Its the Procedure

And Gawande,a Boston-based surgeon and staff writer for The New Yorker,is both a rousing narrator of how old-fashioned checklists have become the new thing in cutting-edge medicine and an advocate for its multi-disciplinary use. But as he makes his case in the competently detailed style of The New Yorker he also,perhaps inadvertently,shines a light on the uncommunicative nature of super-specialist medicine. To the non-medical person,the surprise is not that checklists are so pervasive and useful in aviation,restaurants,disaster management,architecture,etc. The surprise is how late and resistant hospitals have been in adopting this simple tool.

Example: in 2001,Peter Pronovost,a critical care specialist at Johns Hopkins Hospital,came up with a checklist to reduce central line infections from catheters placed in a patients veins. As Gawande tells it,the list was studiedly basic: Doctors are supposed to 1 wash their hands with soap,2 clean the patients skin with chlorohexidine antiseptic,3 put sterile drapes over the entire patient,4 wear a mask,hat,sterile gown,and gloves,and 5 put a sterile dressing over the insertion site once the line is in. Youd think there was no checklist in place because all this is obvious,but Pronovost found that in one out of three patients,one of these steps had been skipped. And when he convinced his hospital to institute the checklist,the 10-day line-infection rate dropped from 11 per cent to zero.

As more detailed checklists have been adopted,Gawande explains that they establish a higher standard of baseline performance and there are two types of checklist,do-confirm performing procedures and then pausing to tick off the stuff that needed to be done and read-do carry out tasks as they are ticked off. But in the super-specialist and hierarchal nature of the modern hospital,they also compel communication,which can be crucial. Drawing lessons from modern architecture and the aviation industry,Gawande underlines the utility of checklists in making sure that decision-making and accountability radiate from the centre or the superspecialist in what are complex tasks involving many people and diverse skills. And the issue,he says,for medicine today is managing extreme complexity. That complexity has been handled by dividing tasks among various specialties,and a checklist is a way of coherently re-assembling those pieces to the benefit of patients. They provide,he says,a kind of cognitive net.

Call it the Mamp;M principle. The American band Van Halens contracts with concert promoters had a clause that a bowl of Mamp;M chocolates be kept backstage,but that there be no brown candy. This provision,which Van Halen reportedly invoked on at least one occasion to cancel a show,was,Gawande finds,drawn from the checklist manifesto. David Lee Roth wrote in his memoir that Van Halen shows involved so much equipment and therefore attention to detail,that the drill for each concert was very complicated. So,they put in that brown Mamp;M embargo into the manual as a test: When I would walk backstage,if I saw a brown Mamp;M in that bowl,well,wed line-check the entire production.