December 25, 2014

The checklist manifesto by Atul Gawande

The checklist manifesto by Atul Gawande
How to get things right

On any given day in the United States alone, some ninety thousand people are admitted to intense care. Yet given how much surgery is now done - American today undergo an average of seven operations in their lifetime, with surgeons performing more than fifty million operations annually - the amounts of harm remain substantial. We continue to have upwards of 150,000 deaths following surgery every year - more than three times the number of road traffic fatalists. Moreover, research has consistently showed that at least half of our deaths and major complications are avoidable. The knowledge exists, but mistaken are still made. Medicine, with its dazzling success but also frequent failures, therefore poses a significant challenge.

Two professors who study the science of complexity - Brenda Zimmerman of York University and Sholom Glouberman of the University of Toronto - have proposed a distinction among three different kinds of problems in the world. the simple, the complicated and the complex.

  • Simple Problems: are ones like baking a cake from a mix. There is recipe. Sometimes there are a few basic techniques to learn. But once these are mastered, following the recipe brings a high likelihood of success.

  • Complicated problems: are ones like sending a rocket to the moon. They can sometimes be broken down into a series of simple problems. But there is no straightforward recipe. Success frequently requires multiple people, often multiple teams, and specialized expertise. Unanticipated difficulties are frequent. Timing and coordination become serious concerns. Once you learn how to send a rocket to the moon, you can repeat the process with other rockets and perfect it. One rocket is like another rocket.

  • Complex problems: are ones like raising a child. But not so with raising a child, the professors point out. Every child is unique. Although raising one child may provide experience, it does not guarantee success with the next child. Expertise is valuable, but most certainly not sufficient. Indeed, the next child may require an entirely different approach from the previous one. And this brings up another feature of complex problems: their outcomes remain highly uncertain. Yet we all know that it is possible to raise a child well. It is complex that is all.
Plus people are individual in ways that rockets are not - they are complex No two pneumonia patients are identical. Even with the same bacteria, the same cough and shortness of breath, the same low oxygen levels, the same antibiotic, one patient might get better and the other might not. Medicine contains the entire range of problems - the simple, the complicated and the complex - and there are often times when a clinician has to just do what need to be done.

In complex environment, common failures are because fallibility of human memory and attention - esp. tasks which are considered mundane and routing. Secondly, skipping steps because they don't always matter.. Until they do.
Author compares the surgical complexity with the construction high rise building. In the construction world, they have series of checklist, tracking of checklist completion mix with communication - that are important for risk free constructions. As per a senior construction engineer, the biggest cause of serious error in this business is a failure of communication. The construction industry’s checklist process has clearly not been foolproof at catching problems. Nonetheless, its record of success has been astonishing.

Surgery has essentially, four big killers wherever it is done in the world: infection, bleeding, unsafe anesthesia, and what can only be called the unexpected. For the first three, science and experience have given us some straightforward and valuable preventive measures we think we consistently follow but don’t. These misses are simple failures - perfect for classical checklist. But the fourth killer is an entirely different kind of failure, one that stems from the fundamentally complex risks entailed by opening up a person’s body and trying to tinker with it.

Author was part of WHO group, to create a checklist that is looking for a measurable, inexpensive and substantial reduction in the overall complication from surgery. There are good checklists and bad.

Bad checklists are vague and imprecise. they are too long; they are hard to use; they are impractical. They are made by desk jockeys with no awareness of the situation in which they are to be deployed. They turn people’s brains off rather than turn them on.

Good checklists are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything - a checklist cannot fly a plane,. Instead they provide reminders of only the most critical and important steps - the ones that even the highly skilled professional using them could miss. Good checklists are, above all, are practical.

The checklist cannot be lengthy. A rule of thumb some use if to keep it to between five and nine items, which is the limit of working memory.

DO-Confirm - checks after tasks are done often done separately by different team members
READ-DO: carry out tasks as they are checked off

All learned occupation has a definition of professionalism, a code of conduct. It is where they spell out their ideals and duties. The codes are sometimes stated, sometimes just understood. But they all have at least three common elements.

First is an expectation of selflessness: that we who accept responsibility for others - whether we are doctors, lawyers, teachers, public authorities, soldiers or pilots - will place the needs and concerns of those who depend on us above our own.

Second is an expectation of skill: that we will aim for excellence in our knowledge and expertise.

Third is an expectation of trustworthiness: that we will be responsible in our personal behavior toward our charges.

Aviators, however add a fourth expectations, discipline: discipline in following prudent procedure and in functioning with others. This is a concept almost entirely outside the lexicon of most professions, including medical profession. Discipline is hard - harder than trustworthiness and skill perhaps, even than selflessness. We are by nature flawed and inconstant creatures. We can’t even keep from snacking between meals and we are not built for discipline. We are built for novelty and excitement, not for careful attention to detail.

Author ending the book with the importance and need of discipline in medical practice.

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