Wednesday, January 6, 2010

The Checklist

I made a New Year's resolution. (I am still in that New Year's resolution mode.) My resolution was to read more books this year. So I started off with “The Places in Between,” by Rory Stewart; followed by “Robert Altman,” a biography of the filmmaker by Mitchell Zuckoff; and then “The Checklist Manifesto,” by Dr. Atul Gawande.  Now, you might ask, how did I read three books in the first six days of the year? Well, I actually cheated, starting during the 2009 holiday season.

The Polymath

The author of "The Checklist Manifesto" is a rather remarkable individual.  He’s a surgeon at Brigham and Women's Hospital in Boston specializing in endocrine cancer. He’s rather prolific contributor to The New Yorker, where he’s a staff writer focusing on medicine and healthcare.  He’s a MacArthur Fellow.  He’s an associate professor at the Harvard School of Public Health.  He leads the World Health Organization’s Safe Surgery Saves Lives program.  He’s published three books.  He’s a frequent television guest. And he’s also the father of three children.  (Where did he find the time?)

Now who would ever want to read a book about checklists? Can you think of a more mundane topic to write about or read about?  A book about a piece of paper? The answer is, I wanted to, and not only did I enjoy it immensely, but I'm willing to bet that you will, too..

Just having finished the book, I was fortunate enough to attend a lecture by Dr. Gawande at Memorial Sloan-Kettering Cancer Center yesterday. And then last night, he appeared on Charlie Rose.

Why Checklists?

The checklist was created to help skilled people deal with complex situations.  It’s not about their ignorance, it’s about their ineptitude.  As he writes in the book, “In a complex environment, experts are up against too many difficulties. The first is the fallibility of human memory and attention, especially when it comes to mundane, routine matters that are easily overlooked under the strain of more pressing events. A further difficulty, just as insidious, is that people can mold themselves into skipping steps even when they remember them.”

Aviation Checklists

The concept of a checklist is probably most associated with aviation. It started being adopted by military and civilian pilots in the 1930s in order to deal with the increasing sophistication of aircraft. 

Some 45 years ago, when I learned to fly a Cessna 150, the checklist looked something like this:

Eight checklist items for takeoff, four for cruise, four for pre-landing, and five for approach. Twenty-one items to make it less likely I land in the Hudson River.  Just for fun, I went online and found Boeing’s checklist for its 777. In principle the big jet’s checklist is the same; just a few more items to check off.

BTW, for the good of society, I retired as a pilot after accumulating a license and 100 hours in the air.  It was not my calling (as the tower at Teterboro kept reminding me when I too often drifted into the Newark traffic pattern).  There was no checklist item to the effect of  “Are you drifting into the Newark pattern”?

Surgical Checklists

In aviation, checklists are mandatory, and over eight decades have been a major contributor to the incredible safety record of commercial aviation. But until recently, checklists haven't been widely adopted in surgery for a variety of reasons, the most likely one being that many surgeons have not been convinced of their value. What surgeon would feel it's necessary to be questioned by a nurse in the operating room before, during and after a procedure with such questions as: "Has the patient confirmed his/her identity, site, procedure, and consent”?  Or, "Is the site marked?" Or to “confirm all team members have introduced themselves by name and role.”

The person who kick-started the surgical checklist was Dr. Peter Pronovost, a Johns Hopkins critical care specialist.  That brainchild has led to a recently completed worldwide study by the World Health Organization. What prompted the interest in checklists by Dr. Pronovost and the WHO?

There are about 234 million inpatient operations performed annually around the world. In the United States it's about 50 million. While surgery is overwhelmingly successful in its role of healing patients, there are always risks of complications and even death. Major complications from surgery range worldwide from 3% to 17%.  That’s a lot of complications – surgical-site infection, unplanned return to operating rooms, pneumonia and death.

The role of the checklist is to make sure that the surgical team -- surgeon, nurses, anesthesiologists, and other operating room personnel -- make absolutely sure that the basic safety items are adhered to. Without the checklist, these items are almost always remembered. But the operative word here is "almost." Forgetting a single list item -- e.g., "has antibiotic prophylaxis been given within the last 60 minutes?" -- can result in infection or worse.  Just as forgetting to set the takeoff trim on an airplane can have dire results.

The WHO Experiment

In 2007, the World Health Organization designed a 19-item checklist intended to be globally applicable and to reduce the rate of major surgical complications. The worldwide test was initiated in eight hospitals. Between October 2007 and September 2008, eight hospitals in eight cities participated: Toronto, New Delhi, Amman, Auckland, London, Seattle, Manila, and Ifakara, (Tanzania). Patients in these eight hospitals represented a variety of economic circumstances and diverse populations.

About 4,000 patients were enrolled in the program. Data were compiled for three months without use of the checklist, and then for the following three months with it. The results are remarkable.

The Astonishing Results – Double-digit Improvements

The rate of complications -- surgical site infection, unplanned return to the operating room, pneumonia, death – fell from 11% to 7.0%, a decline of 36%. The drop in the death rate alone fell from 1.5% to 0.8%, or a decline of 47%. And these improvements were noticeable in hospitals ranging from those with the most crowded conditions (e.g., the Tanzanian hospital with 124 beds per O.R.) to the least stressed (e.g., the University of Washington Medical Center with 17 beds per O.R.).  From those with the most modern equipment and highly skilled staff to those with the least.

Let's apply the outcomes data from the WHO test to the 50 million inpatient surgeries performed in the United States annually. Without use of surgical checklists, 5.5 million patients would encounter surgical complications. With universal use of surgical checklists, the number of complications would fall to 3.5 million patients.

With regard to deaths from surgical complications, the number would decrease from 750,000 per year to 400,000. Now 400,000 deaths is not something to be proud of, but saving 350,000 lives -- from following the procedures on a single sheet of paper -- is impressive.

Small Efforts, Big Payoffs

Consider, now, what we’re talking about, and what Dr. Gawande is proselytizing and writing about. Remarkable improvements in patient outcomes have been effected not from massive federal programs and not from biomedical research breakthroughs. They have resulted from methodically paying attention to the simple things, the very simple things that allow planes to fly safely and allow patients to undergo surgery with fewer complications.

The response to the article published in the January 29, 2009, issue of the New England Journal of Medicine has been encouraging. Many state medical societies have begun recommending the use of surgical checklists, and more and more hospitals are adopting it on their own.  And France has just required its adoption for all 8,000 hospitals in the country.

The book is more than numbers. Dr. Gawande is as talented an author as he is a skillful surgeon.  Those of you who read his New Yorker pieces are well aware of his ability to gracefully describe complex topics.

I Don’t Like It, But Use It on Me

Here’s one anecdote from the book: More than 250 staff numbers -- surgeons, anesthesiologist, nurses and others -- filled out an anonymous survey after three months of using the WHO checklist. In the beginning, most were skeptical. But by the end, 80% reported that the checklist was easy-to-use, did not take a long time to complete, and had improved the safety of care.

Nonetheless, some skepticism persisted. After all, while 80% were favorably disposed, there were 20% who did not find it easy to use, thought it took too long, and felt it had not improved the safety of care.

Then the staff was asked one more question. “If you're having an operation, would you want to checklist to be used?"

93% said yes.

Back From the Dead

Another:  The opening chapter describes the case of a three-year-old Austrian girl who fell into an icy fishpond. After a 30-minute search, rescuers located her and pulled her from the pond bottom to the surface they then raced her to the hospital. Her lungs were filled with water and debris.  Her body temperature on arrival was 66 degrees.  Her brain function had ceased. She was gone. But -- the hospital was prepared.

There had been previous hypothermia victims in the area served by this small Alpine hospital, and all had died in the hospital.  Either the required people weren’t there in time, or the equipment wasn’t available, or the sequence of procedures wasn’t followed.  So the hospital set about to create a checklist to make sure that in the future everyone and everything was in place, and that everyone knew what to do when. By using this homegrown checklist, the girl in the pond was in effect brought back to life.  She is now a completely normal five-year-old girl.

Oh Well, Nobody’s Perfect

My one fault with the book: In his almost unbounded enthusiasm for checklists, Dr. Gawande goes one step too far in suggesting its universality. He illustrates convincingly how effective checklists are in the aviation and construction industries. But not leaving well enough alone, he claims -- based on a single paper by an academic -- that checklists would work well in the venture capital industry as well. Now venture capital is something I know something about (as opposed to surgery). My reaction after 15 years as a VC trying to sort out good ideas from bad, talented entrepreneurs from the ordinary, and great ideas from the mundane -- the checklist won't work here.

Having just written this, all of a sudden I'm worried.  I’m beginning to sound like a skeptical prima donna: "I don't need no stinkin' checklist."


  1. Apparently checklists were critically important in Capt. Sullenberger's Hudson landing last year. A commercial pilot friend of mine tells me that pilots can access checklists electronically on an Airbus, including a rarely used one for water landings. Sullenberger and his co-pilot did this. Checklists are not so easily available on Boeing aircraft and, for this reason, Boeing pilots (including my friend) sometimes look down on Airbus pilots. But he had to admit that if he had tried to find the checklist in Sullenberger's situation, he might have still been looking through the manuals when the plane hit the water.

  2. Now I have to add Dr. Gawande's book to my reading checklist. I also wish we could find a succesful one for making venture investments :)

  3. Jim,

    There's a chapter in the book on the Hudson landing that I think you'd find interesting.

  4. Howard,

    When you find the VC checklist, let me know.

  5. How do you find the right Checklist?

    I guess like in a Hospital, 1000s of things can wrong on a plane. So how does the pilot find the appropriate checklist?

    I tried recently to find a policy in our hospital for "How to arrange an endoscopy out of hours" - still not found it.

    Yet in the Hudson River landing in 3 minutes they found and went through the "both engines failed" and "land on water" Checklists - I guess there was not time to Google it.

    What is the secret in the cockpit to finding the appropriate Checklist?

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