We almost always follow a holiday weekend with a book review. This time we actually have reviews on books from 2 patient safety icons: Peter Pronovost’s “Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out” and Atul Gawande’s “The Checklist Manifesto: How to Get Things Right”.
Since the most famous patient safety checklist is the one devised by Peter Pronovost, you would expect his book to be about checklists. But his book is all about culture – the culture of medicine – and his struggle to create change in some of the toughest places to implement change. You’ll love this book. It is full of characters you will readily recognize from your own hospital! You’ll find yourself saying “Hey, that surgeon’s just like Dr. ___!” or “That’s what happened when we tried to implement that here!”.
About a year ago we reviewed John Nance’s book “Why Hospitals Should Fly” (see our June 2, 2009 Patient Safety Tip of the Week “Why Hospitals Should Fly…John Nance Nails It!”). Nance’s basic premise was that, despite all the sound patient safety practices we know about, we have not significantly improved patient safety. And his explanation is that we have failed to change the culture of medicine. How true. Pronovost’s book expands on that concept. He gives anecdote after anecdote of the hierarchical structure of medicine interfering with good patient care.
And Pronovost did change culture. Whether dealing with reducing central line infections, ICU daily goals, handoffs/timeouts/debriefings, etc. he managed to create change. Up against a “we already know how to do that” attitude in his own department, his own hospital (Johns Hopkins), statewide hospital groups in several states, and multiple countries, he almost always got people to come around.
There were a number of key success factors he highlights. Foremost is doing it right. That meant that he had to collect valid data to show that the projects in fact were improving care. That commitment to scientific principle was a key in converting some skeptics. On several occasions, when physicians or other groups claimed they were already doing it well or could do it better, he challenged them to show him their data. When they couldn’t, they usually came around to participating in the collaboratives. The second major success factor was involving and empowering front line people in development of the projects. He often pointed out that the front line people were more likely to get on board than were the “experts”. And a third major success factor was commitment from hospital executives. That was what kept several collaborative projects on target. His ability to get buy-in from executives was helpful not only in the projects but in day-to-day activities. He describes a harrowing experience where he, as the anesthesiologist, correctly suspected a deteriorating patient had a potentially life-threatening latex allergy during surgery. He implored the surgeon in every way possible to change his gloves to non-latex ones and the surgeon refused until Pronovost put out a page to the hospital administration!
Pronovost’s book is a great collection of stories and great example of how to overcome adversity when you’re dealing with something you are committed to.
Atul Gawande’s book really is about checklists. Of course he talks about Peter Pronovost’s checklist for preventing central line infections (remember he did that in his essay “The Checklist” that appeared in The New Yorker). In that essay, he eloquently expounded upon the simplicity and sophistication of Peter Pronovost’s success in introducing the concept of the checklist to improve medical care.
But he goes on to talk about use of checklists in other industries before he describes his collaborative work in the development of the WHO Surgical Safety Checklist (see our July 1, 2008 Patient Safety Tip of the week “”.)
Most striking is his description of a building being constructed in Boston. He takes a tour inside as the building is going up and wonders at the incredible complexity requiring timely coordination of innumerable workers from multiple different companies – a stark contrast to the often piecemeal, uncoordinated care we see in medicine. When he goes to the “command center” of that construction project he is amazed to see that it is really operated upon checklists – one checklist after another after another!
After preliminary development of the WHO checklist, he tries it out himself and it fails miserably. He realizes it is too long, too unclear, too distracting. Shortly thereafter he pays a visit to Daniel Boorman, an expert on aviation checklists at Boeing. There he was introduced to tomes of manuals used in aviation that were really individual checklists. And there were checklists not only for the “normal” things encountered in flying but also ones for a whole host of abnormal conditions and events that might take place. Moreover, for those rare potentially catastrophic events, pilots can practice using the checklists in simulators. But, critically, pilots learn to trust the checklists.
At Boeing he was introduced to READ-DO checklists and DO-CONFIRM checklists. He also learned the characteristics of good and bad checklists. One important point is that there needs to be a natural pause before you would implement a checklist. Secondly, the checklist cannot be long – not more than 7 to 9 items. If checklists are too long, they become distractions to other activities and people start taking shortcuts. Simple wording in the “language of the profession” is important and even the type of font used is important (sans serif fonts work best). Most importantly, you have to test the checklist in real world conditions and expect that most checklists will fail on first draft. And Boorman cautioned not to put on checklists “those things that pilots never fail to do” because they just become distractions.
By the way in our September 23, 2008 Patient Safety Tip of the Week “Checklists and Wrong Site Surgery” we referenced another excellent guidance from the UK Civil Aviation Authority on the proper design, presentation and use of checklists.
Even the issue of who initiates the checklist is important. In aviation, it’s usually begun by the “pilot not flying” so the “pilot flying” would not skip steps in the checklist because of other distractions. So they decided the circulating nurse should call the start of the checklist.
Gawande goes on to describe how the WHO collaborators tweaked the checklists, often compromising and lopping off items that were not absolutely essential in favor of keeping the checklist(s) brief. Getting a good baseline was critical to successful demonstration that the checklist actually improved care. Sampling data at multiple hospitals, they found as many as one third of appendectomy patients failed to get their pre-op antibiotics correctly. When they began to review the results after implementation of the WHO checklist at pilot hospitals in eight countries, Gawande was amazed at the outcomes and kept looking for flaws in the data. But there were none. The striking outcomes were published in the New England Journal of Medicine (See our January 20, 2009 Patient Safety Tip of the Week “”). Mortality at 30-days post-op decreased from 1.5% before introduction of the checklist to 0.8% after. Rate of any complication decreased from 11% to 7%. Both these outcomes were highly statistically significant. That’s a relative risk reduction of approximately 36% for mortality and major morbidity! Of important specific surgery complications, both surgical site infections and unplanned reoperations decreased significantly. Improvements were seen at all participating sites.
But the book is also about culture. He encountered many of the same barriers that Peter Pronovost talked about in his book. He talks about how the checklist may have fostered better teamwork. He cites work done by Brian Sexton in which surgeons rate their impression of teamwork much better than do all other members of the team and how those measures of perception of teamwork improved after implementation of the checklist and pre-op huddles. He cites his own experience as a good example as well. He says that the introduction of all team members by name at first appeared “hokie’ to him, but once team members got to know each other their communication ratings improved considerably.
Having surgical chiefs and other opinion leaders be first to implement the checklist at participating hospitals was helpful. He describes a unique approach to the checklist at Columbus Children’s Hospital. The head of surgical administration there, who was both a pediatric cardiac surgeon and a pilot, developed a “Cleared for Takeoff” theme with a checklist on the whiteboards in each OR room. But he also designed a little “tent” with the cleared for takeoff theme on it and it covered the surgical instrument, forcing the surgeon to do the checklist before using the instruments. Use of these devices eventually got them to 100% performance of the checklist. Though some might call this a forcing function, it is more along the lines of a “nudge” (see our July 7, 2009 Patient Safety Tip of the Week “Nudge: Small Changes, Big Impacts”).
In fact, one of the points of debate is whether the striking improvement is attributable to use of the checklist per se or to the change in “culture” that accompanied use of the checklist. To that debate we say “who cares?”. If merely using a checklist results in such powerful improvement in the culture of safety and promotion of better communication and teamwork, use it!!!
Gawande also talks about a trait of good pilots that is often missing in physicians – discipline. He notes that this often takes a back seat to “autonomy” in medicine. But discipline is one of the things that helps pilots stay focused in even the most dire of emergencies.
Gawande is both a dedicated patient safety guru and master story teller. You’ll enjoy this book.
Pronovost P, Vohr E. Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out. Hudson Street Press 2010
Gawande A. The Checklist Manifesto.
The Checklist Manifesto: How to Get Things Right. Metropolitan Books 2010
Gawande Atul. The Checklist. If something so simple can transform intensive care, what else can it do? The New Yorker. December 10, 2007
Civil Aviation Authority (UK). CAP 676: Guidance on the Design, Presentation and Use
of Emergency and Abnormal Checklists. January 2006.