“So what do we do?” Gawnade asks. “Our usual approach? More technology? Or train people longer and longer?
“So we decided to try something new,” he explains, “which was a checklist” –much like the check-lists that pilots and co-pilots use. The checklist is used before surgery begins. It is designed make sure that everyone in the OR is on the same page, and most importantly, understands that they are part of a team. “We worked with Boeing to learn how they made checklists for cockpits,” says Gaande. “We made a two-minute checklist for operating rooms. And when we implemented it in eight hospitals, ranging from rural Tanzania to Seattle and London, the average reduction in deaths was 46 percent.”
The study began in the spring of 2008, and the results were mind-boggling. Without adding a single piece of equipment or spending an extra dollar, all eight hospitals saw the rate of major post-surgical complications drop by 36 percent in the six months after the checklist was introduced; deaths fell by 47 percent. “In every site, introduction of the checklist had been accompanied by a substantial reduction in errors.”
Too Much Airplane for One Man to Fly
I first wrote about Gawande's “Checklist” in 2007, the year that I began this blog. At the time, he had just published an article in the New Yorker, describing why and when the pilot’s checklist was invented.
Gawande takes us back to “October 30, 1935, at Wright Air Field in Dayton, Ohio. “ There, “the U.S. Army Air Corps held a flight competition for airplane manufacturers vying to build its next-generation long-range bomber. Everyone thought they knew who would win. Boeing’s “gleaming aluminum-alloy Model 299” was the clear favorite. “It could fly faster than previous bombers and almost twice as far. A small crowd of Army brass and manufacturing executives watched as the Model 299 . . . roared down the tarmac, lifted off smoothly, and climbed sharply to three hundred feet. Then it stalled, turned on one wing and crashed in a fiery explosion. Two of the five crew members died, including the pilot, Major Ployer P. Hill,” the U.S. Army Air Corp’ chief of flight testing.”
The cause of the crash? Pilot error. “Substantially more complex than previous aircraft, the new plane required the pilot to attend to the four engines, a retractable landing gear, new wing flaps, electric trim tabs . . . and constant-speed propellers whose pitch had to be regulated with hydraulic controls . . .While doing all this, Hill had forgotten to release a new locking mechanism on the elevator and rudder controls. The Boeing model was deemed as one newspaper put it, ‘too much airplane for one man to fly.’”
Perhaps the pilot should have had more training. “But it was hard to imagine having more experience and expertise than Major Hill,” Gawande observes. “Instead, they came up with an ingeniously simple approach: they created a pilot’s checklist, with step-by-step checking for takeoff, flight, landing and taxing.”
With that checklist, “pilots would go on to fly the Model 299 a total of 1.8 million miles without one accident,” Gawande writes. “The army ultimately ordered almost thirteen thousand of the aircraft, which is dubbed the B-17.”
“Medicine has entered its B-17 phase,” Gawande declared in that New Yorker article published the end of 2007. “Substantial parts of what hospitals do . . . are now too complex for clinicians to carry them out reliably from memory alone.” Hi-tech medicine “has become too much medicine for one person to fly.”
The Complexity of Modern Medicine
In his Manifesto, Gawande expands on that idea: “Medicine has become the art of managing extreme complexity –and a test of whether such complexity can, in fact, be humanly mastered.”
The problem is not that we don’t know enough—though that of course is also an obstacle—but that we know too much. What some have called an “information bomb” threatens the 21st century.
Gawande asks the reader to consider heart attacks. At one time, there was little that doctors could do. Now, they have a smorgasbord of effective therapies to choose from: clot-busting drugs, cardiac catheters, open heart surgical techniques. Meanwhile, “in some cases, we have learned that all we really have to do is to send you to bed with some oxygen, an aspirin, a statin, and blood pressure medication."
Faced with an array of possibilities, making the right choice can be difficult, Gawande notes, even for “expert clinicians. . . whatever the chosen treatment each involves abundant complexities and pitfalls. Careful studies have shown for example, that if a patient is going to undergo cardiac balloon therapy it should happen within 90 minutes of his arrival at the hospital. After that survival falls off sharply.”
Pulling this off is not so easy. Every patient who arrives in the ER complaining of chest pain must be tested; doctors must make a correct diagnosis and set up a plan; they must discuss the plan with the patient; obtain agreement; confirm that there are no allergies or medical problems that they should worry about; line up a cath lab and team; and transport the patient—all within 90 minutes.
How likely is it that all of this will happen in the in average hospital in the U.S.? In 2006, Gawande reports, the odds were 50/50.
This is not unusual. “Studies show that at least 30 percent of patients with stroke receive incomplete or inappropriate care from their doctors,” Gawande notes, “as do 60 percent of patients with pneumonia. Getting the steps right is proving brutally hard—even if you know them.”
This is where we stand at the beginning of the 21st century: “We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled and hard-working people in our society.” And yet, avoidable errors are “common and persistent.” The reason, he argues is that “the volume and complexity of what we know has exceeded our ability to deliver its benefits safely, correctly, or reliably.”
He proposes a partial answer to our dilemma: "Man is fallible, but maybe men are less so.”
Two years after Gawande wrote his original “Checklist” piece for the New Yorker, less than 20 percent of U.S. hospitals use the surgical checklist that we know can reduce complications following surgery by roughly one-third.
This simple, inexpensive tool has run into what Gawande terms “cultural resistance.” Meanwhile, other health care systems have embraced the idea. Not long ago, France went live in all 8,000 of their operating rooms, with surgeons using the checklist to reduce harm in care.
Many American physicians believe that they don’t need a checklist. It can seem demeaning to call out the obvious things that everyone knows that they are supposed to do.
Reforming the System From Within
In part two of this post, I’ll talk about how checklists can save, not only lives, but billions in health care dollars if they are used, not only before surgery, but in ICUs, in ERs, and when patients being discharged.
Many complain that health care reform legislation does not contain adequate cost controls. But the truth is, as White House Budget director Peter Orszag noted not long ago, not all of the important reforms have to be in the legislation.
I’ll explain why what Gawande calls “good checklists” can’t be legislated. And I’ll discuss his Checklist Manifesto as a powerful example of how health care professionals can begin to reform healthcare from inside the system.
For the time being, Congress has done all it can or will do. I continue to look for amendments. And I believe that Medicare can set an example.
But it’s time to launch a reform movement on the ground—a movement, like the civil rights movement, that moves minds, challenging the conventional wisdom about what is and isn’t possible.
“Inside agitators” are needed to spearhead this movement: doctors, nurses, residents, hospital administrators and public health experts–professionals who are willing to stand up and insist that we move from theories about health care reform to action.
They can begin asking why their hospitals aren’t using checklists. (Hospital legal departments might also raise this question.) They can call for infection control programs that integrate what doctors in Norway—and in Billings, Montana—have learned. They can institute programs that change procedures for discharging patients like the program that the Society of Hospitalists has launched.. (The program rolls out this spring; I’ll be talking more about it in the future.)
Doctors in private practice can be part of the movement. One HealthBeat reader wrote in to say that he was going to Xerox the AP article about infection control in Norway and hand it to ever patient who complained when he wouldn’t prescribe antibiotics. This is just one example of how individual physicians can begin educating patients. There is no need to wait for 2014.
When people don’t change, they risk becoming caricatures of themselves. Remember McAllen, Texas, the town Gawande wrote about in the June 1 New Yorker? http://www.healthbeatblog.com/2009/05/dr-atul-gawande-on-the-fight-for-the-soul-of-american-medicine.html
In McAllen, Gawande explained, a “culture of money” had set health care priorities. While health care providers racked up profits, patients were exposed to procedures that they just didn’t need. After the article appeared in the New Yorker, physicians from McAllen decided to visit communities where doctors have figured out how to deliver better care for less.
Grand Junction, Colorado was on their itinerary. Gawande likes to tell the story: when they arrived “one of the folks in Grand Junction, Colorado called me up to say, ‘You wouldn’t believe it, but these doctors arrived in a private jet.’”