"Get the stupid stuff right"

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In thinking ways in which to provide the best care possible to our patients at GBMC, I came across one recently that looks promising.

If there was a new product on the market that could reduce the rate of major complications in patients undergoing surgical operations by 36% and mortality rates by 47% would it be worth the investment? With 30 OR’s and 32,000 surgical procedures per year and a NSQIP mortality rate of 0.68% and an HSMR rate of 0.65%, perhaps we don’t need this new product. With healthcare reform still somewhat in the works, this new product might not be cost effective. Besides we have other priorities, such as showing that our EMR meets all the meaningful use criteria set forth by the federal government, making sure we can provide access to the newly insured and keeping a strong bottom line. But, just what is this new product? Perhaps we should make this investment, but what will it cost?

It turns out, it costs almost nothing. It’s the World Health Organization’s Surgical Safety Checklist. Published just over a year ago in the New England Journal of Medicine why hasn’t the surgical world embraced a tool that has been shown in a world-wide study to reduce morbidity and mortality? The answer is probably, us, the surgeons. It’s just not our culture. After spending a recent Sunday afternoon reading Atul Gawande’s new book, The Checklist Manifesto, I was struck, not only by his usual engaging review of the origin and use of checklists in other industries, but by his personal journey from skeptic to advocate. From the B-17 flying fortress that was felt to be too complex to fly, to the construction of modern skyscrapers, to the operations of a restaurant’s kitchen, Gawande shows that complex tasks can be completed with ease when managed by the use of checklists. Checklists help us not to forget the important things. They need to be simple and embraced as important tools to perform complex activities, like landing a jetliner or performing surgery.

For the past six months I have been using the WHO Surgical Safety Checklist in my OR’s, just to try it out and see how it feels. It’s different from our usual “time-outs” in a couple of ways. First it is divided into three parts: before induction of anesthesia, before skin incision, and before the patient leaves the operating room. It is a structured communication tool. It fosters teamwork as each member of the team, stops and introduces himself or herself by name and states their role. We use first names, like the airlines. It allows for communication between the surgery and the anesthesiology teams that is all too frequently absent. Besides checking for the proper patient identification, verification of the site of the procedure and consent, we confirm the proper functioning of equipment, the risk of excessive bleeding, review the critical steps, anesthesia concerns, and confirm the administration of prophylactic antibiotics as well as thromboembolism prevention. This 19-step checklist process takes less than sixty seconds to complete.

In order to ensure lasting adoption of this tool we are working to develop a process that will emphasize the results that can be gained with its use and align the most resistant members of our surgical teams so that they can become checklist champions. We will also look for other areas in the hospital, both in patient care settings and in operations where checklists will allow us to, as Gawande says: “get the stupid stuff right”.

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