Make a Checklist and Check It Twice
Late in 2007, Atul Gawande made a stir with his New Yorker article, The Checklist.
Maybe it would be more accurate to say that Dr. Peter Pronovost, the subject of the article, has made a stir in the world of intensive-care medicine with his work introducing systematic checklists to monitor ICU procedures.
The concept is simple: For many medical procedures, the bulk of problems can be avoided and the bulk of benefits gained by hewing closely to best practices that are well-known within the medical profession. In many cases, these practices arent complicated; they include things like making sure that all doctors and nurses wash their hands thoroughly right before a procedure, or covering a patients entire body with antiseptic drapes when inserting a stent.
Simple as these individual steps may be, remembering them all is tough to do amid the hurly-burly of an emergency room or an ICU. So Pronovost, an M.D./Ph.D. with lots of smarts and lots of energy, has worked on setting up procedures for using checklists that take care of the remembering for you. A nurse is responsible for ensuring that medical staff adhere to every step of the checklist in every case.
As Gawande tells it, the results have been little short of astounding. Heres a sampler:
Pronovost and his colleagues monitored what happened for a year afterward. The results were so dramatic that they werent 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 patients 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 patients bed was propped up at least thirty degrees so that oral secretions couldnt go into the windpipe, and antacid medication was given to prevent stomach ulcers. The proportion of patients who didnt 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.
What this brings to my mind is the importance of crucial basics. Ill come back to this below and in many other posts to come, no doubt but for now Ill say this: Theres a reason so many smart coaches of youth sports drill their players over and over and over on crucial basics. How to dribble. How to shoot. How to position your feet or your hands or whatever it is.
When you get the knowable details right, over and over, it frees you up to be creative and concentrate on the oddities, the quirks, the outliers. And I firmly believe that most of us would be much better off if we embraced a boring, master-the-basics approach to our working lives.
Of course, carrying out such a transition can be tough. As Gawande points out, it often takes some organizational muscle to accomplish:
The [Michigan hospital] executives were reluctant. They normally lived in meetings worrying about strategy and budgets. They werent used to venturing into patient territory and didnt feel that they belonged there. In some places, they encountered hostility. But their involvement proved crucial. In the first month, according to Christine Goeschel, at the time the Keystone Initiatives director, the executives discovered that the chlorhexidine soap, shown to reduce line infections, was available in fewer than a third of the I.C.U.s. This was a problem only an executive could solve. Within weeks, every I.C.U. in Michigan had a supply of the soap. Teams also complained to the hospital officials that the checklist required that patients be fully covered with a sterile drape when lines were being put in, but full-size barrier drapes were often unavailable. So the officials made sure that the drapes were stocked. Then they persuaded Arrow International, one of the largest manufacturers of central lines, to produce a new central-line kit that had both the drape and chlorhexidine in it. 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 Michigans I.C.U.s decreased by sixty-six per cent. The typical I.C.U.including the ones at Sinai-Grace Hospitalcut its quarterly infection rate to zero. Michigans infection rates fell so low that its average I.C.U. outperformed ninety per cent of I.C.U.s nationwide. In the Keystone Initiatives 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 yearsall because of a stupid little checklist. [Emphasis added and well worth adding.]
As Gawande makes clear, the hospitals in question already had good, experienced doctors and nurses in them, along with all the usual challenges that face the average public hospital.
Think, for a minute, about what this sort of focus on crucial basics could do for your own work, your own company, your own industry. You might be in an average company. You might be in an industry as tough or as ordinary as Michigans public hospitals. But you might still reap disproportionate rewards by figuring out what the crucial basics are, and then making super-duper-sure that those crucial basics are carried out.
Will Pronovosts innovations sweep through all American hospitals? The signs are mixed at best. Heres Gawande again:
Pronovost remains, in a way, an odd bird in medical research. He does not have the multimillion-dollar grants that his colleagues in bench science have. He has no swarm of doctoral students and lab animals. Hes focussed on work that is not normally considered a significant contribution in academic medicine. As a result, few other researchers are venturing to extend his achievements. Yet his work has already saved more lives than that of any laboratory scientist in the past decade. I called Pronovost recently at Johns Hopkins, where he was on duty in an I.C.U. I asked him how long it would be before the average doctor or nurse is as apt to have a checklist in hand as a stethoscope (which, unlike checklists, has never been proved to make a difference to patient care). At the current rate, it will never happen, he said, as monitors beeped in the background. The fundamental problem with the quality of American medicine is that weve failed to view delivery of health care as a science. The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia. Its viewed as the art of medicine. Thats a mistake, a huge mistake. And from a taxpayers perspective its outrageous. We have a thirty-billion-dollar-a-year National Institutes of Health, he pointed out, which has been a remarkable powerhouse of discovery. But we have no billion-dollar National Institute of Health Care Delivery studying how best to incorporate those discoveries into daily practice. 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, mostly for the technical work of signing up hospitals to participate state by state and coördinating a database to track the results. Hes already devised a plan to do it in all of Spain for less. We could get I.C.U. checklists in use throughout the United States within two years, if the country wanted it, he said. So far, it seems, we dont. The United States could have been the first to adopt medical checklists nationwide, but, instead, Spain will beat us. I at least hope were not the last, Pronovost said.
(Even worse than this cultural resistance: Pronovosts techniques might get swallowed up by the federal medical-research bureaucracy. For more details see here and here.)
Dr. Bob Wachter, one of the leading hospitalists in the world praised the work of both Gawande and Pronovost with this comment:
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.
I encourage you to read Gawandes article and ruminate on how dogged attention to crucial basics might help your career and your organization.
