In his new book The Checklist Manifesto, Atul Gawande argues that in our increasingly complex and specialized world checklists can be a powerful tool to improve performance. While at first glance the claim seems far-fetched, Gawande makes his argument by citing examples of highly successful endeavors that rely on checklists in fields as various as aviation, venture capital, and architecture. In his own field, surgery, Gawande and his colleagues created a Safe Surgery Checklist that has been shown to reduce deaths and complications from surgery by more than one-third in various hospitals around the world. My interest in a checklist for preventive health and Gawande’s book is no coincidence. In the Summer of 2007, I had the opportunity and pleasure of working on the Safe Surgery Saves Lives initiative while at the World Health Organization (WHO) in Geneva. In fact it was my experiences from the WHO and from working with another checklist pioneer, Peter Pronovost, that got me thinking about the idea of creating a checklist to improve the delivery of preventive health care (see http://beyondapples.org/checklist ).
Gawande argues that checklists work because they enable us to manage complexity as science and technology advance, we are less and less limited by know-how as we are by our ability to make good on what we know. It’s easy for people to see operating on a massive tumor as complex, but what about preventive health care? What’s so hard about referring a patient for a colonoscopy or following up on a cholesterol blood test? The sad truth is that it can be harder you think. Most primary care practices are inundated with patients. Physicians literally scurry from room to room, examining patients, listening to concerns, filling out paperwork, holding hands, writing prescriptions. Few patients walk into a clinic when they’re healthy. Instead they come with colds and coughs, back pain, and disability papers. By the time a physician addresses what brought the patient into the clinic in the first place, the 15-minute office visit is almost up. In the few remaining minutes at the end of the visit, we try to address preventive health but in a rushed, high stress environment it’s easy to let one or more preventive health services slip through the cracks. Just like Gawande’s surgical checklist creates an opportunity for the OR team to review essential steps in the operation (e.g, verify the patient and procedure, administer antibiotics, discuss potential complications), a preventive health checklist can help doctors and patients make sure they are getting the preventive health care they need.
To even Gawande’s surprise, the Safe Surgery Checklist improved outcomes even in resource limited settings. Gawande describes a hospital in rural Tanzania where poor roads sometimes cut off critical supplies for weeks at a time and where members of the health care team sometimes are compelled to step in and donate their own blood. It is hard to imagine a checklist being effective in such an environment or even a priority. “They don’t need a damn checklist, they need more resources,” is a sentiment I can imagine many people having. People make similar criticisms in preventive health care. Doctors lament that the delivery of preventive health is suboptimal because of “the system.” I agree but only in name. When doctors talk about “the system” they are usually talking about health insurance or reimbursement, what policymakers have to contend with. But to me the more pressing issue and the one we have greater control over is “the system” we have for health care delivery. In prevention, few clinics have built-in reminder systems or prompts for doctors to remember to administer vaccines or screen for cancer. Instead, we rely on our memories and an incomplete, often inaccessible medical record system. “Goodwill and luck,” is what characterizes our current system of health care delivery. The solution that many doctors have for low rates of counseling, screening, and vaccination is to wait for health care reform from Washington. Until we have universal health care, things won’t get better; until I get paid for talking to patients, not just doing procedures, things won’t get better. But deep down we know that’s not true. There are steps we can take to improve “the system.” We don’t have to wait for expensive computerized medical records or for policymakers to finally align reimbursement with patient value. Through checklists, we can improve the preventive care our patients receive with minimal cost.
The most striking observation Gawande makes is that the sum effect of the surgical checklist was greater than its parts. Using the checklist, the surgical staff were more likely to appropriately administer antibiotics and to make sure the necessary equipment was available at the start of a case, but somehow the impact of the checklist in terms of complications prevented and lives saved was greater than each of these individual improvements. Gawande’s explanation is better teamwork. While each item on the checklist was itself life-saving, the process of going through a checklist had an even greater impact because it created a surgical team where one did not exist before. By having members of the team simply introduce themselves (Yes! In many ORs, the people in the room you don’t even know each others’ names!) and working through the checklist together, the checklist created a spirit of shared enterprise that was previously lacking. I have the same goal for my preventive health checklist. Most of us recognize that primary care is a partnership between a doctor and a patient. I can prescribe as many pills as I want and talk about dieting and exercise until I’m blue in the face, but unless my patient takes his or her medicine and follows my advice primary care is ineffective. My hope is that when a patient brings his checklist to the clinic and his doctor reviews it with him, it will help identify prevention as a priority and tie both the doctor and patient into a shared partnership towards preserving health.