Advances in Medicine: The Checklist
OM Blog 6: January 5, 2010
By Ken Boyer, Fisher College of Business, Ohio State University and Rohit Verma, Cornell University
Authors: Operations and Supply Chain Management for the 21st Century, 2009, Southwestern Cengage Publishing
Magnetic Resonance Imaging (MRI), Image-guided Radiofrequency Ablation (RFA), Computed Tomography Angiography (CT) and Checklists. In this list of the “latest and greatest” in medical treatments, which one would seem not to belong? Checklists? Really? In 2009 with all the DNA mapping, computer assisted and imaging technologies that have contributed to improved medicine (and often substantially increased costs), simple checklists are being proffered as a critical tool for improving medical care and outcomes.
In a new book released in mid-December (The Checklist Manifesto: How to Get Things Right, Metropolitan Books, 2009), Dr. Atul Gawande, explores the nature of complexity in our lives and in medicine in particular. Gawande, bestselling author of Better and Complications, MacArthur Fellow, general and endocrine surgeon at Boston’s Brigham and Women’s Hospital and an associate professor at the Harvard Medical School offers his observations, experiences and research on the use of checklists. His central argument: medicine has advanced to a point where there is tremendous know how an ability to effectively treat many medical conditions, yet there are over 150,000 deaths from surgery every year – at least half of which are attributable to preventable error. Why so many errors? Because medicine is complicated and with many complex pressures it is common for doctors, nurses or other medical professionals to either forget a step or perform a critical step out of order. A powerful illustration of this can be drawn from Gawande’s writing:
Central Line Infections:
In 2001, Dr. Peter Pronovost, a critical care specialist at Johns Hopkins Hospital decided to tackle the challenge of reducing (preventing) infections when patients received a central line. He wrote the following steps on a piece of paper:
- Wash hands with soap
- Clean patient’s skin with Chlorhexidene Antiseptic
- Place sterile drapes over the entire patient
- Wear a mask, hat, sterile gown and gloves
- Put a sterile dressing over the insertion site once the line is in.
As Gawande writes, “These steps are no brainers: they have been known and taught for years”. And yet, when Pronovost recruited nurses in the ICU to observe doctors for one month, he found that in more than one third of the patients, AT LEAST ONE STEP WAS SKIPPED!
Dr. Patchen “Patch” Dellinger reads off of a checklist for surgery at the University of Washington Medical Center
The next step involved Pronovost and his team persuading administrators at Johns Hopkins to authorize nurses to stop nurses if they saw doctors skipping a step. Nurses were also encouraged to ask doctors each day whether any lines should be removed – thus not leaving them in any longer than necessary. Now, Gawande being a surgeon has better authority regarding medical practices than any non-medical professional has, but essentially he writes that nurses have always had ways of nudging physicians and reminding them to perform critical steps. Yet, this approach was revolutionary – encouraging nurses to intervene and “checklist” the doctors. The results were amazing – the ten day infection rate dropped from 11 percent to zero. Pronovost and colleagues calculated that in just one hospital, the new checklist had prevented forty-three infections and eight (8) deaths and saved $2 million in costs.
I will not reveal more of Gawande’s writing here – I highly encourage you to buy or borrow a copy of the book and read it yourself. The point is – technology does not have to be complicated to be effective. Operations management professionals in a variety of service and manufacturing industries have been employing checklists for years. Other basic, yet effective tools covered in most textbooks include:
- Pareto Analysis
- Bar charts
- Histograms
- Scatter Diagrams
- Run charts
- The Five S: sort, straighten, shine, standardize, sustain
- Poka-yoke
While people often fall for the fancy and impressive technologies and medical treatments, often getting the simple stuff right can be more important. So, think of ways that you use checklists in your daily life – both for personal use and for business use. Maybe you should have one for your doctor the next time you see him or her?
Discussion Questions:
Sources:
Dr. Atul Gawande, The Checklist Manifesto: How to Get Things Right, Metropolitan Books, 2009)
Pronovost, P.J., et al., 2003, “Improving Communication in the ICU Using Daily Goals” Journal of Critical Care, V. 18, pp. 71-75.
“UW Medical Center Using Surgical Checklist to Improve Safety”, Carol M. Ostrom, Seattle Times, June 26, 2008
