Checking – 1, 2, 3

January 11, 2010

Atul Gawande is the latest in a line of physicians (general and endocrine surgeon, Professor at Harvard Medical School, Rhodes Scholar, MacArthur Fellow, author, New Yorker columnist – you know, the usual stuff) to whom the nation turns from time to time to make sense of the medical profession. Given the heat and light surrounding the health care issue, however, his contribution to the discussion takes on an entirely different tenor as some of these writings could wind up subjects of a White House briefing.

He’s now trained his sights on a very specific, and uncommon issue: that of the use of checklists during surgical procedures.

The Checklist Manifesto: How to Get Things Right

Seems like an odd thing for a surgeon of international renown to spend his time on: the lowly checklist. But the results speak for themselves. In a controlled trial involving eight hospitals all around the globe (from rural Tanzania, to Amman, Jordan to Seattle, Washington) they observed double-digit reductions in major surgical complications and in deaths. He correctly notes that if there were a pharmaceutical drug or medical device that could produce these results, every newspaper around the world would be blaring the headlines. But, in this case, there’s no big payday – only improved outcomes for patients.

As it happens, Seattle was one of the first stops in the obligatory book tour that ensues, so I got a chance to meet and speak with him. In his talks, he provides some greater context to the work in the book. For example, the impetus for exploring the approach of using checklists during surgery (his study focuses exclusively on surgery) was engendered by the success of checklists in aviation. It may come as a surprise that there are checklists for pilots even in emergency cases like the plane landing on the Hudson last year.

Truth be told, the pioneer of using checklists in medical procedures is Dr. Peter Pronovost of Johns Hopkins. By creating a brief (must take no longer than 90 sec), simple checklist of the most crucial items needed to ensure central line catheters are applied safely, his checklist resulted in Johns Hopkins eliminating (as in reducing to –0-) infections for these procedures. He went on to do a pilot for all the hospitals in Michigan which led to those hospitals becoming the exemplar for patient safety for central line catheterization. But he doesn’t write for the New Yorker. Nor did he take on the massive effort of organizing a controlled study in hospitals all over the globe (that’s massive) and organize the team to produce the results of those efforts.

One additional thing to note about these checklists (in addition to their brevity) is that they need to be very carefully crafted to ensure that only the most critical items that are likely to be missed/overlooked are covered. It’s common to think of a checklist as being exhaustive, detailed and cumbersome. Obviously, that wouldn’t work in this context. Further, as you can’t set foot in the OR unless you know what you’re doing, the checklist is not a READ-DO checklist (like a recipe), but a DO-CONFIRM checklist where you’re pausing before each critical juncture to confirm that everyone is on the same page and has completed all the crucial activities for the safety of the patient and the increased success of the surgery.

One final insight that occurs to me is that this idea could have legs with patients. This is because once this issue becomes common knowledge, it could be one of those things that patients begin demanding of their providers. It’s something any patient can easily grok (Do you have a checklist, or don’t you?) without having to know anything about the intricacies of care.

Here are a couple of media links you might find interesting as well:

Doctor Saved Michigan $100 Million (Pronovost)

Atul Gawande on Charlie Rose