The Checklist and Future Culture of Medicine

Like many New Yorkers, I learned about the checklist in a magazine. I remember thinking, in late 2007, that maybe I’d seen something on the subject in The New England Journal. Indeed, a year earlier Dr. Peter Pronovost and colleagues reported on a simple, inexpensive strategy to save lives in a now-landmark article, “An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU.” Still, I’d missed the paper. Or at least I’d overlooked the significance.

Fortunately I had the opportunity to hear Pronovost, a still-youngish Professor at Johns Hopkins and recent MacArthur award recipient, speak at the annual meeting of the Association of Health Care Journalists in Chicago. After hearing his talk, I couldn’t wait to read more.

The checklist refers to 5 steps doctors can take to reduce the likelihood of patients getting serious infections from catheters placed in the ICU. One problem with Pronovost’s quintet is that it’s, well, unexciting. In his book Safe Patients, Smart Hospitals he reveals what a person shouldn’t forget before inserting an intravenous (IV) tube through a vein to the heart’s entryway:

1. wash hands with something like soap before the procedure;

2. set up a clean work area by covering the patient with a sterile drape and donning a gown, cap, mask and sterile gloves;

3. insert the catheter in a place other than the patient’s groin, if possible;

4. wipe down the patient’s skin with antiseptic fluid, chlorhexidine;

5. remove catheters that are no longer needed.

Pronovost, an intensive care specialist who holds an MD and a PhD in Public Health, first tested the checklist on his home turf, the surgical ICU at the Johns Hopkins Hospital in Baltimore, MD, in 2001. At the start, he distributed the list and asked ICU staff nurses to mark physicians’ compliance. It turned out the doctors skipped at least one step in over a third of central catheter placements. Next, he upped the list’s power by talking to Hopkins administrators. Nurses, they said, could call out a physician if they didn’t stick to the rules.

“This was revolutionary,” said Atul Gawande in the New Yorker.

What’s the big deal, you may wonder. It’s this – first, in the usual culture of medical practice, doctors don’t follow orders but give orders. And second, what’s implicit in the checklist is that physicians – even at one of the world’s most renowned medical facilities – are fallible to such a degree that their work can improve, and measurably so, by using something as ordinary as a checklist. It’s humbling.

“We don’t use checklists in health care because we still have his myth of perfection,” Pronovost said at the journalism conference.

In the year after Pronovost’s team implemented the checklist at Hopkins, the rate of central catheter infections there dropped from eleven percent to zero. As for how much good this did – the estimate runs at 43 infections spared, 8 deaths avoided and $2 million saved in one year at that hospital alone. The work expanded, soon to cover ICUs in most hospitals in the state of Michigan. There, after a lot of fuss, administrative hurdles and number crunching of results for some 375,757 catheter-days’ worth of infection data, the incidence of central line-associated bacterial infections snapped from 2.7, on average, for every 1000 days a patient was in a Michigan ICU with at least one central line, down to 0 (zero!).

These numbers are supported by impressive stats, with p-values falling below 0.002 in the original study. Estimates for the Keystone Initiative render some 1000 lives saved and $175 million in hospital costs reduced in a single year in Michigan. What’s more, all of this was accomplished without the use of expensive technology or additional ICU staffing.

This is a win/win intervention with huge implications. Every day some 90,000 people receive care in ICUs in North America. The annual incidence of catheter-related blood infections is 80,000 per year in the U.S.; the cost of treating each line infection runs around $45,000. In the U.S., we might save over $3 billion in expenses per year.

So why aren’t more hospitals and states adopting these and other, similar measures? Gawande addresses this, to some extent, in the New Yorker piece and in his book, The Checklist Manifesto. “There are hundreds, perhaps thousands, of things doctors do that are at least as dangerous and prone to human failure as putting central lines into I.C.U. patients,” he writes. “All have steps that are worth putting on a checklist and testing in routine care. The question – still unanswered – is whether medical culture will embrace the opportunity.”

Poka-yoke, a Japanese term for rendering a repetitive process mistake-proof, may be familiar to business students and corporate executives.  This concept, that simple strategies can reduce errors in highly complex works, is not the kind of thing most doctors pick up in med school. Rather, it remains foreign.

Pronovost is unusual because he examines health care delivery, in itself, rather than attempting an innovative cure for cancer or surgical method. His work just isn’t sexy enough to sell. I suspect that’s the reason he came to the health care journalism conference in Chicago and gave such an impassioned talk about the checklist, so that a few of us might help get the word out.

Things change, after all, and sometimes they do get better.

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  • This was close to home for me and makes me wonder how many different things would be affected by close attention to detail and procedure. My story is about high blood pressure. I turned down my doctor’s recommendation of medication choosing to work on life style. My doctor is excellent and her staff capable but they did not follow AHA protocol when taking blood pressure.
    Six months after turning down the blood pressure medication I found myself in a medical study for an unrelated medical issue. At the screening my blood pressure reading was borderline high 139/90. I told the study nurse that it fluctuated. She looked at me and said we will do it again and follow AHA procedure: sit for a few minutes with knees apart, both feet flat on the floor, arms resting on a table, relaxed and looking straight ahead.
    She takes my blood pressure every two weeks and I take it at home weekly for the study. Since following this protocol my blood pressure readings are consistently 115 -120/66-72. I think they were sometimes high in the past because I was sitting with my legs crossed and body twisted to talk to the nurse while she took my blood pressure.
    I thoroughly enjoy reading your blog. Thank you.

  • There’s a reason that airline pilots use check lists. They work. We physicians, however, are a tough cohort to train. We dont’ welcome external advice regarding our quality, whether it comes from the hospital, insurance companies or the government. Our profession has been lax in spearheading meaningful and sustained quality review. I do advocate a judicious approach so that every medical intervention, large and small, does not become a ‘check list’ opportunity. Beware of mission creep which can bury the true mission.

  • I am a student doing research on the Checklist phenomenon and the future of CHECKLISTS. I have gone through a number of articles documenting the dramatic effects of checklist applications. As the concept gets recognition far and wide, we are looking over to broader horizons. How far could we apply the checklist? Would it be feasible to have detailed checklists for every step or rather every crucial step in surgery?

    • Everyone, Thank you for these thoughtful comments.

      I suspect there are potential checklists that might be used in most fields of medicine including heme/onc (which I practiced, such as prior to giving infusions) and in pathology (like checking, for example, that the control stains work for each “run” of samples – this sort of thing is presumably done already). But at some point as a doctor you have to stop running lists and actually analyze/think.

      It’ll be interesting to see how these develop, and which sorts of lists take hold over time.

  • I am a physician. I think we need more checklists – they clearly help us to do things better.
    I’m interested in how we interact with patients:

    Do we

    Properly introduce ourselves?
    Ask about what really concerns our patients?
    Give time to hear patients concerns?
    Ask whether they are happy with the care they are receiving?
    Communicate patients concerns to other health care professionals in the team?
    Invite patients to ask a carer or other advocate to be present when we give them important information?

    I could add to this list, but that will do for now.

    Dropsy of wardroundstuff

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