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GawChec10-06-075 |
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The
Checklist Manifesto How to Get Things Right Atul
Gawande Metropolitan
Books, 2009, 209 pp. ISBN 978-0-8050-9174-8 |
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Gawande is a general and endocrine surgeon in Boston, a staff writer for The New Yorker, and an associate
professor at Harvard Medical School.
In today’s world we have stupendous know-how, but avoidable failures
plague us because the volume and complexity of knowledge exceeds our individual
ability to consistently, correctly, and safely use it. Drawing examples from the worlds of
surgery, air flight, and construction, Gawande
shows how simple checklists can make a world of difference. I was amazed at the numbers of preventable,
serious errors that occur in the world’s most advanced hospitals. We may fail because of ignorance or
ineptitude. The balance has shifted
and it is most clear in medicine. In
the 1950s we didn’t know what caused heart attacks or how to prevent or treat
them. Today we have several ways to reduce
the likelihood of a heart attack and a whole panel of effective therapies if
you have one. But there are abundant
complexities and pitfalls. At least
30% of stroke patients, 45% of asthma patients, and 60% of pneumonia patients
receive incomplete or inappropriate care from their doctors! (10)
Complexity is the issue.
Mistakes are frequent in almost any endeavor requiring mastery of
complexity and large amounts of knowledge.
There is too much to manage and get right. (11-12) “The volume and complexity of what
we know has exceeded our individual ability to deliver its benefits
correctly, safely, or reliably.” The
answer: a checklist. (13) The author tells a long involved story of a girl
rescued after 30 minutes under water in the Alps. The hospital was able to save her by a
multitude of heroic measures. The
marvel is that everyone got it right.
Clinicians now have some six thousand drugs and 4000 medical and
surgical procedures. It’s a lot to get
right. “Americans today undergo an average of seven
operations in their lifetime, with surgeons performing more than fifty
million operations annually…” (31) There are more than 150,000 deaths
following surgery every year, 3 times the number of road traffic
fatalities. At least half are
avoidable. When the B-17 was being flown in a flight competition
in 1935, the air corps’ chief of flight testing crashed the plane and
died. He forgot one switch. The plane was too complicated to be left to
the memory of one person to fly it.
But after checklists were developed and used, the B-17 flew 1.8 million
miles with an accident. (34) In one hospital, researchers found that out of 5
simple steps to avoid infection, doctors skipped at least one step in a third
of the patients. (38) They also “found that simply having the doctors and
nurses in the ICU create their own checklists for what they thought should be
done each day improved the consistency of care to the point that the average length of patient stay in intensive care dropped by half.”
(39) The question when to follow one’s judgment and
when to follow protocol is central to doing the job well. You want to leave room for craft and
judgment and the ability to respond to unexpected difficulties. Checklists are clearly of help for simple
problems. So how do they get it all right when they build
huge buildings with the sixteen different trades and all the sequential steps
and all the machinery? No longer does
one master builder oversee everything.
On the walls are butcher-block-size printouts of check lists with
line-by-line, day-by-day listings of every building task. On another wall are similar lists of difficult
and unexpected problems that must be addressed by the appropriate people. Failure of communication is the biggest
source of serious errors. The U.S. has
only about 20 serious ‘building failures’ per year, or less than 0.00002
percent. (71) Katrina revealed huge blockages in government aid
getting to the right places. “The
trouble wasn’t a lack of sympathy among top officials. It was a lack of understanding that, in the
face of an extraordinarily complex problem, power needed to be pushed out of
the center as far as possible.
Everyone was waiting for the cavalry, but a centrally run,
government-controlled solution was not going to be possible.” (75) Oddly enough Wal-Mart did the best relief
job. The CEO issued a simple edict.
“This company will respond to the level of this disaster. A lot of you are going to have to make
decisions above your level. Make the
best decision that you can with the information that’s available to you at
the time, and above all, do the right thing.”
Wal-Mart got half of their stores reopened within 48 hours and then
shifted to helping the people, distributing diapers, water, baby formula,
ice, etc. and developing all kinds of creative make-shift methods including
crude paper-slip credit systems for first responders. The lesson is that under deep complexity, efforts
to dictate from the center will fail.
People need room to act and adapt.
They need a contradictory mix of freedom and expectation to coordinate
and measure progress toward common goals.
Checklists can help achieve that balance, one set for the stupid but
critical steps, the other to ensure people talk about, coordinate, and accept
responsibility while being given the power to manage the unpredictables. Bad checklists are vague and imprecise, too long,
hard to use, impractical. Good
checklists are precise, efficient, to the point, easy to use. They do not try to spell out everything,
only the most critical and important steps, the ones even highly skilled
professionals might miss. (120) 5 to 9 items in large print on one page is
about right. It has to be tested in
the real world. Very short checklists
are employed at particular pause points.
In 2004, surgeons throughout the world were
performing some 230 million major operations annually, with estimates of
complication rates for hospital surgery from 3 to 17 percent. (87)
The author worked with a team from WHO to develop checklists for
hospitals. One of the items is for the
team to talk to one another, to get acquainted. Simply introducing themselves and
mentioning possible concerns at the beginning of a case seems to help
teamwork. The final WHO safe surgery
checklist spelled out 19 checks in all, 7 before anesthesia, 7 more after
anesthesia but before incision, and 5 final checks before wheeling out the
patient. As an example, here are the first 7:
The WHO checklists were evaluated in 8 hospitals
around the world. The rate of major
complications in all 8 hospitals fell by 36% after introduction of the
checklist. Deaths fell 47%. When they finished, the last question they
asked the staff was, “If you were having an operation, would you want the
checklist to be used?” 93% said
yes. (154-77) “We have an opportunity before us, not just in
medicine but in virtually any endeavor.
Even the most expert among us can gain from searching out the patterns
of mistakes and failures and putting a few checks in place.” (158) “We don’t like checklists. They can be painstaking. They’re not much fun. But I don’t think the issue here is mere
laziness. There’s something deeper,
more visceral going on when people walk away not only from saving lives but
from making money. It somehow feels
beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs
about how the truly great among us—those we aspire to be—handle situations of
high stakes and complexity. The truly
great are daring. They improvise. They do not have protocols and checklists. Maybe our idea of heroism needs updating.”
(173) The final illustration shows how checklists and
teamwork saved US Airways Flight 1549 that went down in the Hudson River with
Captain Sully and his team. “In a world in which success now requires large
enterprises, teams of clinicians, high-risk technologies, and knowledge that
outstrips any one person’s abilities, individual autonomy hardly seems the
idea we should aim for. … What is
needed …is discipline.” (183) “We’re obsessed in medicine with having great
components—the best drugs, the best devices, the best specialists—but pay
little attention to how to make them fit together well.” Optimizing parts is not a good route to
system excellence. “We don’t look for
the patterns of our recurrent mistakes or devise and refine potential
solutions for them. But we could, and
that is the ultimate point.” “When we
look closely, we recognize the same balls being dropped over and over, even
by those of great ability and determination.
We know the patterns. We see
the costs. It’s time to try something
else. Try a checklist.” (184-86)
“To my chagrin, however, [says the author] I have
yet to get through a week in surgery without the checklist’s leading us to
catch something we would have missed.”
(187) |
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