I recently read the Checklist Manifesto. Additionally, I had the opportunity to interview Atul Gawande.
The book has received significant press attention, some praising and some criticizing. Here are 2 reviews:
The utility of formal protocols, according to organizational experts, varies with the nature of the activity—some activities are highly systemized, like engineering, and others dependent on the judgment and personality of the individual. Spontaneity and imagination are important in many jobs, including teaching and management of all kinds. Dr. Gawande seems to assume that formal checklists will be an unalloyed benefit. But most people can think of only one thing at once: If they're thinking about a checklist, they may not be focusing on solving the problem at hand. Many tasks require trial and error—not checklists designed to avoid error. "Hell, there ain't no rules around here," Thomas Edison famously said. "We're trying to accomplish something."
But Gawande’s missionary zeal can give the book a slanted tone. For instance, there is almost no discussion of the unintended consequences of checklists. Today, insurers are rewarding doctors for using checklists to treat such conditions as heart failure and pneumonia. One item on the pneumonia checklist — that antibiotics be administered to patients within six hours of arrival at the hospital — has been especially problematic. Doctors often cannot diagnose pneumonia that quickly. But with money on the line, there is pressure on doctors to treat, even when the diagnosis isn’t firm. So more and more antibiotics are being used in emergency rooms today, despite the dangers of antibiotic-resistant bacteria and antibiotic-associated infections.
Apparently I have drunk the Kool-Aid. I find Gawande's book persuasive and cautious. I read the book differently from these two well-meaning critics.
Gawande spends significant time discussing the challenges of developing usable checklists. He focuses on the length of the checklist and the relevance of the content. He writes about the need for testing of checklists prior to adoption. He even talks about ongoing checklist revision.
As an internist who no longer does procedures, I can imagine how checklists can help my profession. I will give a couple of examples.
1. Hospitalist caring for undifferentiated patient:
- Does patient have an IV – is is still necessary?
- Does patient have a Foley catheter – is it still necessary?
- Are we providing adequate nutrition?
- Have we started discharge planning?
- Does the patient need PT/OT?
2. Any internist caring for a patient with diabetes:
- Feet – have we checked them – if the patient has tinea pedis are we treating it?
- Lipids – is the patient taking a statin – if not why not
- Eyes – when was the last eye exam
- Control – what is the control and how might we improve it
- Kidneys – does the patient have diabetic nephropathy (check creatinine and U/P protein)? Are we treating hypertension successfully?
- Shots – is the patient up to date on immunizations?
I can, and do , differentiate checklists from performance measures. As I read the book, we can and should use checklists to help us remember things we should not forget. Why shouldn't we develop some basic checklists that might decrease hospital errors or outpatient oversights?
As I see checklists, we should use them to insure that we dot our i's and cross our t's. How can that be bad?
{ 5 comments… read them below or add one }
I agree that checklists are often helpful for things a friend calls "ash and trash". I.e. there are things that every physician should know, do, and remember, and there are others that, while important, are better left to allowing a different tool to assist you in remembering.
Checklists are not a one-size-fits-all solution. But, they can help.
Absolutely nothing wrong with checklists- you have yours, I have mine, I use them in teaching my students and residents. These are checklists that I (and you, I'm confident), have developed on an ad hoc basis in dealing with common situations in our practice. It may be a formal written checklist, a mnemonic, a song that you sing to yourself, or anything else that works for you. The problem comes when checklists are imposed from above as someone else's idea of how you and I should manage our patients. The checklist then becomes an end and not a means of getting to the end, which is good care, however you and I define it. Good care now is defined by how fast the antibiotic is given, not whether it's the right antibiotic, or if the physician has done a good job determining if it's needed at all (if an ER patient is given an antibiotic within the approved time frame, but it later is proven that it was not necessary, is there a decrease in the quality indicator for the hospital's score?).
In the OR, it's the "Timeout." Declaring that the timeout is being done, and, more importantly, having the RN and anesthesiologist document that the Timeout was done, and documenting that the timeout was done at the same minute, takes priority over actually accomplishing what the time out is intended to do. You will likely find that difficult to believe, but not after you ask a surgical colleague. We should encourage checklists when they are useful, from a bottom-up perspective. Students and trainees should be taught to be methodical, to take a minute or more and review the situation and ensure that every aspect of care is covered. Not everything that can be counted, counts, and not everything that counts can be counted. Every day a rent-seeking administrator tries to come up with something that we do that they can count, so they have more to do. This has nothing to do with the practice of medicine.
I agree with the premise that checklists are useful, important and necessary. I designed an encounter form that I use that is essentially a checklist that covers most of what I need to do at each patient encounter. It helps me every day. Residents when they work in my office are required to use my encounter form. Many like it but some also use extensive notes to organize their thinking and planning.
Our EMR copies over the Assessment/Plan section of the most recent progress note into the current one. For the past few years, I have ended every note with the problem heading, "Hospital Care". The sub-headings of this checklist include items 1, 2, 3, and 5 on your checklist and also: code status, DVT prophylaxis, family contact information, and PCP contact information. (I don't include "discharge planning" because it's a given in our organization – we discuss each patient our case managers at least 2 times a day, often more than that.)
One simplistic and undeniable truth about absolute need in one specific checklist area is the need to follow service procedures that protect a patient from hospital introduced infections. Every medical service should have the logistics in place and every health professional should be mandated to give and receive the simple, lifesaving reminders to protect patients – physicians’ egos notwithstanding.