The Checklist Manifesto_ How to Get Things Right - Atul Gawande [64]
Take the safe surgery checklist. If someone discovered a new drug that could cut down surgical complications with anything remotely like the effectiveness of the checklist, we would have television ads with minor celebrities extolling its virtues. Detail men would offer free lunches to get doctors to make it part of their practice. Government programs would research it. Competitors would jump in to make newer and better versions. If the checklist were a medical device, we would have surgeons clamoring for it, lining up at display booths at surgical conferences to give it a try, hounding their hospital administrators to get one for them—because, damn it, doesn’t providing good care matter to those pencil pushers?
That’s what happened when surgical robots came out—drool-inducing twenty-second-century $1.7 million remote-controlled machines designed to help surgeons do laparoscopic surgery with more maneuverability inside patients’ bodies and fewer complications. The robots increased surgical costs massively and have so far improved results only modestly for a few operations, compared with standard laparoscopy. Nonetheless, hospitals in the United States and abroad have spent billions of dollars on them.
But meanwhile, the checklist? Well, it hasn’t been ignored. Since the results of the WHO safe surgery checklist were made public, more than a dozen countries—including Australia, Brazil, Canada, Costa Rica, Ecuador, France, Ireland, Jordan, New Zealand, the Philippines, Spain, and the United Kingdom—have publicly committed to implementing versions of it in hospitals nationwide. Some are taking the additional step of tracking results, which is crucial for ensuring the checklist is being put in place successfully. In the United States, hospital associations in twenty states have pledged to do the same. By the end of 2009, about 10 percent of American hospitals had either adopted the checklist or taken steps to implement it, and worldwide more than two thousand hospitals had.
This is all encouraging. Nonetheless, we doctors remain a long way from actually embracing the idea. The checklist has arrived in our operating rooms mostly from the outside in and from the top down. It has come from finger-wagging health officials, who are regarded by surgeons as more or less the enemy, or from jug-eared hospital safety officers, who are about as beloved as the playground safety patrol. Sometimes it is the chief of surgery who brings it in, which means we complain under our breath rather than raise a holy tirade. But it is regarded as an irritation, as interference on our terrain. This is my patient. This is my operating room. And the way I carry out an operation is my business and my responsibility. So who do these people think they are, telling me what to do?
Now, if surgeons end up using the checklist anyway, what is the big deal if we do so without joy in our souls? We’re doing it. That’s what matters, right?
Not necessarily. Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is. And if we recognize the opportunity, the two-minute WHO checklist is just a start. It is a single, broad-brush device intended to catch a few problems common to all operations, and we surgeons could build on it to do even more. We could adopt, for example, specialized checklists for hip replacement procedures, pancreatic operations, aortic aneurysm repairs, examining each of our major procedures for their most common avoidable glitches and incorporating checks to help us steer clear of them. We could even devise emergency checklists, like aviation has, for nonroutine situations—such as the cardiac arrest my friend John described in which the doctors forgot that an overdose of potassium could be a cause.
Beyond the operating room, moreover,