The Checklist Manifesto_ How to Get Things Right - Atul Gawande [57]
Operations require many more than nineteen steps, of course. But like builders, we tried to encompass the simple to the complex, with several narrowly specified checks to ensure stupid stuff isn’t missed (antibiotics, allergies, the wrong patient) and a few communication checks to ensure people work as a team to recognize the many other potential traps and subtleties. At least that was the idea. But would it work and actually make a measurable difference in reducing harm to patients? That was the question.
To find the answer, we decided to study the effect of the safe surgery checklist on patient care in eight hospitals around the world. This number was large enough to provide meaningful results while remaining manageable for my small research team and the modest bud get WHO agreed to furnish. We got dozens of applications from hospitals seeking to participate. We set a few criteria for selection. The hospital’s leader had to speak English—we could translate the checklist for staff members but we didn’t have the resources for daily communication with eight site leaders in multiple languages. The location had to be safe for travel. We received, for instance, an enthusiastic application from the chief of surgery in an Iraqi hospital, which would have been fascinating, but conducting a research trial in a war zone seemed unwise.
I also wanted a wide diversity of participating hospitals—hospitals in rich countries, poor countries, and in between. This insistence caused a degree of consternation at WHO headquarters. As officials explained, WHO’s first priority is, quite legitimately, to help the poorer parts of the world, and the substantial costs of paying for data collection in wealthier countries would divert resources from elsewhere. But I had seen surgery in places ranging from rural India to Harvard and seen failure across the span. I thought the checklist might make a difference anywhere. And if it worked in high-income countries, that success might help persuade poorer facilities to take it up. So we agreed to include wealthier sites if they agreed to support most, if not all, the research costs themselves.
Lastly, the hospitals had to be willing to allow observers to measure their actual rates of complications, deaths, and systems failures in surgical care before and after adopting the checklist. Granting this permission was no small matter for hospitals. Most—even those in the highest income settings—have no idea of their current rates. Close observation was bound to embarrass some. Nonetheless, we got eight willing hospitals lined up from all over the globe.
Four were in high-income countries and among the leading hospitals in the world: the University of Washington Medical Center in Seattle, Toronto General Hospital in Canada, St. Mary’s Hospital in London, and Auckland City Hospital, New Zealand’s largest. Four were intensely busy hospitals in low-or middle-income countries: Philippines General Hospital in Manila, which was twice the size of the wealthier hospitals we enrolled; Prince Hamza Hospital in Amman, Jordan, a new government facility built to accommodate Jordan’s bursting refugee population; St. Stephen’s Hospital in New Delhi, an urban charity hospital; and St. Francis Designated District Hospital in Ifakara, Tanzania, the lone hospital serving a rural population of nearly one million people.
This was an almost ridiculous range of hospitals to study. Annual health care spending in the high-income countries reached thousands of dollars per person, while in India, the Philippines, and East Africa, it did not rise beyond the double digits. So, for example, the bud