Aubrey Daniels’ Blog

When I read The Checklist Manifesto: How to Get Things Right by Atul Gawande three things occurred to me.  The first was a joke someone sent me in e-mail last week. “ A man is recovering from surgery when the Surgical Nurse appears and asks him how he is feeling. ’I'm O. K. but I didn’t like the four letter-words the doctor used in surgery,’ he answered.  ‘What did he say?’ asked the nurse.   He said, ‘Oops!’   

The second was a quote by Norman Cousins, longtime editor of the Saturday Review.  After being hospitalized with ankylosing spondylitis, he said, “I soon realized a hospital was no place for a person with a serious illness.”  I would certainly not recommend The Checklist Manifesto to anyone scheduled for surgery.  Even with the impressive gains he reports for hospitals using the checklist methodology, a lot of dangerous things still happen in the surgery suite.  

The third was that team leadership is not a highly developed skill of most surgeons.

Dr. Gawande defines a checklist as a way of organizing that empowers people at all levels to put their best knowledge to use, communicate at crucial points, and get things done. 

I can tell you with certainty that a checklist does not empower anyone to take critical actions required to avert disaster or even to question the actions of other team members.  The history of aviation is filled with examples of co-pilots who will not question the captain of an airliner even when he observes the captain making a fatal error.  Dr. Gawande gives an example of one in his book. The Tenerife airport disaster in 1977 occurred when a KLM plane crashed into a Pan AM flight that was still on the runway.  Twice when questioned about whether clearance to take-off had been given, once by the co-pilot and once by the engineer, the captain ignored them and continued the take-off resulting in the deadliest airline disaster in history. 

Is it possible that even with checklists, a nurse or resident would fail to correct an action of the surgeon?  Dr. Gawande says that Brian Sexton, a Johns Hopkins psychologist, found that 25% of surgeons believe that junior team members should not question the decisions of a senior practitioner.

Dr. Pronovost, who started the checklist idea at John’s Hopkins, said in an interview in The New York Times, “When I began working on this, I looked at the liability claims of events that could have killed a patient or that did, at several hospitals — including Hopkins. I asked, “In how many of these sentinel events did someone know something was wrong and didn’t speak up, or spoke up and wasn’t heard?”

He went on to say, “Even I, a doctor, I’ve experienced this. Once, during a surgery, I was administering anesthesia and I could see the patient was developing the classic signs of a life threatening allergic reaction. I said to the surgeon, “I think this is a latex allergy, please go change your gloves.” “It’s not!” he insisted, refusing. So I said, “Help me understand how you’re seeing this. If I’m wrong, all I am is wrong. But if you’re wrong, you’ll kill the patient.” All communication broke down. I couldn’t let the patient die because the surgeon and I weren’t connecting.  So I asked the scrub nurse to phone the dean of the medical school, who I knew would back me up. As she was about to call, the surgeon cursed me and finally pulled off the latex gloves.” 

I ask you, what nurse, resident or anesthesiologist would have done what Dr. Pronovost did? Consider the power of position, of rules of conduct, and of histories of reinforcement for ‘showing respect’ in the medical field. 

A checklist is nothing more than a job-aid.  We have helped people in all kinds of organizations develop and use them for almost 40 years, so I don’t dispute their value.  While a checklist adds value to almost any process, the real value is determined by what happens to the behaviors surrounding actions required by the checklist.  What Dr. Gawande fails to realize is that he is really introducing a new process into the surgery room.  The checklist only gives him access to opportunities for implementing his process.  It does not empower anyone, it is just another of the tools that assist medical personnel in completing the job in the best possible manner.  If the checklist did what he purports, “empowers people at all levels to put their best knowledge to use, communicate at crucial points, and get things done,” surgery omissions and other errors could be immediately addressed by giving all who enter a checklist to follow.  

In all the successful cases reported in the book, the behavioral consequences were changed for the surgery team.  The task of constructing a checklist forces the surgery team to pinpoint tasks, roles and responsibilities more specifically than before.  In addition, spending time together deciding on content and conduct of the checklist changes the working relationships. 

Most of the places where good results were obtained were places where the surgeon personally introduced the checklist.  This generally produces a different reception of a new process than if someone from Training or Infection Control had done it. By having the surgeon introduce the checklist, at a minimum it implies, even if it is not said, that “I want us to follow this procedure during this surgery.”  This  immediately changes the consequences of speaking up or calling attention to items on the checklist.  It actually increases the probability that the behavior of stopping the process or calling attention to a problem will be positively reinforced rather than punished. Simply taking time to introduce the members of the team to one another before starting the operation, which is not always done, produces expectations in many people that this is a different kind of operating room than they encountered in the past.  Such a seemingly inconsequential step can change the consequences for team member behavior.  Consequences change behavior; checklists don’t. 

In spite of everything I have written, I would not discourage any hospital from using anything that produces a safer experience for the patient.  It is just that when surgeons, and hospital personnel in general, understand the behavior change process, results will be even better and sustained longer than when they think that major improvements can be made and sustained just by creating a checklist.  What saves lives is people doing  the right things at the right time and in the right way.

In my opinion, hospitals, and med schools need to focus on recruiting physicians who are team players and training the existing ones in the science of behavior.  In order for a good process to work anywhere every team member must feel comfortable speaking up when things don’t seem right.  Team members should be positively reinforced for questioning the actions of any team member, not be punished or ignored. While Dr. Gawande might have thought he was saying these things, the focus of his book is on the checklist not the interactions of the team members—the real key to creating and sustaining change. 

Some of the key actions that must be reinforced to produce the best outcome in the operating room are:

1. introducing the team,
2. reviewing the surgery and all relevant facts about the patient,
3. verbally thanking anyone who questions a procedure, calls attention to a step on the checklist,
4. after the surgery reviewing what went right and what was problematic,
5. calling attention to good performance of individual team members during surgery, and
6. modifying the checklist as necessary so that the next team will be able to perform even better than before 

In the final analysis, following a checklist requires behavior.  Whether it will be done well, poorly or at all is dependent on the consequences surrounding them.  Without a good understanding of the behavioral process, checklists have an uncertain future in the operating room or any other part of medical practice.  With it more lives will be saved.