Transformation: The Checklist.

31 January 2015

If you want to see me get passionate about something, ask me about the Checklist.

The WHO Safe Surgery Saves Lives - Safe Surgical Checklist (aka. the Checklist) is a tool that was developed by the World Health Organization (a bunch of really smart people) a few years ago.

The WHO version looks like this:

If you've had surgery in the half decade or so you will recall being asked several times on the day of your surgery who you are, what you are having surgery on, etc.  When they asked me those questions before shoulder surgery a few years ago, I thought to myself, "huh? aren't you supposed to know this?" well, now I understand - they DO know it, they are just verifying it, as a part of the checklist.


Because we are all human. And humans, by very nature, make mistakes, forget things, or make assumptions.  The example my friend and colleague Michelle always uses is we know we are supposed to floss our teeth. We know it's a good thing and it's beneficial to our health for numerous reasons. However, we don't do it every day.  After we go to the dentist we might be good at it for a month or two, but eventually, we skip it one night or forget one morning. The same is true for washing our hands.  We all know the benefits of washing our hands, but do we do it enough? Probably not.

So if you take that to the medical arena, what if your surgeon misread your chart and took out your gall bladder instead of your spleen? Or what if the anesthetist that met with you the night before falls sick, and the replacement doesn't know you're allergic to a certain drug?  Or when the gauze they use in surgery gets bloody and they can't see it, and it gets left behind in your body? These things happen, and if you do the research, it happens far too often.

But that's the idea behind the Checklist.  Read this book: The Checklist Manifesto.  It's written by the guy who spearheaded the writing of the checklist, but it's super applicable to just about any job. I've started making checklists for just about everything - because we can't be expected to remember everything, all the time.  Trust me, you will be glad you read it, no matter what arena you work in.

But I digress.  So that's my lay-reader version of what is the checklist.  Why is it important? It's been PROVEN to decrease operating room mortality by about 50%, and complications and infections dropped very significantly as well.  And it isn't fancy, expensive equipment, or new drugs, or huge investments of time or capital.  Meaning it can have as significant an impact in Minneapolis as it does in Nairobi or Toamasina, regardless of resources. (Read more about the Checklist and research to it's effectiveness here: WHO Safe Surgery)

So with all that you are probably thinking "well, that seems simple enough. Just tell people about it and they will use it!"  ... if only it was that easy.  Behavior change is hard, and just because you know you should floss your teeth doesn't mean you actually do it. Just because you know you should use a checklist before surgery doesn't mean you actually do it.

So one of the big projects we are working on as a part of our medical education program is trying to figure out how to implement the checklist.  How can we go beyond just explaining why it is important, where everyone nods their heads and agrees, to actually seeing successful implementation in 100% of surgical cases?

We don't have the answers, but we are trying.  We did some intense work in Congo last year with some positive immediate results and I'm looking forward to returning there soon to see how they are doing. Here in Madagascar we are working with the local hospital in re-writing the checklist (the WHO version is a guide, meant to be modified to fit each practice and hospital).  We have been doing a lot of simulations, getting them to try it out and get comfortable with it before trying to implement it under the stress of having a patient on the table.  It's going well, and hopefully in a few more months we will have a great success story to write!  This week I head out with a team to travel to other hospitals in Madagascar and try some different methods; more intensive teaching for a shorter time frame, etc.  

It's our hope that through this simple checklist that we could see transformation of surgical care in this country, and in the world.  It's exciting work to be a part of - thank you for your prayers and support!!

Me helping the local team go through simulation training.

Talking through the process in the OR

1 comment :

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