My son referred me to this December 2007 article by Atul Gawande, an American doctor and journalist, in the New Yorker magasine. The article is entitled, ‘The Checklist‘ with a sub heading, ‘If something so simple can transform intensive care, what else can it do?’
This simple tool, the checklist, is introduced early on our Lean Six Sigma and Continuous Process Improvement training courses. This simple tool is no new, ground-breaking, expensive medical treatment but this article shows how powerful a tool it can be.
Gawande’s article is well-worth reading but I have to warn you that it’s long. Here are extracts:
A decade ago, Israeli scientists published a study in which engineers observed patient care in I.C.U.s for twenty-four-hour stretches. They found that the average patient required a hundred and seventy-eight individual actions per day, ranging from administering a drug to suctioning the lungs, and every one of them posed risks. Remarkably, the nurses and doctors were observed to make an error in just one per cent of these actions—but that still amounted to an average of two errors a day with every patient. Intensive care succeeds only when we hold the odds of doing harm low enough for the odds of doing good to prevail. This is hard.
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This is the reality of intensive care: at any point, we are as apt to harm as we are to heal. Line infections are so common that they are considered a routine complication. I.C.U.s put five million lines into patients each year, and national statistics show that, after ten days, four per cent of those lines become infected. Line infections occur in eighty thousand people a year in the United States, and are fatal between five and twenty-eight per cent of the time, depending on how sick one is at the start. Those who survive line infections spend on average a week longer in intensive care. And this is just one of many risks.
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In 2001, though, a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give it (checklists as used in flying) a try. He didn’t attempt to make the checklist cover everything; he designed it to tackle just one problem, … line infections. On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting a line in. 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 sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter 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 just for them. Still, Pronovost asked the nurses in his I.C.U. to observe the doctors for a month as they put lines into patients, and record how often they completed each step. In more than a third of patients, they skipped at least one.
The next month, he and his team persuaded the hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask them each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary … The new rule made it clear: if doctors didn’t follow every step on the checklist, the nurses would have backup from the administration to intervene.
Pronovost and his colleagues monitored what happened for a year afterward. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from eleven per cent 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.
Pronovost recruited some more colleagues, and they made some more checklists. One aimed to insure that nurses observe patients for pain at least once every four hours and provide timely pain medication. This reduced the likelihood of a patient’s experiencing untreated pain from forty-one per cent to three per cent. They tested a checklist for patients on mechanical ventilation, making sure that, for instance, the head of each patient’s bed was propped up at least thirty degrees so that oral secretions couldn’t go into the windpipe, and antacid medication was given to prevent stomach ulcers. The proportion of patients who didn’t receive the recommended care dropped from seventy per cent to four per cent; the occurrence of pneumonias fell by a quarter; and twenty-one fewer patients died than in the previous year. The researchers found that simply having the doctors and nurses in the I.C.U. make their own checklists for what they thought should be done each day improved the consistency of care to the point that, within a few weeks, the average length of patient stay in intensive care dropped by half.
The checklists provided two main benefits, Pronovost observed. First, they helped with memory recall, especially with mundane matters that are easily overlooked in patients undergoing more drastic events … A second effect was to make explicit the minimum, expected steps in complex processes.
Gawande stated that Pronovost is hardly the first person in medicine to use a checklist, but that he was among the first to recognize its power to save lives and take advantage of the breadth of its possibilities.
Gawande then described how Pronovost then took his findings on the road, showing his checklists to doctors, nurses, insurers, employers—anyone who would listen. He spoke in an average of seven cities a month while continuing to work full time in Johns Hopkins’s Hospital. But this time he found few takers.
There were various reasons. Some physicians were offended by the suggestion that they needed checklists. Others had legitimate doubts about Pronovost’s evidence. So far, he’d shown only that checklists worked in one hospital, Johns Hopkins, where the I.C.U.s have money, plenty of staff, and Peter Pronovost walking the hallways to make sure that the checklists are being used properly. How about in the real world—where I.C.U. nurses and doctors are in short supply, pressed for time, overwhelmed with patients, and hardly receptive to the idea of filling out yet another piece of paper?
Michigan Health and Hospital Association went ahead adopted Pronovost’s ideas in 2003. The project became known as the Keystone Initiative.
In December, 2006, the Keystone Initiative published its findings in a landmark article in The New England Journal of Medicine. Within the first three months of the project, the infection rate in Michigan’s I.C.U.s decreased by sixty-six per cent. The typical I.C.U. … cut its quarterly infection rate to zero. Michigan’s infection rates fell so low that its average I.C.U. outperformed ninety per cent of I.C.U.s nationwide. In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated hundred and seventy-five million dollars in costs and more than fifteen hundred lives. The successes have been sustained for almost four years—all because of a stupid little checklist.
Gawande stated that Pronovost has since had requests to help Rhode Island, New Jersey, and Spain do what Michigan did.
Gawande suggests we consider: there are hundreds, perhaps thousands, of things doctors do that are at least as dangerous and prone to human failure as putting central lines into I.C.U. patients. It’s true of cardiac care, stroke treatment, H.I.V. treatment, and surgery of all kinds. It’s also true of diagnosis, whether one is trying to identify cancer or infection or a heart attack. All have steps that are worth putting on a checklist and testing in routine care. The question—still unanswered—is whether medical culture will embrace the opportunity.
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I (Gawande) called Pronovost recently at Johns Hopkins … I asked him how much it would cost for him to do for the whole country what he did for Michigan. About two million dollars, he said, maybe three …
This is the end of my extracts from the article. In my opinion two million, maybe three for a country the size of the USA seems like petty cash when one observes the results being achieved and in the context of the overall cost of US healthcare.
Can you imagine if we achieved these results here in Ireland!
I highly recommend that you read the full article, (link at top of the post).
More here on Gawande. Gawande’s book; ‘The Checklist Manifesto: How to Get Things Right’, was released in 2009. This book reached the New York Times Hardcover nonfiction bestseller list this year.
Any comments on use of checklists?
