After participating in a three-month study on the difference a checklist could make in preventing complications during surgery, 250 healthcare providers — surgeons, anaesthesiologists, nurses, and others — were polled. In an anonymous survey, 80 per cent said that the 19-point checklist had been easy to use, and that it did not hold up their work, and also had “improved the safety of care”; 78 per cent responded that its use had in fact averted an error. Twenty per cent said the checklist was not easy to use, was time-consuming and had no significant impact on safety of care. But here’s the catch. The staff were now asked, “If you were having an operation, would you want the checklist to be used?” Ninety-three per cent said yes. Do the math.
Those 250 respondents were among the staff of eight hospitals around the world which had signed on to a World Health Organisation study Atul Gawande was associated with, and the results on the safety dividend of checklists during surgery were published in the New England Journal of Medicine in January 2009. Since then, there has been a rapid increase in the number of hospitals and medical teams to have adopted a checklist.
And Gawande, a Boston-based surgeon and staff writer for The New Yorker, is both a rousing narrator of how old-fashioned checklists have become the new thing in cutting-edge medicine and an advocate for its multi-disciplinary use. But as he makes his case — in the competently detailed style of The New Yorker — he also, perhaps inadvertently, shines a light on the uncommunicative nature of super-specialist medicine. To the non-medical person, the surprise is not that checklists are so pervasive and useful in aviation, restaurants, disaster management, architecture, etc. The surprise is how late and resistant hospitals have been in adopting this simple tool.
Example: in 2001, Peter Pronovost, a critical care specialist at Johns Hopkins Hospital, came up with a checklist to reduce central line infections (from catheters placed in a patient’s veins). As Gawande tells it, the list was studiedly basic: “Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorohexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a mask, hat, sterile gown, and gloves, and (5) put a sterile dressing over the insertion site once the line is in.” You’d think there was no checklist in place because all this is obvious, but Pronovost found that in one out of three patients, one of these steps had been skipped. And when he convinced his hospital to institute the checklist, the 10-day line-infection rate dropped from 11 per cent to zero.
As more detailed checklists have been adopted, Gawande explains that they establish a higher standard of baseline performance — and there are two types of checklist, do-confirm (performing procedures and then pausing to tick off the stuff that needed to be done) and read-do (carry out tasks as they are ticked off). But in the super-specialist and hierarchal nature of the modern hospital, they also compel communication, which can be crucial. Drawing lessons from modern architecture and the aviation industry, Gawande underlines the utility of checklists in making sure that decision-making and accountability radiate from the centre (or the superspecialist) in what are complex tasks involving many people and diverse skills. And the issue, he says, for medicine today is managing extreme complexity. That complexity has been handled by dividing tasks among various specialties, and a checklist is a way of coherently re-assembling those pieces to the benefit of patients. They provide, he says, “a kind of cognitive net”.
Call it the M&M principle. The American band Van Halen’s contracts with concert promoters had a clause that a bowl of M&M chocolates be kept backstage, but that there be no brown candy. This provision, which Van Halen reportedly invoked on at least one occasion to cancel a show, was, Gawande finds, drawn from the checklist manifesto. David Lee Roth wrote in his memoir that Van Halen shows involved so much equipment and therefore attention to detail, that the drill for each concert was very complicated. So, they put in that brown M&M embargo into the manual as a test: “When I would walk backstage, if I saw a brown M&M in that bowl, well, we’d line-check the entire production.”