Atul Gawande’s “The Checklist”

By  |  December 9, 2007 | 

Let’s make this short and sweet. In this week’s New Yorker, Atul Gawande describes Peter Pronovost’s crusade to improve the safety of intensive care through the use of checklists. If it sounds dull, it’s not. In fact, it is thrilling and inspiring.

Gawande glides effortlessly from microscopic detail to panoramic view and back again to help us understand the complexity of modern medicine, how standardization and decision support are essential to improving safety, and how one person – in this case Pronovost – can take a simple idea and change the world. A brief excerpt:

We have the means to make some of the most complex and dangerous work we do – in surgery, emergency care, and ICU medicine – more effective than we ever thought possible. But the prospect pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity – the right stuff, again. Checklists and standard operating procedures feel like exactly the opposite, and that’s what rankles many people.

It’s ludicrous, though, to suppose that checklists are going to do away with the need for courage, wits, and improvisation. The body is too intricate and individual for that: good medicine will not be able to dispense with expert audacity. Yet it should also be ready to accept the virtues of regimentation.

To those of us in the safety and quality fields, having Gawande profile Pronovost is the equivalent of Norman Mailer writing on Picasso, or David Remnick on Muhammad Ali – one virtuoso writing about another, each at the top of his game.

But enough Cliff Notes. Do your best to find 15 minutes to read the article. It is really terrific.

About the Author:

Robert M. Wachter, MD is Professor and Interim Chairman of the Department of Medicine at the University of California, San Francisco, where he holds the Lynne and Marc Benioff Endowed Chair in Hospital Medicine. He is also Chief of the Division of Hospital Medicine. He has published 250 articles and 6 books in the fields of quality, safety, and health policy. He coined the term hospitalist” in a 1996 New England Journal of Medicine article and is past-president of the Society of Hospital Medicine. He is generally considered the academic leader of the hospitalist movement, the fastest growing specialty in the history of modern medicine. He is also a national leader in the fields of patient safety and healthcare quality. He is editor of AHRQ WebM&M, a case-based patient safety journal on the Web, and AHRQ Patient Safety Network, the leading federal patient safety portal. Together, the sites receive nearly one million unique visits each year. He received one of the 2004 John M. Eisenberg Awards, the nation’s top honor in patient safety and quality. He has been selected as one of the 50 most influential physician-executives in the U.S. by Modern Healthcare magazine for the past eight years, the only academic physician to achieve this distinction; in 2015 he was #1 on the list. He is a former chair of the American Board of Internal Medicine, and has served on the healthcare advisory boards of several companies, including Google. His 2015 book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, was a New York Times science bestseller.

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6 Comments

  1. davisliumd December 10, 2007 at 6:19 am - Reply

    “The Checklist” is a great article for a couple of reasons. The sheer simplicity of a checklist which elevates the level of care shows how much more the health care industry must do to provide the right care at the right time. Instead of focusing on more technology and therapies we must also concentrate on the process of delivering care and the coordination of care among providers.

    What prevents us from achieving these gains is that our culture in medicine views checklists, standards, and guidelines, as dumbing down doctors into cooks and chefs instead of seeing them as assets to help us in a role that continues to extraordinarily more complex. Gawande correctly notes we in medicine should “be ready to accept the virtues of regimentation”. Time will tell if that will ever occur.

  2. andrewmc December 11, 2007 at 8:25 pm - Reply

    I’d just like to say that I think your blog is fantastic.

    I think that checklists can be useful in the development of standard work.

    I work with one organization that changed the way that they procured the materials required to put in a Central Line. Historically the organization would order Lines, Gloves, Sutures and so on and so forth separately and when a line was needed to be inserted a nurse or other professional would have to go around and obtain each of these ensuring that they never forgot to wash their hands, obtain a drape etc.

    A supplier approached them and asked whether they could provide lines as a supplier, the organization said no and the supplier asked what they could do to become an approved supplier.

    The supplier went away and came back with a kit. The kit was all the materials required to put in a line in a sterile drape, it included gloves, sutures, the silver line, blades and a custom made drape with a window that the patient can see out of and a hole for the line to be inserted through.

    The supplier agreed to supply this kit with all the materials (including one pair of gloves of every size) for the same price as their competitors supplier just the line.

    The benefit of this is that the organization only needs to order one material (rather placing multiple orders for gloves, lines etc) and when a line needs to be inserted a staff member only needs to pick up one pack.

    The risk of forgetting a specific piece of kit is simply eliminated, it would be impossible to insert a line without having the right materials in the right place at the right time.

    I think that this when combined with the checklist is an enormous move forwards in the development of standard work.

    I don’t know if lines are provided in this type of kit format in the US but I am happy to provide you with photo’s illustrating them.

    Regards

    Andrew

  3. WRS December 12, 2007 at 1:11 am - Reply

    Wow-Checklists!  Can’t wait for the evidence based folks to weigh in:

    Rapid Response Systems: A systematic review

    Rapid Response Teams: Ready for Prime Time?

  4. Bob Wachter December 12, 2007 at 4:14 am - Reply

    It is so hard to determine tone on the web, but I’m guessing my friend “WRS” is being a bit ironic re: evidence-based medicine and checklists — implying that asking for evidence for safety interventions like checklists (or, by inference, Rapid Response Teams) is unrealistic and would slow down safety efforts. It is a familiar concern.

    But Pronovost’s work is living evidence that EBM and safety can go hand in hand, which is part of what makes it so impressive. Peter certainly “believed” that checklists were a good idea, but he did “small tests of change” at Hopkins, honing the intervention, following them with a rigorous NEJM study at more than 100 hospitals in Michigan that proved that the hypothesis was, in fact true.

    http://content.nejm.org/cgi/content/short/355/26/2725

    He has done similar work proving the value of goal cards in the ICU:

    Improving communication in the ICU using daily goals.

    Pronovost’s work demonstrates that patient safety interventions — yes, even checklists — can be studied using strong scientific methods.

  5. Barbara K. December 12, 2007 at 8:46 pm - Reply

    Hi Bob,

    This may not meet your commenting criteria, but it’s one of the artifacts of the health blogosphere. I am tagging you with the “meme challenge.” Have a look here to find out what this entails:

    http://insicknessinhealth.blogspot.com/2007/12/ive-been-tagged.html

    It’s actually an interesting way to get to know fellow bloggers.

  6. Chris W. December 30, 2007 at 10:39 pm - Reply

    Readers of this post should be aware of a recent obtuse and dispiriting decision by the HHS affecting the continuation of the Michigan study. It is explained and discussed (critically) by Atul Gawande in his New York Times op-ed, published online today.

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