Organizational Complexity and the Checklist

The New Yorker has a great article on the effects of technology in emergency medical care, with findings that are worth drawing out more carefully. In particular, the article is about intensive care units, where extraordinary measures are taken to keep patients alive. The question the author asks is, what happens when increased organizational complexity leads to errors? And what do we do about it.

A familiar answer is specialization. And in this world, specialization works. Research findings suggest that putting an intensive care specialist on staff (in ICUs in Maryland at least) had the effect of reducing death rates in intensive care units by a third. But the more effective solution seems to be a rather mundane, analog technology: the check list.

The main proponent of checklists in ICU care is Peter Pronovost, and the article details a single arena of innovation, the IV line. The checklist here consists of: “(1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in. Check, check, check, check, check.” This has two effects: 1) it helps with memory recall; and 2) it provides a minimum set of standards in a complex process.

The introduction of checklists in IV line procedures was pretty miraculous:

In December, 2006, the Keystone Initiative published its findings in a landmark article in The New England Journal of Medicine. Within the first three months of the project, the infection rate in Michigan’s I.C.U.s decreased by sixty-six per cent. The typical I.C.U.—including the ones at Sinai-Grace Hospital—cut its quarterly infection rate to zero. Michigan’s infection rates fell so low that its average I.C.U. outperformed ninety per cent of I.C.U.s nationwide. 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.

This begs the questions, why and in what circumstances is something like a checklist a useful organizational tool. What is it? Alex Pang thinks it’s about predictability, and the solidification of practices and standards in the form of a predictable document. I’m tempted to see this as standardization and to start to tease out when and where standardization works and doesn’t. My old friend commensuration seems not really to apply here.

Incidentally, the author Atul Gawande also wrote a great piece a year or so back on the Apgar score and its effect on childbirthing practices. Similar scene, but there the issue is only sort of a checklist – it was a quantification issue.

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