The Checklist Manifesto_ How to Get Things Right - Atul Gawande [16]
In 2003, however, the Michigan Health and Hospital Association approached Pronovost about testing his central line checklist throughout the state’s ICUs. It would be a huge undertaking. But Pronovost would have a chance to establish whether his checklists could really work in the wider world.
I visited Sinai-Grace Hospital, in inner-city Detroit, a few years after the project was under way, and I saw what Pronovost was up against. Occupying a campus of red brick buildings amid abandoned houses, check-cashing stores, and wig shops on the city’s West Side, just south of Eight Mile Road, Sinai-Grace is a classic urban hospital. It employed at the time eight hundred physicians, seven hundred nurses, and two thousand other medical personnel to care for a population with the lowest median income of any city in the country. More than a quarter of a million residents were uninsured; 300,000 were on state assistance. That meant chronic financial problems. Sinai-Grace is not the most cash-strapped hospital in the city—that would be Detroit Receiving Hospital, where more than a fifth of the patients have no means of payment. But between 2000 and 2003, Sinai-Grace and eight other Detroit hospitals were forced to cut a third of their staff, and the state had to come forward with a $50 million bailout to avert their bankruptcy.
Sinai-Grace has five ICUs for adult patients and one for infants. Hassan Makki, the director of intensive care, told me what it was like there in 2004, when Pronovost and the hospital association started a series of mailings and conference calls with hospitals to introduce checklists for central lines and ventilator patients. “Morale was low,” he said. “We had lost lots of staff, and the nurses who remained weren’t sure if they were staying.” Many doctors were thinking about leaving, too. Meanwhile, the teams faced an even heavier workload because of new rules limiting how long the residents could work at a stretch. Now Pronovost was telling them to find the time to fill out some daily checklists?
Tom Piskorowski, one of the ICU physicians, told me his reaction: “Forget the paperwork. Take care of the patient.”
I accompanied a team on 7:00 a.m. rounds through one of the surgical ICUs. It had eleven patients. Four had gunshot wounds (one had been shot in the chest; one had been shot through the bowel, kidney, and liver; two had been shot through the neck and left quadriplegic). Five patients had cerebral hemorrhaging (three were seventy-nine years and older and had been injured falling down stairs; one was a middle-aged man whose skull and left temporal lobe had been damaged by an assault with a blunt weapon; and one was a worker who had become paralyzed from the neck down after falling twenty-five feet off a ladder onto his head). There was a cancer patient recovering from surgery to remove part of his lung, and a patient who had had surgery to repair a cerebral aneurysm.
The doctors and nurses on rounds tried to proceed methodically from one room to the next but were constantly interrupted: a patient they thought they’d stabilized began hemorrhaging again; another who had been taken off the ventilator developed trouble breathing and had to be put back on the machine. It was hard to imagine that they could get their heads far enough above the daily tide of disasters to worry about the minutiae on some checklist.
Yet there they were, I discovered, filling out those pages. Mostly, it was the nurses who kept things in order. Each morning,