Viewing by month: March 2010

The Checklist Manifesto

The Checklist Manifesto by Atul Gawande (author, medical school professor, and surgeon) tells the story of the development and assessment of the Safe Surgery Checklist for the World Health Organization (WHO).

Along the way, Gawande treats us to stories of near misses and failures in medicine and air flight and shows how the events led to the development of checklists. He also examines other industries that have gotten so complex as to invite checklist use: investment analysis, skyscraper construction, and even the repeated preparation of meals at a fine restaurant.

While it is hard not to picture the smile on his face when Gawande takes the captain's seat in a Boeing 777 simulator, for me the most interesting aspects of this work are not the author's ventures into these other highly complex industries; but two simple aspects of checklists:

1. They are hard to write well
2. They promote communication

When Gawande first tried to use the WHO checklist in his own operating room, flaws appeared: was it to be spoken or just filled out? Some items were ambiguous. Some were unclear. And it took so long it detracted from the patient on the operating table. Off he went to visit an expert at Boeing who had helped develop numerous checklists for pilots. This visit resulted in some checklist guidelines:

• Checklists are difficult to write well
• Be brief, time is important
• Write for the professionals who will use them
• List the critical steps, not the minutiae
• Always test in the real world!

As the WHO task force discussed the possibility of using a checklist, some people with checklist experience mentioned that using them improved communication and sense of teamwork. They said that allowing nurses to "say their names and mention concerns at the beginning of a case, they were more likely to note problems and offer solutions." This spoken introduction of the surgery team was incorporated into the WHO checklist. Communication seems to have been the key resolution when the building industry encountered an unplanned outcome of one of the steps in skyscraper construction.

Even a low tech program Gawande mentions suggests that communication was enhanced. Public health workers in Karachi, Pakistan, delivered bars of soap to impoverished residents and gave them instructions on how to and when to handwash. These people already had soap, but they liked receiving the gift. The main intervention, however, seems to be that this project gave the public health staff an opportunity to communicate with the people who health they were trying to improve.

Do we think that posting pictures and roles of the surgery team by the door to the operating room would have the same results as briefly speaking the same information as the procedure was about to begin? Would mailing the bars of soap with printed instructions produce the same success rate as face-to-face communication?

I come away from this book wondering if the real title is "The Communication Manifesto". Up to a point, all of health care is clinical care. Beyond that point, communication becomes significant, and often affects the patients' perceptions of their care.

I'd be delighted to hear comments on The Checklist Manifesto or on your thoughts about the role of communication in healthcare.

0 comments - Posted by Steve Rauch at 10:39 AM - Categories:

The Great People We Meet

A while back my 4-year old daughter and I were enjoying a day of skiing at Powderhorn. During lunch we were sitting at a communal table and started talking with two women. They were a mother and daughter who had moved to Grand Junction for health reasons several years ago. In true small-world, smaller-town fashion, we discovered that we live in the same neighborhood and I had seen the older woman’s sister some years ago for a diabetes education class.

They shared with me an interesting story of how they had transitioned through different physicians, clinics, and hospitals through their time in the valley. It turns out now they are both recipients of services here at our own Community Hospital. When I told them I work at Community Hospital, they became quite animated and had lots of positive things to say including a comment from the mother about how great the people are that work at Community Hospital. I agreed with her as we continued our conversation. Eventually, we went our separate ways, but her great people comment stuck with me.

Later that same evening, we attended the Moonlight Ski and Campfire event on the Mesa at the Skyway cross-country ski area. Many people on the Community Hospital wellness committee spent lots of time to organize this event. There was an excellent turnout with over 20 employees plus family and friends present.

One person that stands out in my mind is a quintessential cowboy and gentleman named Spurs. Yup, Spurs. He is the friend of a Community Hospital employee who attended the event. Spurs arrived with a flat bad pick-up truck loaded with logs; enough for a week’s worth of fires. Before long he had built a roaring fire, around which many of us huddled. During the evening, he conversed with my young daughter, deftly wielded an axe to cut firewood, and stopped an errant log from escaping the confines of the fire.

As I was leaving a bit earlier than everyone else, I asked Spurs if he would see that my camping table was returned to me. Two days later to my surprise, not only was the table returned, but a long-broken fastening strap had been repaired. What a great guy.

0 comments - Posted by Ray Jensen at 10:54 AM - Categories: