Book Review: The Checklist Manifesto
Saturday, August 21st, 2010I recently read the book The Checklist Manifesto by Atul Gawande – a respected surgeon, noted author, MacArthur fellow, New Yorker staff writer, and a professor at Harvard Medical School.
The premise of the entire book is the author’s dive into the concept of a checklist and how they have dramatically improved the efficiency and reliability of professionals in the medical profession, the aeronautical industry, the architecture industry and even the venture capital industry.
So what is a checklist? It is the minimum set of critical steps for any task to be achieved.
Why are they useful? Because checklists protect against many kinds of dangers. For example:
- “Faulty memory and distraction are a particular danger in what engineers call all-or-none processes – if you miss just one key thing, you might as well not have made the effort at all (whether it is buying ingredients for a cake or preparing an airplane for takeoff).”
- “People can lull themselves into skipping steps even when they remember them. Especially in busy and stressed workplaces (such as hospitals). In complex processes, certain steps don’t always matter, may be it affects only 1 out of 50 times. But when it does, it can be catastrophic.”
One of my favorite passages in the book is as follows (it’s a longer excerpt than I would have liked, but all the parts were really important, so please read the whole passage to understand what’s going on):
Checklists remind us of the minimum necessary steps and make them explicit. They not only offer the possibility of verification but also instill a kind of discipline of higher performance. Which is precisely what happened with vital signs – thought it was not doctors who deserved the credit.
The routine recording of the four vital signs did not become the norm in Western hospitals until the 1960s, when nurses embraced the idea. They designed their patient charts and forms to include the signs, especially creating a checklist for themselves.
With all the things nurses had to do for their patients over the course of a day or night – dispense their medications, dress their wounds, troubleshoot problems – the “vitals chart” provided a way of ensuring that every six hours, or more often when nurses judged necessary, they didn’t forget to check their patient’s pulse, blood pressure, temperature and respiration and assess exactly how the patient was doing.
In most hospitals, nurses have since added a fifth vital sign: pain, as rated by patients on a scale of one to ten. And nurses have developed yet further such bedside innovations – for example, medication timing charts and brief written care plans for every patient. No one calls these checklists but, really, that’s what they are. They have been welcomed by nursing but haven’t quite carried over into doctoring.
Charts and checlists, that’s nursing stuff — boring stuff. They are nothing that we doctors, withour extra years of training and specialization, would ever need or use.
In 2001, though, a critical care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give a doctor checklist a try. He didn’t attempt to make the checklist encompass everything ICU teams might need to do in a day. He designed it to tackle just one of their hundreds of potential tasks, the one that nearly killed Anthony DeFilippo: central line infections.
On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting in a central line. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine 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. Check, check, check, check, check. 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. Still, Pronovost asked the nurses in his ICU to observe the doctors for a month as they put lines into patients and record how often they carried out each step. In more than a third of patients, they skipped at least one.
The next month, he and his team persuaded the Johns Hopkins Hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask the doctors each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. Nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder (“Um, did you forget to put on your mask, doctor?”) to more forceful methods (I’ve had a nurse bodycheck me when she thought I hadn’t put enough drapes on a patient). But many nurses aren’t sure whether this is their place or whether a given measure is worth a confrontation. (Does it really matter whether a patient’s legs are draped for a line going into the chest?”) The new rule made it clear: if doctors didn’t follow every step, the nurses would have backup from the administration to intervene.
For a year afterward, Pronovost and his colleagues monitored what happened. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from 11 percent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths and saved two million dollars in costs.
If that, my friends, does not explain the power of a simple checklist, I don’t know what can.
And yet, despite these results, people were reluctant to adopt checklists. In fact, I know you are dismissing the idea right now. Try writing down 5 reasons why checklists are stupid and won’t work for you. Now write 5 reasons why it will work. Think over it. I bet most people find the 5 reasons against checklists, easier to write, but will be convinced about it after writing the 5 reasons for it.
