Sunday, March 06, 2011

Atul Gawanade: The Checklist Manifesto

I've written about Atul Gawande. I've even read part of this article before at The New Yorker. I even follow him on twitter. You could say I like him. I read this book in one day, because it's a fast read, and because it's good. Read the linked New Yorker for the nutshell version of the book.

Basically, the more complicated medicine (and lots of our world) gets, the better things get. People don't die from heart attacks as much (Gawande knows the statistics, I don't), because there are drugs and surgeries and of course preventatives. Now, people die from complications from the drugs and surgeries and hospitalizations that come from the heart attacks. This alarms Gawande, and it should alarm you. It shouldn't alarm you to the point of luddite-ness, or Christian Scientist-ness, but it got to Gawande, a physician/surgeon/fancy author/doctor person, enough to try something radical: pause and make sure everything was being done that could prevent these complications. Simple things like everyone washing their hands, and wearing gloves. Simple (but disturbingly creepy) things like accounting for all surgical tools after procedures and making sure the right patient was on the table and that everyone in the room was sure of what procedure was being done, and on what side of the body. Simple yet rather innovative things like having everyone in the room introduce themselves.

It turns out that this is groundbreaking in medicine, and hugely effective, whether in first world, cutting edge hospitals, or Global South hospitals where local anesthesia is a luxury. The checklists and procedures can vary, but the outcomes are improved regardless. Slowing down, being conscious of your work, and being aware of the most basic steps as well as the most elaborate ones saves lives. It also turns out that airline pilots have been doing this for, well, ever. They are mandated to as both airline companies and as individual pilots. This results in few crashes and few instances of turbulence, etc. Passengers don't even know what didn't hit them. One of the lines that sticks out is the instruction (this is true) from one of the flight checklists: "Fly the Plane." These simple instructions remind pilots that even in times of crisis, they know what they're doing, they just need to remember to do it. Slow down and remember what you're there for: Fly the Plane.

Doctors, especially in the US, as I read it, are resistant to Gawande and the World Health Organization's distribution of the checklist. Medicine is seen as an art, as practiced by well-educated geniuses who Know What They're Doing. These kind of men don't need checklists. They are a wealth of knowledge unto themselves. Of course they've got the basics covered (and the checklists are only a reminder of the basics). For surgery, Gawande developed "Pause Points": before anesthesia, before surgery, and before finishing the surgery/wheeling out the patient. At each point, Gawande writes about personal "saves": situations where drastic harm and possibly death were avoided. The checklists cause the whole team to work together: although this is the age of The Hero, Gawande believes a checklist requires teamwork, and that the usage of it makes the save a team project.

I've been thinking a lot about this book for the last week, since I finished it, and how checklists could help in animal welfare- where they would be useful. Modern animal welfare seems such a divisive, maverick-favoring kind of place (think of the big names in no-kill and dog training- it's almost cult of personality). Checklists in animal dispositioning may help slow down the process, and rather than dictating an outcome, force a return to the basics. Pause points- evaluation of the temperament, health, options- might lead to better outcome for each animal. The resistance to the idea would be immense- "we don't have enough time!"- "I don't' want to work with them!"- "it's working just fine!"- but as in the airline and medicine fields, might increase the live-release rate. Imagine a group of animal welfare leaders from all types of shelters sitting down to design a checklist that has just a few questions for each pause point: intake, assessment, disposition. The possibilities are endless. The questions have never been asked, at least not systematically.

2 comments:

Joni said...

"how checklists could help in animal welfare"

I agree! It would help save more shelter pets' lives to have a good check list that one goes through. Not sure of what all should be put in the list but do feel it would be a great help.

The shelter intake person could have a check list for each pet taken in. Starting with, 1. Smile and remember that you are here to serve. Do it to the best of you ability. 2. Ask person to fill out a form or ask them the questions as you fill out the form (paper or computer). Don't skip anything. 3. If a person is giving up a pet ask them for some reasons that the pet would make a good pet for someone else and what they feel would be the best type of home for this pet. 4. Ask if the pet is up to date on shots and heartworm meds. 5. Take the pet's photos while the owner is there and the pet is not as frighten as when left alone in the shelter with people it doesn't know. 6. Let the person know that pets can be sponsored and that this can influence pet rescuers to take on this pet. 7. Ask them if they would like the option of taking the pet back if the pet is put on the kill list. 8. ? 9. ? 10. ?.

The kennel manage should have a check list to go though for each pet too. And one of these should be, "Have your really done ALL you could to find this pet a rescue or new home?"

themacinator said...

hey joni, nice to see you :)

i think these are great places to start. check out the article i linked to and also the actual WHO checklist and implementation. it might give you an idea of some other places. i found the book really inspirational about all the places this could be applied effectively.

http://www.who.int/patientsafety/safesurgery/ss_checklist/en/index.html