Continuing medical education providers have long known the value of checklists as follow-up reminders to implement what has been learned in their CME activities. Now Atul Gawande, author of numerous articles in The New Yorker magazine and of the books Complications and Better, makes a powerful case that the humble checklist should be elevated to a new level of importance in healthcare in his new book, The Checklist Manifesto.
Gawande, who is a general and endocrine surgeon at the Brigham and Women’s Hospital in Boston and an associate professor at Harvard Medical School and the Harvard School of Public Health, begins with the premise that it’s not so much a lack of knowledge that causes most medical errors, but an inability to reliably follow through on every step of an exceedingly complex activity such as surgery.
Gawande tells of the amazing success Peter Pronovost, a critical-care specialist at Johns Hopkins, had in reducing infections in patients with central intravenous lines by introducing a checklist of five things that need to be done to avoid infection. These were simple things like washing hands and cleaning the patient’s skin with chlorhexidine antiseptic. “These steps are no-brainers; they have been known and taught for years. So it seemed silly to make a checklist for something so obvious,” Gawande writes. But Provonost made the checklist anyway, and he put the ICU nurses in charge of making sure each item was performed and checked off. Central line infection rates dropped from 11 percent to zero within a year.
Gawande decided to institute a checklist of his own as part of his work with the World Health Organization. He consulted with experts in everything from construction to aviation in order to understand how to design a truly useful surgical-care checklist (There’s much more to it than you would think.) that his team could institute in eight hospitals worldwide, from Tanzania to Seattle. There were many challenges involved in getting hospitals to participate in the project, which began in 2008, but use of the surgical checklist produced striking results. Within six months, major postsurgical complications dropped by an average of 36 percent at participating hospitals. Deaths decreased by 47 percent.
While many of the improvements in care can come from, as he says, “getting the stupid stuff right,” he also makes a point about another area CME has been focusing on of late: team-based care. Part of his pre-surgical checklist was a brief conversation that began with medical team members introducing themselves and their roles in the procedure to the rest of the team, along with a quick rundown of exactly how the surgery would proceed and contingency plans on what to do if something went wrong. This not only helps catch potential mistakes, but also solidifies the team so it can work seamlessly, especially if a problem develops, he writes.
Is the checklist the answer to maintaining competence in an increasingly complex world? When it comes to improving healthcare and reducing medical errors, Gawande makes a pretty convincing case that it is at least one element that should not be ignored.