The Checklist: If something so simple can transform intensive care, what else can it do?

Fascinating article By ATUL GAWANDE in the New Yorker Magazine, Annals of Medicine DECEMBER 10, 2007 ISSUE

Selected quotes:

There are degrees of complexity, though, and intensive-care medicine has grown so far beyond ordinary complexity that avoiding daily mistakes is proving impossible even for our super-specialists. The I.C.U., with its spectacular successes and frequent failures, therefore poses a distinctive challenge: what do you do when expertise is not enough?

The checklists provided two main benefits, Pronovost observed. First, they helped with memory recall, especially with mundane matters that are easily overlooked in patients undergoing more drastic events. A second effect was to make explicit the minimum, expected steps in complex processes. Pronovost was surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions.

In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated hundred and seventy-five million dollars in costs and more than fifteen hundred lives. The successes have been sustained for almost four years—all because of a stupid little checklist.

But the prospect pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity—the right stuff, again. Checklists and standard operating procedures feel like exactly the opposite, and that’s what rankles many people.

“The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science. The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia. It’s viewed as the art of medicine. That’s a mistake, a huge mistake. And from a taxpayer’s perspective it’s outrageous.

Which was followed by this book: The Checklist Manifesto: How to Get Things Right – January 4, 2011

If its good enough for surgeons and airline pilots, is it good enough for evaluators?

See also this favorite paper of mine by Scriven : “THE LOGIC AND METHODOLOGY OF CHECKLISTS, 2005

Procedures for the use of the humble checklist, while no one would deny their utility, in evaluation and elsewhere, are usually thought to fall somewhat below the entry level of what we call a methodology, let alone a theory. But many checklists used in evaluation incorporate a quite complex theory, or at least a set of assumptions, which we are well advised to uncover— and the process of validating an evaluative checklist is a task calling for considerable sophistication. Interestingly, while the theory underlying a checklist is less ambitious than the kind that we normally call program theory, it is often all the theory we need for an evaluation.

Here is a list of evaluation checklists, courtesy of Michegan State University

Serious question: How do you go about constructing good versus useless/ineffective checklists? Is there a meta-checklist covering this task? :-)

Here is one reader’s attempt at such a meta-checklist:


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