Communication Currents

Check Yourself: Improving Health Care and Performance

April 1, 2010
Health Communication

Notice popular press coverage of Dr. Atul Gawande's new book, The Checklist Manifesto: How to Get Things RightCheck.Devour his easily digestible account of a simple way to dramatically improve the effectiveness of health care and various other occupational activities. Check. Consider the critical role of, and implications for, communication in Gawande's perspective on work life. Check. Devise a pithy method for introducing the checklist principle to Communication Currentsreaders. Check?  

In the penultimate chapter of The Checklist Manifesto, medical writer Atul Gawande portrays the discomfort of Captain Chesley B. “Sully” Sullenberger III with accepting credit for piloting US Airways Flight 1549 to a safe crash landing in Manhattan's Hudson River in January 2009. Sullenberger maintains that his actions in saving 155 passengers, whose lives were threatened by his Airbus A320's encounter with Canadian geese, were merely part of a professional team's discipline and adherence to established protocols. Flight 1549's copilot, First Officer Jeffrey Skiles, turned control of the plane over to Sullenberger and immediately began working his way through checklists for restarting the engines, preparing for emergency landings, and invoking evacuation procedures. In fact, the aviation industry has a longstanding legacy of implementing checklists to overcome happenstance and errors that create deadly circumstances.

Gawande, a Harvard professor and endocrine surgeon, was most interested in the checklist's potential for alleviating failure in health care. He profiles the efforts of Dr. Peter Pronovost to improve critical care by way of the checklist. Pronovost, an intensive care specialist at Johns Hopkins Hospital, represents the contemporary shift to extreme specialization in the medical profession. Despite the acute expertise of pros like himself, Pronovost was alarmed by the frequency with which simple errors, or lack of either attention or anticipation, could have drastic consequences for patients on life support.

Pronovost designed a five-step checklist to prevent the infections that can develop in the lines inserted into patients' arteries and veins. In his own hospital, with adherence to the checklist by care teams, Pronovost eliminated errors such as not washing hands or covering the patient with sterile drapes. Infection rates after ten weeks dropped from 11% to 0% and checklisting was projected to have saved eight lives and two million dollars. Subsequent studies of this and other tasks, such as mechanically ventilating patients and medicating their pain, by Pronovost and later by Gawande and the World Health Organization, similarly supported the power of the checklist to decrease error and to respond to unforeseen difficulties in surgery and treatment.

Gawande's book reveals his discovery of checklists being employed effectively in various industries such as financial investing and fine dining. But it was only in his investigation of the construction of a new building on his hospital's campus that the true understanding of why checklists functioned so well emerged.

Construction had veered from the master builder model, with an expert of great experience and knowledge presiding over all, to an era of intense specialization. Gawande learned that scholars who study the science of complexity distinguish among simple problems (addressed by defined steps like cooking recipes), complicated problems (such as landing on the moon that require many experts of different types) whose eventual solutions are repeatable, and complex problems (raising a child) that feature variable characteristics and unpredictable challenges. Like medicine, construction was prone to each of these kinds of problems.

A structural engineer revealed to Gawande the approach that governed safe construction of the tallest skyscrapers: maintenance of two checklists to cover simple, complicated, and complex problems. A room full of huge, color-coded checklists guided the performance of a myriad of electrical, plumbing, and concrete workers. This prevented the omission of countless necessary but potentially mundane and forgettable steps. Another checklist enforced the regular meeting and discussion of experts in each field to insure progress, but also to solve unanticipated difficulties, such as an uneven upper floor.

According to Gawande, the secret to checklisting is to ensure that “the stupid but critical stuff is not overlooked” and that “people talk and coordinate and accept responsibility.” The secret ingredient to the checklist phenomenon is the facilitation of communication, often in groups. The builders trusted in “the power of communication” and “the wisdom of the group” to solve the complex problems that reminders to do the seemingly obvious do not address.

Communication is emphasized so much that surgical teams and aircraft pilots are instructed in their respective checklists to introduce themselves and their roles before beginning work. This enforced the dedication to discipline that Sullenberger and Skiles enacted over the Manhattan skyline despite having never worked together before. It also empowered a female Jordanian nurse in Amman to demand that her male surgeon replace his contaminated glove before making the first cut of a gallbladder operation.

I was not terribly surprised by a void I noticed in a book labeled as a manifesto. Gawande notes the potential for creating bad checklists that are too lengthy, imprecise, or condescending to users. He recounts the reluctance of proud surgeons and Right Stuff pilots to relinquish their control to a checklist. But what Gawande may have left out of his own checklist for authoring the manifesto was consideration of the potential drawbacks of checklisting.

Of course, adherence to systems of any kind at the expense of freedom to respond and to enact accumulated expertise in the face of adversity is problematic. My own consulting experiences in the welfare context proved that even the best-programmed computer software was a poor substitute for the informed autonomy of the social workers it augmented or replaced. To be fair, Gawande at least implies similar concerns.

His confidence in the nearly inevitable success of groups to solve problems of any kind, no less complex ones, however, flies in the face of what group and organizational communication scholars know. Groups of experts are no less vulnerable to the pitfalls of posing solution alternatives without first understanding problems and solution criteria, over-relying on authority and tradition, or groupthink phenomena such as illusion of unanimity and self-censorship, than were the unfortunate players in the Bay of Pigs and space shuttle Challenger fiascoes.

As a health communication scholar heartened by the progress of medical education institutions in augmenting the interaction skills of health care providers, I shudder to think about surgeons and others who may attach a checklist for communicating with patients to their bedside clipboards.

Finally, I wonder, in an information society such as ours, where products and outcomes of work are often less tangible than a safe landing or building--do checklists offer as many benefits? Will my students profit from a displayed checklist of objectives for each classroom session? How about the work of therapists, career advisers, sports coaches?

In any case, the evidence supporting the thoughtful and adaptive implementation of checklists in appropriate work contexts is impressive and the general advisability of doing so seems inarguable. As does Dr. Gawande, I urge each of us to consider adopting them.