The Checklist Manifesto_ How to Get Things Right - Atul Gawande [59]
We also asked the hospital leaders to introduce the checklist in just one operating room at first, ideally in procedures the chief surgeon was doing himself, with senior anesthesia and nursing staff taking part. There would surely be bugs to work out. Each hospital would have to adjust the order and wording of the checklist to suit its particular practices and terminology. Several were using translations. A few had already indicated they wanted to add extra checks. For some hospitals, the checklist would also compel systemic changes—for example, stocking more antibiotic supplies in the operating rooms. We needed the first groups using the checklist to have the seniority and patience to make the necessary modifications and not dismiss the whole enterprise.
Using the checklist involved a major cultural change, as well—a shift in authority, responsibility, and expectations about care—and the hospitals needed to recognize that. We gambled that their staff would be far more likely to adopt the checklist if they saw their leadership accepting it from the outset.
My team and I hit the road, fanning out to visit the pilot sites as the checklist effort got under way. I had never seen surgery performed in so many different kinds of settings. The contrasts were even starker than I had anticipated and the range of problems was infinitely wider.
In Tanzania, the hospital was two hundred miles of sometimes one-lane dirt roads from the capital, Dar es Salaam, and flooding during the rainy season cut off supplies—such as medications and anesthetic gases—often for weeks at a time. There were thousands of surgery patients, but just five surgeons and four anesthesia staff. None of the anesthetists had a medical degree. The patients’ families supplied most of the blood for the blood bank, and when that wasn’t enough, staff members rolled up their sleeves. They conserved anesthetic supplies by administering mainly spinal anesthesia—injections of numbing medication directly into the spinal canal. They could do operations under spinal that I never conceived of. They saved and resterilized their surgical gloves, using them over and over until holes appeared. They even made their own surgical gauze, the nurses and anesthesia staff sitting around an old wood table at teatime each afternoon cutting bolts of white cotton cloth to size for the next day’s cases.
In Delhi, the charity hospital was not as badly off as the Tanzanian site or hospitals I’d been to in rural India. There were more supplies. The staff members were better trained. But the volume of patients they were asked to care for in this city of thirteen million was beyond comprehension. The hospital had seven fully trained anesthetists, for instance, but they had to perform twenty thousand operations a year. To provide a sense of how ludicrous this is, our New Zealand pilot hospital employed ninety-two anesthetists to manage a similar magnitude of surgery. Yet, for all the equipment shortages, power outages, waiting lists, fourteen-hour days, I heard less unhappiness and complaining from the surgical staff in Delhi than in many American hospitals I’ve been to.
The differences were not just between rich and poor settings, either. Each site was distinctive. St. Mary’s Hospital, for example, our London site, was