He suggests that "Know-how and sophistication have increased remarkably across almost all our realms of endeavor, and as a result so has our struggle to deliver on them." (p11) This is because the systems delivering have become too complex for individuals to master. This causes deep customer dissatisfaction. "Failures of ignorance we can forgive. .... But if the knowledge exists and is not applied correctly, it is difficult not to be infuriated." (p 11) This is the point at which failure becomes negligence.
His examples are mostly from surgery. Most operations involve a team of people, often including newcomers, attempting to apply standard procedures to a very individual patient. In the barely controlled chaos of an operation obvious steps are sometimes missed. Furthermore, the team is often handicapped by a lack of communication or by hierarchy and subservience preventing people from over-ruling the god-like surgeon. Gawande believes that checklists have two functions: firstly they prevent obvious steps being missed (he says that since using checklists he has not spend a single week without discovering that a step was about to be missed in his own operating theatre) and secondly they increase team spirit and help to flatten the hierarchy.
He claims that the classic hospital checklist is the four 'vital signs' (temperature, pulse rate, blood pressure and respiratory rate) chart which was introduced by nurses not doctors in the 1960s.
Builders have used checklists since buildings became too complicated for a single 'Master Builder' to construct. Builders use two sorts of checklists: one for which jobs have been done and one for ensuring that everyone who needs to be informed has been informed.
His checklist rules.
- Every item on a checklist must be non-ambiguous.
- Some checklists are proactive and should be read out before performance, others are retroactive and should be a check after performance.
- One's procedure needs to incorporate one or more 'pause points'. Each pause point contains a single checklist.
- Checklists should be physical; ideally the whole team should agree that each item can be checked.
- Each checklist should take no more than sixty seconds.
When Gawande was designing a surgical checklist he took a lot of time to reduce the list to the barest bones (sorry about the pun!). He deliberately left out complicated items (because they might be ambiguous) and he only included items that had leverage. Operating theatre fires kill many fewer patients than post-operative infections so the checklist focuses on antibiotics rather than asbestos. This keeps the list short enough that surgeons will use it even in high pressure situations.
He emphasises that checklists help communication and team working.
He also points out that there has been significant resistance to introducing checklists into surgery despite the remarkable success rates of the WHO research that he worked on. Human beings (and perhaps especially prima donna surgeons) don't like discipline.
I would add that his checklists typically operate in situations where the system is complex but each part can be broken down into simple steps. Can they be equally successfully in the arcane mystery that is persuading pupils to learn?
Like many American books his message is very small; I think I have encapsulated it above. He spins it into a (short) book by telling stories and adding lots of detail in the stories and lots of statistics. Nevertheless, this is an enjoyable and thought-provoking read.
December 2011; 193 pages