Check

Atul Gawande has a terrific article in last week's New Yorker on an information technology that, after several years' testing, looks like it could transform intensive care. It's mainly been used in the reduction of line infections, which Gawande explains are

so common that they are considered a routine complication. I.C.U.s put five million lines into patients each year, and national statistics show that, after ten days, four per cent of those lines become infected. Line infections occur in eighty thousand people a year in the United States, and are fatal between five and twenty-eight per cent of the time, depending on how sick one is at the start. Those who survive line infections spend on average a week longer in intensive care.

This new technology was developed a few years ago by Johns Hopkins professor Peter Pronovost. After the first trial using it in a hospital,

The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from eleven per cent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital... [it] had prevented forty-three infections and eight deaths, and saved two million dollars in costs.

For years we've heard that information technology could solve some of the most tractable problems with our health care system, and this seems to make that promise true. So what is this technology?

A checklist.

Not a gigantic database, or RFID tags in unconscious patients, or steerable needles (which boffins at UC Berkeley are now working on); but pieces of paper listing the steps you're supposed to take when doing something. You know what they are.

So why are they good-- good to the point of being able to save lots of lives and millions of dollars in an average hospital? Checklist offer

two main benefits, Pronovost observed. First, they helped with memory recall, especially with mundane matters that are easily overlooked in patients undergoing more drastic events. (When you’re worrying about what treatment to give a woman who won’t stop seizing, it’s hard to remember to make sure that the head of her bed is in the right position.) A second effect was to make explicit the minimum, expected steps in complex processes. Pronovost was surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions. In a survey of I.C.U. staff taken before introducing the ventilator checklists, he found that half hadn’t realized that there was evidence strongly supporting giving ventilated patients antacid medication. Checklists established a higher standard of baseline performance.

Tools like checklists aren't just accidental media containing information; when you look at how they're used, they turn out to be aids to memory, objects that help standardize what can be chaotic practices. Under some circumstances, they're tools for diffusing practices and raising standards.

The power of checklists rests in their simplicity, particularly the simplicity of their use. Documents behave predictably. That predictability, I would argue, in turn is important for its incorporation into work practices. With a checklist, you can easily see that steps have been followed: it's a bit like how strips of paper in air traffic control centers serve as tools for tracking who has responsibility for a plane.

Comments

[Jason Downs]

Sounds good in theory (and practice), but the problem with lists is that they 'trap your thinking'. Don't beleive me? Give someone a problem with multiple (say, 4)solutions, and then provide them with a two X two matrix that seems to provde a solution. Chances are that 99/100 time all you get is an answer that fits into one of the boxes. Ever thought that maybe there might be 6,7,8,9,10 etc solutions? We've been trained to think that the tool (the checklist/matrix) solves the problem. While you are busy following the checklist, you are not thinking for yourself. Sure, you might be adjusting headrests, but are you paying attention to numb fingers? What about sweaty palms? There has to be a balance; and checklists don't provide balance. The secret is to start with the checklist and then switch to independant, creative thought in order to solve problems. The challenge is that most people don't make the jump.

Be careful about offering checklists as solutions. Most of the time checklists only save the lazy and useless from making simple mistakes.

Maybe a better solution would be to properly train (and then provide ongoing training) to professionals who aren't financially tied to 'thruput'. Ask if the system demands quickness instead of care.

Seems harsh? Consider this the other end of the balance.

[Alex Soojung-Kim Pang]

Jason, Point taken. And certainly all lists or workflows tend to concentrate attention in ways that can be counterproductive.

I think that where something as simple as checklists can make an unambiguous difference for the better is in complex, high-risk situations. Gawande talks about how bomber pilots during World War II adopted checklists to help them fly increasingly complex planes. Likewise, doctors and nurses in ICUs have to make hundreds of small decisions every day, often under pretty stressful conditions; the experience with using checklists when inserting lines radically decreases infection rates, because they serve as reminders of all the things you have to do to put in a line correctly.