checklists.  Using simple, low-tech, step-by-step guides for specific procedures, doctors in one sample study avoided an estimated eight deaths, 43 infections and $2 million in costs.

Even with their years of study, internship, residency and intense specialization, physicians experience risk in the area of human-driven, ad-hoc processes.  A management tool – in this case, checklists – enabled them to significantly lower that risk.  There is a lesson there for businesses – not just for doctors, but for the healthcare industry in general.

Management tools for knowledge work and knowledge worker productivity is a hot topic in the process management community.  The market is coming to the realization that knowledge work makes up a large and growing  part of today’s modern economies; and  studies show that while cost of goods sold (COGS) has gone down 2.7 percent over the last decade, sales, general and administrative (SG&A) costs haven’t budged (see “Five ways CFOs can make cost cuts stick”). Knowledge work isn’t the only component in SG&A costs – but it is the biggest and one that has traditionally thwarted attempts at management and control.

Topics like social business process management, adaptive case management and unstructured process management are different terms currently being used in the business process community for approaches to solving the problem of knowledge work productivity. The adaptive case management approach is particularly relevant in the healthcare industry, since case management is a recognized, well-established discipline in the field. Adaptive case management is an expansion of traditional case management technology and approaches.  It’s an attempt to look at knowledge work as a case process – not the kind of structured task that business process management tools address, but rather the barely repeatable, emergent processes done through meetings, conversations, e-mail and documents. There is no predefined rigorous model — the cornerstone of structured process management — so a different approach is needed. The goal of adaptive case management is to provide enough structure to knowledge work to make it manageable, but not so much as to strangle it.

So what’s unique about these types of processes? Well, first and foremost the focus is on the process instance, not a rigorous model of the process in general. The characteristics of these types of processes are:

1. They consist mainly of interactions between human participants.
   1. Collaboration and negotiation are important components of the process.
   2. Documents are an integral part of the process. Documents are both consumed and produced as part of the process.
   3. Participants control the process and change it on a case-by-case basis.
      1. Participants are in charge of the flow, participant list and activities.
      2. Every process instance has an owner.
      3. Every process instance has a goal, deadline and a defined work product  (and often an associated guideline or best practice).

When analyzing unstructured knowledge processes, many times I have seen best practices and guidelines presented as checklists or a series of checklists (usually as Microsoft Word documents, or Microsoft Excel spreadsheets). Of course, checklists are a far cry from full-fledged process models.  They don’t go into enormous detail, they don’t prescribe how things should be done and they generally focus on a small part of a larger process.  However, checklists ensure that knowledge workers adhere to best practices, and they are much more fitting for human-centric processes than the models derived for more rote, automated tasks, such as business process management products.

Gawande explains in his article that the lowly checklist is quite effective as an aid for memory recall, particularly for those jobs associated with mundane matters that might be easily overlooked.  He also notes the value of explicitly stating the minimum, expected steps in any given process.

On his “Strategies for Internet Citizens” blog, Jon Udell notes that while the simplicity of the checklist might initially offend highly skilled workers, it is a valuable tool for any field, including IT and business.

Certainly, the complex, changeable processes that comprise 60 to 80 percent of the work performed in any business need a safety net for the risks inherent in human-centric activities.    Checklists are a start, and adaptive case management solutions are their extension.  By building in prompts for required process steps and establishing a means to audit business-critical, ad hoc tasks, adaptive case management provides organizations with the medicine they need to perform comprehensive action tracking and avoid the business equivalent of the ICU.

So which processes are candidates for adaptive case management?  They include:

• Strategic and tactical management and decision-making
• Processes that cross organizational boundaries
• Processes requiring negotiations and commitments
• Processes that change their structure and participants as work progresses
• Processes that require an audit trail of commitments and actions to demonstrate compliance
• Process that have deep implications and require investigation, such as suspected fraud or new business risk

Adaptive case management provides a process-oriented IT framework for managing these types of processes – or as Scott Francis puts it in his blog, “optimizing the outcome of an individual run of a process by providing better information and tools to the case worker:”

• Ensuring every process instance has an owner
• Ensuring every process instance has a goal, deadline and a defined work product
  • A goal defines what must get done, not how the process is done
  • May also provide an associated guideline or best practice (usually in the form of a checklist) that gives a generic outline of the process ****
  • Providing visibility within the context of the execution of a process instance or after it is complete
    • Details on both the emerging flow of the process (the hand-offs between participants) and the work done by each participant (either in summary or detail form)
    • Minimizes failed handoffs which are the most likely cause of process failure
    • Providing management and control through tracking, deadlines and goals
      • Process participants decide how to best achieve their goals,
      • Process owner can track the current process state and progress
      • “Hawthorne effect” can change participant behavior

The doctors Gawande mentions in his article balked at the checklists; they were unfamiliar tools in the realm of their workplace.  This is not so for adaptive case management solutions, which can be integrated into familiar Microsoft Office applications, enabling workers to easily adopt them as a natural extension of traditional methods for monitoring and tracking tasks.