The Checklist Manifesto_ How to Get Things Right - Atul Gawande [61]
The introduction of the checklist was rocky at times. We had our share of logistical hiccups. In Manila, for instance, it turned out there was only one nurse for every four operations, because qualified operating nurses kept getting snapped up by American and Canadian hospitals. The medical students who filled in were often too timid to start the checklist, so the anesthesia staff had to be persuaded to take on the task. In Britain, the local staff had difficulties figuring out the changes needed to accommodate their particular anesthesia practices.
There was a learning curve, as well. However straightforward the checklist might appear, if you are used to getting along without one, incorporating it into the routine is not always a smooth process. Sometimes teams forgot to carry out part of the checklist—especially the sign-out, before taking the patient from the room. Other times they found adhering to it just too hard—though not because doing so was complicated. Instead, the difficulty seemed to be social. It felt strange to people just to get their mouths around the words—for a nurse to say, for example, that if the antibiotics hadn’t been given, then everyone needed to stop and give them before proceeding. Each person has his or her style in the operating room, especially surgeons. Some are silent, some are moody, some are chatty. Very few knew immediately how to adapt their style to huddling with everyone—even the nursing student—for a systematic run-through of the plans and possible issues.
The introduction of names and roles at the start of an operating day proved a point of particularly divided view. From Delhi to Seattle, the nurses seemed especially grateful for the step, but the surgeons were sometimes annoyed by it. Nonetheless, most complied.
Most but not all. We were thrown out of operating rooms all over the world. “This checklist is a waste of time,” we were told. In a couple places, the hospital leaders wanted to call the curmudgeons on the carpet and force them to use it. We discouraged this. Forcing the obstinate few to adopt the checklist might cause a backlash that would sour others on participating. We asked the leaders to present the checklist as simply a tool for people to try in hopes of improving their results. After all, it remained possible that the detractors were right, that the checklist would prove just another well-meaning effort with no significant effect whatsoever.
Pockets of resistance notwithstanding, the safe surgery checklist effort was well under way within a month in each location, with teams regularly using the checklist in every operating room we were studying. We continued monitoring the patient data. I returned home to wait out the results.
I was nervous about the project. We had planned to examine the results for only a short time period, about three months in each pilot site after introduction of the checklist. That way any changes we observed would likely be the consequence of the checklist and not of long-term, ongoing trends in health or medical care. But I worried whether anything could really change in so short a time. The teams were clearly still getting the hang of things. Perhaps we hadn’t given them enough time to learn. I also worried about how meager the intervention was when you got right down to it. We’d provided no new equipment, staff, or clinical resources to hospitals. The poor places were still poor, and we had to wonder whether improvement in their results was really possible without changing that. All we’d done was give them a one-page, nineteen-item list and shown them how to use it. We’d worked hard to make it short