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This post introduces a great book, essentially about checklists, that contains a compelling set of ideas for improving the performance of the US healthcare system…

 Contractors, architects and engineers use checklists to guide them through the complex process of building a skyscraper.  When I was in college working as a  laborer on a construction site these lists were referenced from a larger project schedule, or Gantt chart.  Back then (the ’80’s), the architects, engineers and contractors would get together and update the Gantt and its subsidiary checklists as the project progressed, usually through project meetings.  At the conclusion of the meeting the draftsperson would issue an updated set of governing project documents.  This system was designed to keep the job on schedule, avoid catastrophic mistakes and adjust the project plan, in real time, to changing site conditions.  After spending time as a laborer I went on to become a project engineer for Johnson Controls, where I took on the responsibility of developing and managing the checklists for large mechanical installations.  By the time I left the construction business in 1991, Gantts (checklists) were developed on site through a computer and printed out on green and white lined dot matrix paper.  Today, a large construction site contains arrays of computer terminals, simulating everything in accordance with the project plans and shop drawings, searching for conflicts and errors and updating the Gantts on demand.  Yet the printed checklists and in-person project meetings remain, and the buildings go up, finished with structures and electrical and mechanical systems in synch.  

 Consider the task of flying modern day aircraft.  As most of us know, airplanes have extremely powerful computers and back-up systems, and the safety record of commercial air travel is extraordinary.  It turns out that checklists are used extensively in the commercial airline business.  Before pilots, like, for example, First Officer Jeffery Skiles and Captain Chelsey B. Sullenberger (“Sully”), fire up the engines on a commercial flight, like, for example, US Airways Flight 1549, leaving New York’s LaGuardia airport and headed for Charlotte, North Carolina on January 14, 2009, they introduce themselves to one another, run through a standard checklist designed to verify the safety of the plane, and they discuss the weather forecast and other potential issues they may have to deal with during the flight.  In the case of Flight 1549, shortly after take-off the plane flew into a flock of Canadian geese, very big birds, about 10 pounds each, three of which were ingested through the two Airbus A320‘s engines, causing a trip in an engine safety control that cut power to the engines (otherwise the engines would have had a high probability of exploding).  Not surprisingly this event was hardly anticipated, yet on board were checklists for restoring power to the engines and for activating the proper control functions to allow Pilot Scully to manually glide the plane.  It turns out that power could not be restored to the engines in time, but Scully successfully landed the plane in New York’s Hudson River.  While the Pilots found the proper landing site, flight attendants ran through their own checklists for a water landing, coaching the passengers on landing posture, life vest operation and orderly exit from the fuselage.  The result, the pilots and crew of Flight 1549 saved all 155 persons on board, as simulated during training.

Large construction projects and flying commercial aircraft are highly complex functions.  Their interconnectivity and details are simply too immense for one or a group of human beings to handle.  The checklists serve as a reminder of the minimum requirements for safety and success and provide the foundation for the improvisation that is inherently necessary to deal with unexpected difficulty.  We nod our head and think, “of course they use checklists” in these trades.  It must be essential.

 Query:  is the use of checklists SOP in the field of medicine?

 Answer:  No.

 Atul Gawande, MD, along with other proselytizers like Peter Pronovost, MD at John Hopkins, is attempting to inculcate doctors to develop and use checklists in the practice of medicine in the name of sharply reducing medical errors.

 Gawande makes his case in his latest book, The Checklist Manifesto, which is, oddly, quite a page turner, particularly given the perceived straight forwardness of its subject matter.  It (the book) will, I think, evolve into one of the more important books of this new decade with respect to our nation’s pursuit of improved performance of the US healthcare system.

 The examples of the modern-day construction site and Flight 1549 sit among a broad collection of stories (many of medical origin) that  Gawande uses to demonstrate what happens in complex circumstances when checklists are used, or not.  Kudos to Gawande, the book is a wonderful read for the stories alone.  But what struck me, and apparently comedian Jon Stewart, among others, also (see Dr. Gawande’s brief interview with Jon Stewart here, it’s pretty funny), is that doctors seem to require a lot of convincing  to implement team-oriented checklist procedures, even though they are faced with many more true life-and-death emergencies than pilots, who apparently recognized the complexity of their jobs decades ago when the development and implementation of checklists became status quo.

 In fact there is such a politeness to Gawande’s book it’s startling.  You cannot help but note that he seems to be taking great pains to convince us of the premise that checklists can be useful in medicine, when, frankly, I was convinced of the notion before I even started to read the book.  It turns out that I am not the one who needs the convincing, doctors are.

 Last week I had the opportunity to hear Dr. Gawande speak and read from his book at an event in New York City sponsored by a local bookstore, 192books.  During the talk he pointed out that he and his surgical staff developed a checklist and procedure that resulted in reducing the number of surgical deaths by 50%, yet 20% of the doctors that used the checklist stated that they thought it wasn’t easy to use and that they did not think it actually improved safety.  However, when that same group was asked if they would want the checklist implemented if they were the patient, 93 percent said yes.

During the book reading session, a member of the audience jokingly mentioned to Gawande that he had recently survived open heart surgery and the “free” staph infection he obtained after surgery.  In fact, hospital contracted infections are one of the biggest targets of this nascent checklist movement.  Doctors and hospital staff simply do not follow the letter of the law in infection prevention, and its become a very big deal.  So much so that in some cases Medicare will cap hospital compensation for the treatment of a preventable infection. 

Clearly there are many ramifications to what I see as a new movement in medical safety.  For balance, I also point out that there is a lot to developing checklists, and as Sandeep Jauhar points out in his New York Times review of the book, there is an anti-checklist case to be made.  I will turn to these issues, which are not trivial, in future posts.

 I like Gawande and his research, I think he adds a lot of value.  For now, take his latest book, the Checklist Manifesto as one entry point into the ongoing dialogue on how to improve the efficiency of the healthcare system.