The Checklist Manifesto
by Atul Gawande
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UNTIL a decade or so ago, severe trauma was managed in a fragmented way in Australian hospitals. Ambulances took seriously injured patients to the nearest hospital, which often didn’t have the diagnostic or management capabilities to deal with complex cases. So, in a rare instance of interdisciplinary cooperation, all of the players involved in the care of injured patients worked together to develop checklists. They created a list of criteria for patients who needed to be taken immediately to a large trauma centre. Paramedics were given a checklist to help keep the patient in the best possible shape until they reached the hospital. Emergency department staff used a checklist of conditions to triage patients and activate the trauma team, with up to eight doctors and nurses working together like a formula one crew changing a tyre and refuelling. Each member had a role dictated by a checklist.
Then there were checklists to funnel the patient though the next possible steps: further investigations; more immediate action; a trip straight to an operating theatre; or admission to the intensive care unit. And so checklists drive the patient via a continuum of coordinated care through the hospital and into rehabilitation.
This method of managing severe trauma is a great example of what the American surgeon and New Yorker contributor Atul Gawande advocates in his new book, The Checklist Manifesto. In essence, he argues that medicine can be practised more effectively if doctors and administrators standardise the steps that can be standardised and free up decision-making for the more complex and unpredictable problems. As in his first two books, Complications and Better, Atul Gawande thinks outside the box, in this case using many non-medical examples to show how complex procedures are made easier by checklists.
But as the trauma example shows, the idea of using checklists is not new in health. Indeed, the example Gawande uses of pilots using checklists to make flying one of the safest forms of transport has been used as a healthcare model for many years. What Gawande does is to take the argument a step further and discuss the challenge of how to make sure that checklist systems are not only designed but implemented and maintained. He takes us to the World Health Organization headquarters in Geneva, where whole walls of bookshelves are stocked with policy documents, pamphlets, booklets and “position statements” put together by experts from around the world. This rings bells for all of us working directly in healthcare delivery. Fact finding documents and policies abound on every bookshelf, or nowadays in every computer, but those who deliver healthcare and who are ultimately responsible for implementing the policies rarely find them of much use. Gawande puts a strong case for changing the focus from policy to implementation. He uses examples that all of us could relate to, such as the use of concise and intuitively appealing checklists in routine surgery. Significantly, however, he reports great resistance to their uptake among his colleagues.
But it is the decentralisation of decision-making, which Gawande discusses elsewhere in the book, that I found particularly interesting. Gawande uses the powerful example of the events around Cyclone Katrina to emphasise the importance of devolving responsibility within the healthcare system.
According to Gawande, the head of Walmart in the United States has admitted that neither he nor his board had any idea what was happening on the ground in New Orleans as a result of the cyclone. They empowered their staff on the ground to do what was necessary to help, and staff members worked quickly and creatively within this broad brief. They soon understood the extent of the suffering and threats to life and believed it was within their brief to care for the whole population of New Orleans, where possible, rather than protecting the contents of their stores. The goods in the stores, distributed for free, saved lives and reduced suffering. Meantime, government and other private organisations were paralysed (even to this day) into inaction and delay.
This is a very different subject from checklists and may almost be the opposite type of challenge – so much so that one could make an argument for adding “decentralisation” to “checklists” in the title. Decentralisation in medicine is difficult. The system operates within centuries-old hierarchies, where the doctor “in charge” of the patient has responsibility for total care even if he or she is only there for a fraction of the time. Like many doctors, Atul Gawande is a busy man. He operates on patients, works in an intensive care unit, runs a research centre, travels extensively and writes articles and books. He obviously cannot be at his patient’s bedside 24/7. He must devolve part of the responsibility for the care of his patients to doctors in training and nursing staff. Yet redefining traditional roles and providing appropriate training in order to devolve real authority and responsibility is not common in medicine. Nursing staff record vital signs such as pulse rate and blood pressure but are not empowered to act on them. They call trainee medical staff who may or may not be able to deal with all the possible emergencies that can occur in surgical patients. Increasingly, the surgical procedure is straightforward; it is the multiple medical co-morbidities that a patient comes into hospital with that result in serious complications and deaths. Management of these patients requires a different system, built around the needs of the patient rather than the admitting doctor, structured in ways that we are yet to explore.
Gawande also discusses the decentralisation of responsibility, emphasising that everyone involved in the construction of multi-storey buildings, for example, is individually empowered to draw attention to any potential fault in the building. He discusses how the empowerment of everyone in the system is as important as and, indeed, supersedes other checklists when they fail.
The United States spends more than any country on health, and yet it rates thirty-seventh in the world on WHO criteria. Currently, the US health system records more potentially preventable deaths than almost any other system in the world. Gawande is aiming to overcome major inherent challenges when he discusses ways to integrate checklists and decentralisation into a system centred so fundamentally on the individual doctor–patient relationship. The most obvious reason for its failings is that the US system operates on a for-profit basis. Doctors who are paid per item and per patient are unlikely to devolve too much responsibility, or to refer too much of their potential income to others for further treatment, or to choose not to perform a procedure when it is their income at stake. It is especially difficult to encourage checklists, teamwork and devolution of power and responsibility in such a climate.
As an Australian intensive care specialist I could relate to Gawande’s account of a man who was operated on in a community hospital and developed such serious complications after fairly routine surgery that he was transferred to the author’s hospital. He was then subject to prolonged intensive care and multiple operations. Gawande sees this as a win because, against the odds, the patient left hospital, but he doesn’t discuss the failure of a different kind of checklist to warn the patient against having surgery in smaller hospitals by clinicians who do not perform the procedure often, or do so without proven good results. Nor does he discuss the inevitable outcome after such prolonged support in an intensive care unit – long-term unemployment, sleep disorders, pain, sexual dysfunction, nightmares and perhaps post-traumatic stress syndrome. The man was forced to sell his previously successful business and his home and move in with his sister, presumably to pay his medical bills.
Towards the end of the book Gawande proposes that research into how patients can benefit from health systems reform is just as important as the more conventional research into new drugs and procedures. Recent research has shown that systems designed to respond rapidly to patients who are deteriorating in hospitals can reduce death rates and cardiac arrest rates by up to one third. There are very few new drugs or procedures that have demonstrated such impressive outcomes. As someone who works in an institution conducting such research – the Australian Institute for Health Innovation – I would join with Gawande in urging governments and the research community to invest more in health services research for developing and evaluating new and innovative patient-centred systems.
The US health system is indeed different from most others in the world, but this in fact makes Gawande’s ideas even more exceptional and exciting. He not only challenges the way we deliver healthcare but offers creative and constructive ways to change it. The subject is tackled head-on in a clear and entertaining style. Once again, Atul Gawande examines shortcomings in healthcare, and at the same time, explores practical and easily grasped ways of improving the system. •
Ken Hillman is Professor of Intensive Care and Director of The Simpson Centre for Health Services Research, an affiliate of the Australian Institute for Health Innovation, at the University of New South Wales.