Dr. Atul Gawande: Failure and Rescue

Researchers at the University of Michigan discovered the answer recently, and it has a twist I didn’t expect. I thought that the best places simply did a better job at controlling and minimizing risks—that they did a better job of preventing things from going wrong. But, to my surprise, they didn’t. Their complication rates after surgery were almost the same as others. Instead, what they proved to be really great at was rescuing people when they had a complication, preventing failures from becoming a catastrophe.

Scientists have given a new name to the deaths that occur in surgery after something goes wrong—whether it is an infection or some bizarre twist of the stomach. They call them a “failure to rescue.” More than anything, this is what distinguished the great from the mediocre. They didn’t fail less. They rescued more.

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Crisis Checklists for the Operating Room: Development and Pilot Testing

Background

Because operating room crises are rare events, failure to adhere to critical management steps is common. We sought to develop and pilot a tool to improve adherence to lifesaving measures during operating room crises.

Study Design 

We identified 12 of the most frequently occurring operating room crises and corresponding evidence-based metrics of essential care for each (46 total process measures). We developed checklists for each crisis based on a previously defined method, which included literature review, multidisciplinary expert consultation, and simulation. After development, 2 operating room teams (11 participants) were each exposed to 8 simulations with random assignment to checklist use or working from memory alone. Each team managed 4 simulations with a checklist available and 4 without. One of the primary outcomes measured through video review was failure to adhere to essential processes of care. Participants were surveyed for perceptions of checklist use and realism of the scenarios.

Results 

Checklist use resulted in a 6-fold reduction in failure of adherence to critical steps in management for 8 scenarios with 2 pilot teams. These results held in multivariate analysis accounting for clustering within teams and adjusting for learning or fatigue effects (11 of 46 failures without the checklist vs 2 of 46 failures with the checklist; adjusted relative risk = 0.15, 95% CI, 0.04–0.60; p = 0.007). All participants rated the overall quality of the checklists and scenarios to be higher than average or excellent.

Conclusions

Checklist use can improve safety and management in operating room crises. These findings warrant broader evaluation, including in clinical settings.

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Ohio University Commencement Address by Dr. Atul Gawande

On June 11, 2011, I got a chance to do one of the more gratifying things an adult can be asked to do—to return to one’s hometown to give a graduation address, in this case the undergraduate commencement address for Ohio University in Athens, Ohio.

A Townie Speaks

Thank you, graduates and Ohio University, for this opportunity. I am a 1983 graduate of Athens High School. Which means, yes, you invited a townie to give your graduation address. I grew up here watching you, the students, come and go. Perhaps that should make you wonder whether it was foolish to have asked a townie to speak. I’m not sure, after all, how much you want me telling your parents about what I saw as a teenager on Court Street on Halloween nights.

What I want to talk about, though, is the huge impression you, the students, and this university made upon me. My sister and I were born in New York City. Our family moved to Athens when the two of us still had our baby teeth. And among the enduring beliefs I absorbed growing up here is a core American idea: Anything is possible in people’s lives. No one should be counted out.

It might seem strange to have learned this in a small Appalachian town. Thirty-five percent of Athens County’s population lives in poverty, the worst in the state. Almost half of my classmates never made it to college. Yet everywhere around me was also evidence that ordinary people could have extraordinary strength and contain possibilities no one imagined—even themselves.

Much of the evidence was right in my home. My parents were immigrants from India and they had somehow found it in themselves to swim against the tides of rural deprivation (in the case of my father) and of restrictions and low expectations for girls (in the case of my mother) to become doctors, to find their way to New York, to meet one another there and marry against caste restrictions, and to ultimately become regarded as local leaders here. But our town and Ohio University provided the rest of the evidence.

I remember, for instance, Karl Fry, a soft-spoken kid in the neighborhood who sometimes mowed our lawn for five bucks when I was in third grade and once showed me a nest of baby copperheads he’d found. When I was in eighth grade, he went to O.U. and made the ice hockey team. By my ninth grade year, he was a starting winger, and I used to go down to Bird Arena to watch him and the team play. I’d stand up against the glass behind the opponent’s goal where I could see up close the incredible speed of the slapshots he and his teammates unleashed, and feel the force of the Bobcats checking the other players against the boards. It seemed to me I was watching a person I had known and yet never knew existed. Karl and the team won the Midwest College Hockey League championship three times. And he also somehow worked hard enough to graduate summa cum laude in computer science, going on to become a computer systems engineer and entrepreneur.

No one comes to Ohio University anointed for the future. Nothing demonstrated that more clearly than the sports. I was here during the dark years of Bobcat football. You learned not to expect much. But you also learned you could still hope for it. My senior year in high school, the O.U. basketball team thrilled us all by winning a berth in the NCAA tournament. I drove my little red Datsun twenty-two hours down to Tampa, Florida, with three friends and two cassette tapes playing over and over—Pink Floyd, “The Wall,” was on one and Def Leppard, “Pyromaniac,” on the other—and we arrived in time to watch the Bobcats pull off a stunning, down-to-the-last-minute, two-point upset of far higher-ranked Illinois State.

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Atul Gawande Speech

Atul Gawande's "CheckList" for Surgery Success

Listen! Listen! Dr. Atul Gawande Speaks on Healthcare Reform!

Key messages:

1. Between 1999 and 2009, the average annual premium for employer-sponsored family insurance coverage rose from $5,800 to $13,400, and the average cost per Medicare beneficiary went from $5,500 to $11,900.
2. In 1900, more than forty per cent of a family’s income went to paying for food.
3. The government never took over agriculture, but the government didn’t leave it alone, either. It shaped a feedback loop of experiment and learning and encouragement for farmers across the country. The results were beyond what anyone could have imagined. Productivity went way up, outpacing that of other Western countries. Prices fell by half.
4. By 1930, food absorbed just twenty-four per cent of family spending and twenty per cent of the workforce.
5. Today, food accounts for just eight per cent of household income and two per cent of the labor force.
6. Our fee-for-service system, doling out separate payments for everything and everyone involved in a patient’s care, has all the wrong incentives: it rewards doing more over doing right, it increases paperwork and the duplication of efforts, and it discourages clinicians from working together for the best possible results. Knowledge diffuses too slowly. Our information systems are primitive. The malpractice system is wasteful and counterproductive.
7. Among the most important, and least noticed, provisions in the reform legislation is one in the House bill to expand our ability to collect national health statistics. The poverty of our health-care information is an embarrassment.
8. At the end of each month, we have county-by-county data on unemployment, and we have prompt and detailed data on the price of goods and commodities; we can use these indicators to guide our economic policies.
9. But try to look up information on your community’s medical costs and utilization—or simply try to find out how many people died from heart attacks or pneumonia or surgical complications—and you will discover that the most recent data are at least three years old, if they exist at all, and aren’t broken down to a county level that communities can learn from.
10. It’s like driving a car with a speedometer that tells you only how fast all cars were driving, on average, three years ago.
11. We have better information about crops and cows than we do about patients.
12. If health-care reform is to succeed, the final legislation must do something about this.

I have the highest respect for Dr. Atul Gawande.

Hope the government read what he just has written.

Regards,

David

Cost is the spectre haunting health reform. For many decades, the great flaw in the American health-care system was its unconscionable gaps in coverage. Those gaps have widened to become graves—resulting in an estimated forty-five thousand premature deaths each year—and have forced more than a million people into bankruptcy. The emerging health-reform package has a master plan for this problem. By establishing insurance exchanges, mandates, and tax credits, it would guarantee that at least ninety-four per cent of Americans had decent medical coverage. This is historic, and it is necessary. But the legislation has no master plan for dealing with the problem of soaring medical costs. And this is a source of deep unease.

Health-care costs are strangling our country. Medical care now absorbs eighteen per cent of every dollar we earn. Between 1999 and 2009, the average annual premium for employer-sponsored family insurance coverage rose from $5,800 to $13,400, and the average cost per Medicare beneficiary went from $5,500 to $11,900. The costs of our dysfunctional health-care system have already helped sink our auto industry, are draining state and federal coffers, and could ultimately imperil our ability to sustain universal coverage.

What have we gained by paying more than twice as much for medical care as we did a decade ago? The health-care sector certainly employs more people and more machines than it did. But there have been no great strides in service. In Western Europe, most primary-care practices now use electronic health records and offer after-hours care; in the United States, most don’t. Improvement in demonstrated medical outcomes has been modest in most fields. The reason the system is a money drain is not that it’s so successful but that it’s fragmented, disorganized, and inconsistent; it’s neglectful of low-profit services like mental-health care, geriatrics, and primary care, and almost giddy in its overuse of high-cost technologies such as radiology imaging, brand-name drugs, and many elective procedures.

At the current rate of increase, the cost of family insurance will reach twenty-seven thousand dollars or more in a decade, taking more than a fifth of every dollar that people earn. Businesses will see their health-coverage expenses rise from ten per cent of total labor costs to seventeen per cent. Health-care spending will essentially devour all our future wage increases and economic growth. State budget costs for health care will more than double, and Medicare will run out of money in just eight years. The cost problem, people have come to realize, threatens not just our prosperity but our solvency.

So what does the reform package do about it? Turn to page 621 of the Senate version, the section entitled “Transforming the Health Care Delivery System,” and start reading. Does the bill end medicine’s destructive piecemeal payment system? Does it replace paying for quantity with paying for quality? Does it institute nationwide structural changes that curb costs and raise quality? It does not. Instead, what it offers is . . . pilot programs.

This has provided a soft target for critics. “Two thousand seventy-four pages and trillions of dollars later,” Mitch McConnell, the Senate Minority Leader, said recently, “this bill doesn’t even meet the basic goal that the American people had in mind and what they thought this debate was all about: to lower costs.” According to the Congressional Budget Office, the bill makes no significant long-term cost reductions. Even Democrats have become nervous. For many, the hope of reform was to re-form the health-care system. If nothing is done, the United States is on track to spend an unimaginable ten trillion dollars more on health care in the next decade than it currently spends, hobbling government, growth, and employment. Where we crave sweeping transformation, however, all the current bill offers is those pilot programs, a battery of small-scale experiments. The strategy seems hopelessly inadequate to solve a problem of this magnitude. And yet—here’s the interesting thing—history suggests otherwise.

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New Yorker: Atul Gawande on Checklist Video

Excellent video on checklist. Very interesting.

This is a great video for medical professionals as well as investors. In fact, for everyone!

MUST-WATCH!