Atul Gawande, M.D., M.P.H., a general and endocrine surgeon at Brigham and Women's Hospital and the Dana Farber Cancer Institute, both in Boston, has received wide acclaim for his research and writing. He has written three New York Times best-selling books, including The Checklist Manifesto: How to Get Things Right (Macmillan, 2009), and is a staff writer at The New Yorker. He is also an associate professor of surgery at Harvard Medical School and of health policy and management at the Harvard School of Public Health. In 2007 he became the director of the World Health Organization's global campaign to reduce surgical deaths.
Gawande will receive the HRET's 2011 TRUST Award on July 17 in San Diego during the Health Forum-AHA Leadership Summit.
You have led measurable success globally with the implementation of the surgical safety checklist. What have been keys to success that can be used in other large-scale improvement efforts?
The keys to success are a combination of things. First, we set a sharp, measurable goal for a high-priority problem: reducing deaths in surgery. It is amazing how unclear goals can be, but we were clear. Second is recognizing the patterns of failure; that is, really trying to look at the experience and research and places that were carrying out surgery and understanding what the actual experience was.
There are 230 million operations worldwide a year. This huge volume of operations had exceeded the volume of childbirth and was growing. The operations also had a death rate that was 10 to 100 times higher than childbirth in any given country. We had identified the big killers, which were bleeding complications, infectious complications, unsafe anesthesia and what we called the unexpected—the numerous individual ways that cases could go wrong.
The next thing we did was distill a set of best practices that people had identified into a usable surgical safety checklist. It took a lot more work than people may recognize from seeing a simple, one-page checklist with 19 items. We have now attempted making checklists for multiple clinical fields, and we have not been able to make one in less than 50 revisions. You make it. You try it. You see what the problems are. The checklist is often too long and not easy to use. Crucial to success has been testing a checklist over and over until we had something that was actually usable on the front line and on a variety of front lines. We were testing and trying out the checklist in places that ranged from rural Tanzania to Boston.
The implementation side has been about leveraging off of multiple studies demonstrating the value. People in medicine do respond to data, and not all industries do. People in medicine do pay a lot of attention if actual, better results are produced. Three studies now—our pilot study, a Veterans Administration study and a Netherlands study—show that a checklist approach to surgery is life-saving. The Netherlands study achieved nearly a 50 percent reduction in deaths, similar to what we achieved in our study.
The VA study gave a nice description of what is required to achieve success on a large scale. First, they had 74 hospitals in their study. It required an average of two months of system preparation in every hospital to define and modify the checklist to fit into their environment. Second, they had a day of training, which is hard for people to create, but essential. They pulled people out of their environment and said, "Our aim is great surgery. Here is a tool that can help us achieve it. Let's practice it, learn why it's being discussed, try it out and role play in simulation to make sure it works." And then they executed.
Often we find you have to execute on a small scale first, starting in one or two operating rooms before going to all the operating rooms. So another key to success has been painstaking attention to detail about implementation, though the checklist seems simple.
You are now taking that experience and going broad and deep in South Carolina. Talk about your goals in South Carolina and how you might scale that nationally.
The partnership was begun by the South Carolina Hospital Association, and we are quickly bringing in other state groups as well. Our aim is to measurably reduce surgical complications and deaths across the state, and our strategy is to ensure that every hospital in South Carolina effectively implements the surgical checklist.
There are 61 hospitals in South Carolina, and surgical teams do more than 800,000 operations a year in the state. So, achieving our goals is a daunting task. But we have learned from other efforts—including HRET's state-by-state rollout of the central line-associated bloodstream infection checklist program. And we have tried to set up a step-by-step process for supporting large-scale adoption as well as some careful measures of results across the state. That includes looking at the rates of surgical death at a statewide level, as well as infection rates and other similar kinds of metrics.
Our aim is to demonstrate that we are improving outcomes within a year. Doing this required first engaging the chief executives from hospitals—and every single one has signed on, which is remarkable. It also requires engaging with the surgery, anesthesia, nursing and administrative leaders from each of the hospitals.
The project is going to require substantial commitment. It's not simply a matter of, "Hey, here's this piece of paper. Stick it up in your operating room." Our studies show that even places that think they have adopted the checklist can have teams that don't use it. The teams check off that it was done. But do they go through the six checks before incision that are supposed to happen? Not consistently. That is partly because people haven't learned how to do it well. But it's also because people may not yet have embraced the values behind the checklist. And the values are really what the checklist is about: fundamental values behind patient safety and patient-centeredness and the work we do.
You talked about culture beyond the checklist. What are some of the promising elements of instilling a culture of safety throughout the organization?
The evidence has reached the point that surgeons are endangering their patients if they do not use the checklist. I think it's become that clear. But the striking source of resistance and difficulty, I think, is that there is a set of values encapsulated in the checklist that may not necessarily be shared. We have seen hospitals that have tried to adopt the checklist, but haven't realized that there's a value change involved.
The first value is humility—that is, the willingness to recognize that we all can fail. In fact, we will fail. We will make errors no matter how experienced, how smart or how well trained we may be.
The second value is discipline—the belief that doing certain basic things the same way, every time, can help overcome our risk of failure.
The third value is teamwork—the belief that, more than autonomy, the ability of an entire team working together effectively is crucial to the safety of patients. No matter who people are, no matter what level those people are, they are an asset to you.
Managing the complexity of surgery more reliably requires recognizing these values and making them a reality. The checklist is the simplest form of tool to help us begin to do that.
Editor's note: In part two of the interview (June 30), Gawande discusses controlling health care costs while improving quality, and moving the science of health care back to the bedside.
Maulik Joshi, Dr.P.H., is the president of HRET and senior vice president for research at the American Hospital Association. He is also a member of Speakers Express.