Monthly archives of “February 2010

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As if on cue… (Checklists, round 2)

Yesterday, I wrote about an absolute must-read book: The Checklist Manifesto: How to Get Things Right

It has been shown in an extensive world-wide study that a simple checklist used in surgery cuts infection rates, cuts death rates, and saves costs. It does all of these by substantial margins, everywhere they’ve been implemented. But so far only a minority of hospitals (Dr. Gawande mentioned 10 percent) have started using the safe surgery checklist, or any others, for that matter.

Yet today, the New York Times has an article titled “Results Unproven, Robotic Surgery Wins Converts.” Here are the most important quotes:

But robot-assisted prostate surgery costs more — about $1,500 to $2,000 more per patient. And it is not clear whether its outcomes are better, worse or the same.

[…]

Last year, 73,000 American men — 86 percent of the 85,000 who had prostate cancer surgery — had robot-assisted operations, according to the robot’s maker, Intuitive Surgical, the only official source of such data. Eight years ago there were fewer than 5,000, Intuitive says.

[…]

[O]nce a hospital invests in a robot — $1.39 million for the machine and $140,000 a year for the service contract, according to Intuitive — it has an incentive to use it. Doctors and patients become passionate advocates, assuming that newer means better.

[…]

And the robot is slow; it typically takes three and a half hours for a prostate operation, according to Intuitive, twice as long as traditional surgery.

So in this particular kind of surgery, a majority of surgeons quickly take up a new technology that has yet to show it can provide any sort of benefit! The same procedure is now slower and much more expensive. And the same doctors are resisting adopting a simple checklist (for little to no cost) that conclusively show improved results.

Not to make too much of a political situation here, but our health care system is clearly a mess. Doctors clearly don’t always know what’s truly important for their patients. I’m not saying surgeons shouldn’t use robots, but exhaust the easy, cheap, and conclusively better tools first! Use a damn checklist!

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The Checklist Manifesto – A hugely important book

Back in 2007 I read a fascinating article called “The Checklist” written by Dr. Atul Gawande in the New Yorker. Atul Gawande is a practicing surgeon, MacArthur Fellow, Rhodes Scholar and professor at Harvard Medical School and Harvard School of Public Health. The article described how a doctor convinced a group of hospitals in Michigan to do a wide-spread trial of a simple experiment: a checklist. The checklist aimed simply at making sure staff completed five key steps to limit central line infections, an unfortunately common source of infections in hospitals.

The result?

In one hospital:

  • 10-day infection rate went from 11% to ZERO
  • Prevented 8 deaths
  • Saved $2million in costs

Across ICU’s in Michigan:

  • In three months cut infections by 66%!
  • Typical ICU cut infection rate to ZERO
  • In 18 months, prevented 1500+ deaths
  • In 18 months, saved $175,000,000

These are amazing results, and his book on checklists, “The Checklist Manifesto,” was recently published. Click below to order it from Amazon.

This book is inspiring, educational, engaging, riveting and fascinating. It’s extremely well-written, and is a fairly easy read. I’ve never written a blog post immediately after finishing a book, but I am now because not only is it GOOD, but this book is IMPORTANT.

Dr. Gawande led a huge study of a “safe surgery” checklist, a simple set of steps to be checked in each surgery. It was used and studied in eight hospitals: four in the developed world (US, UK, etc.) and four in the developing world (Tanzania, New Delhi, Jordan, Manila). Thousands of patients were studied for months before and after checklists were implemented. The results?

  • Rate of complications fell by 36%
  • Deaths fell by 47%
  • Infections fell by nearly half
  • Even in advanced hospitals in developed world, complications were decreased by one-third

I mean…. WOW! Cutting infection rates and death rates in surgery by half (with marginal differences between developed and developing countries) is simply incredible.

But here’s a choice quote from the book:

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 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?

Checklists are powerful, and not just for surgery. Gawande writes about data from investment managers and venture capitalists that shows that those that use checklists are much more successful than those that don’t. They’ve been used in aviation for 70+ years, ever since airplanes became so complicated as to be dangerous without checklists. The modern construction industry uses checklists to ensure their projects are safe and properly constructed.

I’m very familiar with checklists; operating a nuclear reactor in a US Navy submarine means you live with checklists in everything you do. But I accepted it without too much thought since we had no idea there was any other way of running such a complicated machine. It’s amazing to me that other complex professions don’t also use the same procedures.

Checklists are threatening to many people and professions. Using them implies that professionals don’t know what they’re doing, that they don’t have the ability to do their jobs. Even with the results described in surgery above, many surgeons still don’t use them. (Despite the fact that they continually prove to save patients’ lives, everywhere.) As Dr. Gawande describes above, if the same results were achieved through a pill or machine, doctors and hospitals would be racing to adopt them!

Dr. Gawande goes into real detail not only in what makes a good checklist and how to develop them, but also why they work. They work by simply making sure that key simple steps are accomplished, and by freeing your brain from concerning itself about the easy stuff (since the checklist will catch anything you miss). This frees the brain to think about the hard stuff, and able to deal with complications more directly. Good checklists also make communications easier, so that when things do go wrong, the experts involved can address them more directly.

Fundamentally, time after time, in study after study… checklists WORK.

Summary

This is a hugely important book, and I honestly can’t recommend it more highly, It doesn’t matter what industry you’re in, if you deal with or manage complexity, you NEED to read it.

If you want to efficiently improve your performance or your teams’ performance quickly and substantially, a checklist is your way to do it.