Tag: Dr.Atul Gawande

OM in the News: Checklists as a TQM Tool in Hospitals

surgeryHow can we use the TQM tools in Chapter 6 to reduce deaths in surgery? One tool is a kind of poka-yoke called a checklist (see p. 223). The Wall Street Journal (Dec. 13-14, 2014) quotes Dr. Atul Gawande describing how he worked with a team from the airline industry to design what emerged as just a checklist. Surgical blunders, says Gawande, are “most often basically failures of communications. The checklist had some dumb things—do you have the right patient ? But the most powerful components are: Does everybody on the team know each other’s name and role? Has the anesthesia team described the medical issues the patient has? Has the surgeon briefed the team on the goals of the operation, how long the case will take, how much blood they should be prepared to give? Has the nurse been able to outline what equipment is prepared? Are all questions answered? And only then do you begin.”

The result, after he tested in 8 cities around the world, was that in every hospital that used the checklist, complication rates fell. The average reduction in complications was 35%. The average reduction in deaths was 47%. The system has since been replicated in multiple places. Scotland has implemented it and taught it at the frontlines –and has now demonstrated that 9,000 people’s lives have been saved over the last 4 years.

“The hardest part,” says Gawande, “is to bring the culture that has the humility to recognize that even the most experienced people, even the most expert fail.” Doctors fear these kinds of checklist systems. When he surveyed surgeons 3 months after they adopted it and asked, “What do you think about this approach?” he found that about 20%  really dislike it—“It’s paperwork, it’s a pain in the butt, I don’t want to do this.” But when he asked, “If you’re having an operation, would you want the team to use the checklist?” 94% did.

Classroom discussion questions:

1. How else can checklists be used in hospitals?

2. What other TQM tools can be employed in a surgery process?

Good OM Reading: Big Medicine vs. The Cheesecake Factory

It was back in January, 2011 that we blogged about Dr. Atul Gawande’s excellent book on health care quality called The Checklist Manifesto .  Gawande’s newest piece, “Big Med,”‘ which appears in the New Yorker (August 13, 2012) is an amazing read as you prepare to teach quality management in Chapter 6. He argues that healthcare can must learn from all high-reliable industries, from aviation, to pit crews, to construction, to the Cheesecake Factory.

Gawande writes: “In medicine, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven’t figured out how. Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of 2 or 3, even within the same hospital. Big chains thrive because they provide goods and services of greater variety, better quality, and lower cost than would otherwise be available. Size is the key. It gives them buying power, lets them centralize common functions, and allows them to adopt and diffuse innovations faster than they could if they were a bunch of small, independent operations. Such advantages have made Wal-Mart the most successful retailer on earth.”

Physicians, though, have been mostly self-employed, working alone or in small private-practice groups.   But that’s changing. Hospitals  and clinics have been forming into large conglomerates. And physicians—facing  escalating demands to lower costs, adopt expensive information technology, and  account for performance—have been flocking to join them. Only 1/4 of U.S. doctors are now self-employed—an  extraordinary turnabout from a decade ago, when over 50% were independent.

Enjoy Gawande’s description of his tour of The Cheesecake Factory’s kitchen and the disheartening comparison to a hospital’s medical operations. It’s a good 15 minute investment of your time.

Good OM Reading: The Checklist Manifesto

Here is a popular book that deals with quality issues (Ch.6) in medicine by extolling the use of checklists. Dr. Atul Gawande’s The Checklist Manifesto: How to Get Things Right (Metropolitan Books,2009) will add to your TQM lecture with some interesting examples. Gawande points out that just as airline pilots use checklists before takeoff,  surgeons need checklists, which are proven to reduce mortality from operations.

The medical culture, unfortunately, often includes doctors who are just plain rubbed the wrong way by such a tool. Surgeons, in particular, view themselves as individuals whose skill and reputation are all that is needed in the OR. Gawande uses a WHO study to show that surgical complications dropped by more that one-third when checklists were used.

The checklists includes such items as: making sure everyone in the OR knows everyone else’s name; that blood for a transfusion is on-hand; and that the pre-op was performed correctly. Medicine, he says, has become so incredibly complex that mistakes are virtually inevitable.

The Huffington Post (Jan. 6,2011) has a quick review of the book, followed by a 6 minute video clip of Gawande being interviewed recently on the Steven Colbert show. (Note that you have to scroll down about 6″ to get to the video link). I am not a huge fan of the show, but somehow I think your students will find it hilarious. They seem to understand his humor, and at the same time, Gawande does make  his point about checklists.