Surviving complexity--in the operating room and the workplace

How checklists improve patient safety, communication and team dynamics

THURSDAY, MARCH 11, 2010

Dr. Atul Gawande

The challenge facing many unit-based teams leading change at Kaiser Permanente is a familiar one to health care providers everywhere: the complexity of health care itself. “Every day,” says surgeon and best-selling author Atul Gawande, “there is more and more to manage and get right and learn.” That’s why, he says, 30 percent of stroke patients in the U.S. get incomplete inappropriate care; for asthma, pneumonia and certain heart attack patients, the numbers are even higher.

The good news is, there’s a simple solution for preventing these and other avoidable failures: checklists that itemize the key steps necessary before, during and after surgery to achieve good outcomes. In The Checklist Manifesto: How to Get Things Right Gawande explains how and why checklists work—often by way of his own, sometimes harrowing stories of lucky breaks and near misses in the operating room.

His research led the World Health Organization in 2008 to recommend the use of surgical checklists worldwide, and has lessons for every health care professional.

A positive side effect for KP

The Checklist Manifesto cites several health care organizations that have improved the quality of care by codifying simple infection-prevention steps such as hand washing, cleaning the patient’s skin with antiseptic and putting sterile drapes over the patient. For example, after implementing checklists, Johns Hopkins Hospital saw its one-day central-line infection rate go from 11 percent to zero. Over a 27-month study period, the checklist prevented an estimated 43 infections, eight deaths and $2 million in avoided costs.

Among the other organizations Gawande commends for their innovative use of checklists is Southern California Permanente Medical Group. (Kaiser Permanente in general is an acknowledged leader in implementing new patient-safety practices.) In addition to improved clinical outcomes, checklists also helped Southern California PMG achieve unexpected organizational benefits: During the six months that surgical teams tested checklists, the average rating of the teamwork climate improved from “good” to “outstanding,” employee satisfaction rose 19 percent and the rate of OR nurse turnover declined dramatically, Gawande reports.

Which leads to a major theme of the Checklist Manifesto: The best checklists are just not a top-down set of tasks for others to follow. They’re a tool for better team communication, coordination and inquiry.

The case for shared decision making

In high-risk industries—including aviation and high-rise construction as well as health care—Gawande found that good checklists:

“…revealed an entirely different philosophy about power and what should happen to it when you’re confronted with complex, nonroutine problems… The philosophy is that you push the power of decision making out to the periphery and away from the center. You give people the room to adapt, based on their experience and expertise. All you ask is that they talk to one another and take responsibility. That is what works.”

In addition to specifying common sense safety measures, checklists ensured “that people talk to one another about each case, at least just for a minute before starting,” he writes. “[It is] basically a strategy to foster teamwork—a kind of team huddle.”

And, as Kaiser Permanente has found, the benefits of huddles are not limited to the OR. High performing unit-based teams across KP make regular use of them and are getting results that matter to our members and patients.