Checklist manifesto


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Checklist manifesto

  1. 1. The Checklist Manifesto - A Review Astha Gupta, M.Sc MHA PAHM
  2. 2. How to get thing Right 2 “1000 things can go wrong when you’ve got a patient with stab wounds” Anaesthesiologist used the wrong concentration of Potassium No one remembered to ask the ER team what the weapon was
  3. 3. How to get thing Right 3 “1000 things can go wrong when you’ve got a patient with stab wounds” Two main reasons of failure • Ignorance (Don’t know or know partially) • Ineptitude (Know but fail to apply) • Ignorance (1950s – heart patient put on bed rest for weeks in order to avoid strain to heart) • Ineptitude (2006 - only 50% of hospitals had achieved door to balloon of less than 90 min)
  4. 4. Healthcare and its extreme complexity 4 • Complexity at two levels • Diagnosis – ICD 10 14000 codes with open sections for further specificity. ICD-10 CM 68000 • Treatment – 24 hours period in an ICU requires 178 actions either by a nurse or a doctor In Indian ICUs, the rate of vancomycin-resistant enterococcus (VRE), a dangerous hospital infection, is five times the rate in the rest of the world • What do you do when expertise is not enough? • What do you do when super-specialists fail?
  5. 5. Learning from similarly complex sectors 5 Aeronuatics • 1930s saw a major crash of Boeings newly commissioned aircraft • Since then, the same fleet has completed 1.8 million flights without a single accident But we are much more complex • 41000 trauma patients in one state in US led upto 32261 unique combinations of diagnosis Think again • Nursing uses a simple checklist which forms the basis of most complex diagnosis till date • John hopkins – 5 point checklist for preparation towards inserting a central line reduced ten day line infections from 11% to zero (2001)
  6. 6. 6 Helps in memory recall Organises tasks Argument remains…Human body is far more complex!!!!
  7. 7. Learning from similarly complex sectors contd… 7 Construction • Building is a like a human body • Involves 16 separate specialities to come together • Checklist for • Every tasks under the plan • Every foreseen adversary • Communication and handling of the unforeseen • Checklist work – 0.00002% rate of building failures
  8. 8. 8  Helps in memory recall Organises tasks Essential to complex environments Helps in decision making
  9. 9. Learning from similarly complex sectors Contd… 9 Investment Funds • Multiple levels of study • Financials, culture, market outlook etc • Growth prospects etc • Multiple teams working together • Sectors of investment can be as varied as healthcare at one and mining at other end
  10. 10.  Helps in memory recall  Organises tasks  Essential to complex environments  Helps in decision making 10  Inculcates discipline into the process  Process back in focus “FLY THE PLANE”  TEAM WORK
  11. 11. Why Us? 11 • Volumes of surgery exceeds the global totals of childbirth only with death rate 10-100 times higher • Surgeries leave 7 million people disabled and 1 million dead every year. (A rate comparable with any public health concerns like malaria, tuberculosis etc) • The unhealthy proposition of healthcare “One in four surgeons believe juniors cannot question seniors” 64% 39% 28% 10%
  12. 12. The Worrisome Replacement 12 Healthcare Skill Trustworthiness Selflessness Discipline
  13. 13. The Worrisome Replacement 13 Healthcare Autonomy
  14. 14. The WHO Intervention 14 Checklist - The soap of surgical care • Simple • Transmissible • Measurable Counter the four roadblocks of Surgery • Infection • Bleeding • Unsafe anaesthesia • Unexpected - Communication The pause points • Before Anaesthesia Seven Checks • After Anaesthesia Seven Checks • Before Wheeling Out Five Checks
  15. 15. Good Checklist 15 • To the point • Easy to use • Does not spell out the steps • Reminders of the most important and critical steps (Data suggested as most critical and most frequently missed) • Makes priorities clearer • Has simple and exact wording • Always in sentence case • The pilot flying cannot start the checklist (he has a task at hand running through his head) • 60-90 seconds Do Confirm Read - Do
  16. 16. What checklists cannot do 16 Make people use them Be applicable for all conditions Decide inclusions/exclusions Tide over hierarchical structures Increase workload
  17. 17. Essential to Implementation 17 • Top down push for bottoms up implementation • Customized to situation with common DNA • Display positive effects with complying few • Those essential to implementation need to be pulled in via management • Can lead to change in established practices
  18. 18. Way Ahead 18 Specialised Checklist • Hip Replacement Disaster/Emergency Control • Like in Aviation Team work and discipline
  19. 19. About the Author 19 • Atul Gawande is an Indian American surgeon and journalist. • He is widely known as an expert on reducing error, improving safety, and increasing efficiency in modern surgery. • General and endocrine surgeon at Brigham and Women's Hospital in Boston, Massachusetts • Associate director of BWH Center for Surgery and Public Health. • Associate professor at Harvard School of Public Health • Associate professor of surgery at Harvard Medical School. • He has written extensively on medicine and public health