By Atul Gawande, M.D., M.P.H. New York, Metropolitan Books, 2011. Pages: 240. Price: $15.00.
We healthcare providers are not the primary audience for The Checklist Manifesto: How to Get Things Right . Arguably, the concepts discussed are a good fit for the medical profession, but the definition of a manifesto includes the concept of a public declaration of policy and aims. Dr. Gawande's popular nonfiction books about medicine and surgery educate the masses about us and what we do right or wrong, good or bad; this book is no exception.
Wearing his nonfiction book author and New Yorker staff writer hats, Dr. Gawande has produced a work with a premise that has the appeal of apple pie and motherhood. What patient or healthcare provider doesn't want to get things done right in the delivery of health care? In the first chapter, The Problem of Extreme Complexity, Dr. Gawande introduces a challenge that resonates with all healthcare providers. He lays the groundwork for the rationale for checklist use in any complex endeavor, whether banking, building skyscrapers, churning out large numbers of complex gourmet dishes in a restaurant, flying aircraft, or operating on patients. To the chagrin of all healthcare providers, failures have remained an all-too-frequent occurrence despite our healthcare educational system having produced providers with exceptional expertise in all disciplines. According to Dr. Gawande, “the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably.” Medical checklists offer an alternative, nontraditional strategy to overcome the failures of the healthcare system and to reduce the consequent complications and avoidable deaths. Dr. Gawande points out that although checklists augment memory and attention, they cannot replace mastery of a profession or practice experience.
In chapter 2, The Checklist, Dr. Gawande reviews how checklists saved the life of the Boeing Corporation, its B-17 Flying Fortress, and the B-17's future flight crews. The prototype of the B-17 crashed shortly after taking off on its test flight. Crash analysis revealed that a minor error had doomed the flight, and that the airplane was simply too complex for one person to fly. The crew checklist developed for flying the B-17 simplified the preflight check of the B-17, permitting the fleet of B-17s to fly the next 1.8 million miles without an accident. Used in this manner, the checklist acts as a forcing function (an engineering term) that forces necessary behavior. In medical practice, the use of checklists can help make sure that people “get the stupid stuff right,” thereby avoiding the never errors of wrong patient, wrong operation, wrong surgical site.
The building trades have come to the realization that the complexity of building projects, such as the construction of skyscrapers, exceeds the capacity of a master builder to execute without multiple checklists and frequent communication with all involved parties (chapter 4, The End of the Master Builder). As a technogeek, I yearn to see the control room Dr. Gawande describes, the three-dimensional drawings of the plumbing pipes, and the heating/ventilation/air conditioning and electrical systems, and to witness the computer-based coordination of the procurement and timely delivery of voluminous materials necessary for the complex services of the various trades as they erect large structures. As a surgeon, I empathize with the master builder. Dr. Gawande shows us that checklists, together with a team approach rich in communication between the trades, is mandated by the complexity of these projects to get them done right. He has set the stage for application checklists in a medical professional environment rich in communication.
Next, Dr. Gawande takes us on a tour of small things that have made big differences in health care around the world in chapter 5, The First Try. “Surgery has, essentially, four big killers wherever it is done in the world: infection, bleeding, unsafe anesthesia, and what can only be called the unexpected. For the first three, science and experience have given us some straightforward and valuable preventive measures we (healthcare providers) think we consistently follow but don't.” Infection, bleeding, and unsafe anesthesia are situations that provide the opportunity for the checklist to be of value. The use of checklists and purposeful pauses empowers the nonphysicians in the operating room to communicate freely. He explains that pause points, as they are called in aviation, are mandatory times at which the team must stop to run through a set of checks before proceeding. Checklist creation and implementation are daunting tasks for healthcare providers worldwide, and “good checklists … are efficient, to the point, and easy to use even in the most difficult situations. … Good checklists are, above all, practical.”
As we all know, change in medicine does not come easily or quickly, especially when it involves a major cultural change as well, i.e. , a shift in authority from the surgeon centric culture to a spreading-out of the responsibility for critical elements in the patient's care. Dr. Gawande, his colleagues, and the World Health Association initiated their testing and implementation of checklists designed to catch at least the stupid stuff in 2008. By 2009, the word was out regarding the value of checklists.1But the jury is still out on whether the culture of medicine can seize the full opportunity of benefit to patient care afforded by the creation, customization, universal utilization, and collateral communication and staff empowerment benefits of the checklist mentality.
Speaking of forcing functions, the publication of this checklist as a manifesto for the masses will surely put public pressure on all medical professionals to get their act together by genuinely and universally adopting safety checklists. The demands of patients may accelerate favorable change in the safety of health care delivery in less than the one or two decades that it usually takes to incorporate major change into the culture of health care delivery.