The Checklist Manifesto - A ReviewAstha Gupta, M.Sc MHA PAHM

How to get thing Right

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“1000 things can go wrong when you’ve got a patient with stab wounds”

Anaesthesiologist used the wrong concentration of Potassium

No one remembered to ask the ER team what the weapon was

How to get thing Right

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“1000 things can go wrong when you’ve got a patient with stab wounds”

Two main reasons of failure• Ignorance (Don’t know or know partially)• Ineptitude (Know but fail to apply)

• Ignorance (1950s – heart patient put on bed rest for weeks in order to avoid strain to heart)• Ineptitude (2006 - only 50% of hospitals had achieved door to balloon of less than 90 min)

Healthcare and its extreme complexity

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• Complexity at two levels• Diagnosis – ICD 10 14000 codes with open sections for further specificity. ICD-10 CM

68000

• Treatment – 24 hours period in an ICU requires 178 actions either by a nurse or a doctor

In Indian ICUs, the rate of vancomycin-resistant enterococcus (VRE), a dangerous hospital infection, is five times the rate in the rest of the world

• What do you do when expertise is not enough?

• What do you do when super-specialists fail?

Learning from similarly complex sectors

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Aeronuatics• 1930s saw a major crash of Boeings newly commissioned aircraft• Since then, the same fleet has completed 1.8 million flights without a single accident

But we are much more complex• 41000 trauma patients in one state in US led upto 32261 unique combinations of

diagnosis

Think again• Nursing uses a simple checklist which forms the basis of most complex diagnosis till date• John hopkins – 5 point checklist for preparation towards inserting a central line reduced

ten day line infections from 11% to zero (2001)

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Helps in memory recall

Organises tasks

Argument remains…Human body is far more complex!!!!

Learning from similarly complex sectors contd…

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Construction • Building is a like a human body

• Involves 16 separate specialities to come together

• Checklist for • Every tasks under the plan• Every foreseen adversary• Communication and handling of the unforeseen

• Checklist work – 0.00002% rate of building failures

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Helps in memory recall

Organises tasks

Essential to complex environments

Helps in decision making

Learning from similarly complex sectors Contd…

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Investment Funds• Multiple levels of study

• Financials, culture, market outlook etc• Growth prospects etc

• Multiple teams working together

• Sectors of investment can be as varied as healthcare at one and mining at other end

Helps in memory recall

Organises tasks

Essential to complex environments

Helps in decision making

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Inculcates discipline into the process

Process back in focus “FLY THE PLANE”

TEAM WORK

Why Us?

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• Volumes of surgery exceeds the global totals of childbirth only with death rate 10-100 times higher

• Surgeries leave 7 million people disabled and 1 million dead every year. (A rate comparable with any public health concerns like malaria, tuberculosis etc)

• The unhealthy proposition of healthcare

“One in four surgeons believe juniors cannot question seniors”

64% 39% 28% 10%

The Worrisome Replacement

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Healthcare

Skill

Trustworthiness Selflessness

Discipline

The Worrisome Replacement

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Healthcare

Autonomy

The WHO Intervention

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Checklist - The soap of surgical care• Simple• Transmissible• Measurable

Counter the four roadblocks of Surgery• Infection• Bleeding• Unsafe anaesthesia• Unexpected - Communication

The pause points • Before Anaesthesia Seven Checks• After Anaesthesia Seven Checks• Before Wheeling Out Five Checks

Good Checklist

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• To the point

• Easy to use

• Does not spell out the steps

• Reminders of the most important and critical steps (Data suggested as most critical and

most frequently missed)

• Makes priorities clearer

• Has simple and exact wording

• Always in sentence case

• The pilot flying cannot start the checklist (he has a task at hand running through his

head)

• 60-90 seconds

Do ConfirmRead - Do

What checklists cannot do

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Make people use them

Be applicable for all conditions

Decide inclusions/exclusions

Tide over hierarchical structures

Increase workload

Essential to Implementation

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• Top down push for bottoms up implementation

• Customized to situation with common DNA

• Display positive effects with complying few

• Those essential to implementation need to be pulled in via management

• Can lead to change in established practices

Way Ahead

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Specialised Checklist• Hip Replacement

Disaster/Emergency Control• Like in Aviation

Team work and discipline

About the Author

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• Atul Gawande is an Indian American surgeon and journalist.

• He is widely known as an expert on reducing error, improving safety, and increasing efficiency

in modern surgery.

• General and endocrine surgeon at Brigham and Women's Hospital in Boston, Massachusetts

• Associate director of BWH Center for Surgery and Public Health.

• Associate professor at Harvard School of Public Health

• Associate professor of surgery at Harvard Medical School.

• He has written extensively on medicine and public health