I recently read a story about quality initiatives in medicine in the New Yorker Magazine written by Atul Gawande, a Brigham & Women’s Hospital (Boston) surgeon, that I thought had nothing to do with medicine. I am a WWII history nut who thought I was a World War II desk reference. As proof, my father, two brothers and I went on a whirlwind World War II history tour last summer. We started at Omaha Beach and wound through 4 countries over 10 days, ending in Stiring-Wendel in France where a few awesome French townspeople helped us find and honor the exact spot on the Kreuzberg Ridge where Pfc. Henry O. Robey, my father’s uncle, was killed on March 3, 1945 while trying to liberate the town. A great day I’ll long remember. A long, but great, story for another time.

But I had never heard that my favorite WWII bomber almost never got past it’s maiden flight. In October 1935, at Wright Air Field in Ohio, the four-engine Boeing model “299″ was pitted against Martin and Douglass’ two-engine bomber, with the winner to lead the Army Air Forces heavy bomber direction until 1945. The Boeing Corporation’s 299 was everything the Army could want, so much so a reporter called it a “flying fortress”.

As bad luck often hinders great ideas, such was the case here. Major Ployer P. Hill, the Air Corps’ chief test pilot, got the 299 airborne and seconds later crashed in a fireball, killing himself and one of his 4 crewman. The 299’s 4 engines and other integrated flight systems required constant fine tuning from take-off to landing, as it was far more advanced than other planes of that era. Hill simply had forgotten to unclasp some lever on his rudder and elevator controls. It had been certain disaster when Hill missed that single step.

Renee, our local French guide, dedicated his life to the memory of the American 70th Infantry “The Trailblazers” who liberated his town after years of German occupation (he drives a 70th Infantry jeep flying a U.S. flag everyday in France). Similarly, a group of devoted Boeing test pilots in 1935 honored Major Hill by defeating the complexity of flying Boeing’s 299. They simply devised a pilot’s and co-pilot’s checklist. The list outlined in a step-by-step fashion how the flight crew would:

1. make a pre-flight check
2. perform a takeoff,
3. maintain level flight,
4. land the aircraft,
5. and even taxi the aircraft to and from the runway.

With those checklists in place, the 299 was saved and flew almost 2 million test flight miles with no crashes. The plane, renamed the “B-17 Flying Fortress” went from almost sure failure to one of the most important cogs in the Allied war machine in World War II.

If you listened to U.S. Airways Capt. Sullenberger about how he landed his airplane on the Hudson River without a single fatality, his 30 years experience were guided by the repetition of his using military checklists when he was a fighter pilot.

It is clear from our current experience that medicine, even more so than a B-17, is just so complex that memory alone cannot serve veterinary practice clinicians well. The knowledge base in veterinary medicine grows daily at a fantastic rate. To be expected to be a reliable medical “quarterback”, truly competent in gastroenterology, radiology, dermatology, nephrology, and oncology, among many other disciplines, really requires some help.

For example, the New Yorker reported a summary of a study of 41,000 trauma patients. The collective group possessed over 1,200 different medical diagnoses in over 32,000 unique combinations. It is unreasonable to think of a flow chart or checklist designed to manage all of their care in such a dynamic setting. But if you could manage each of the discrete steps in medical care where problems may arise, maybe that could make a difference. I distinctly remember treating trauma patients that had closed head injuries, but they more often than not also had injuries like splenic or diaphragmatic ruptures as well, which mandated an exponential level of attention, despite sometimes working with unfamiliar EMS agencies or helicopter staff. The same could be said about the interaction of co-morbid disease processes such as diabetes and cardiac disease. It’s usually not the single problem or disease that will overwhelm you, but the introduction of others, and staff and, et.al., into the mix that will harm a patient.

Johns Hopkins critical-care specialist Dr. Peter Pronovost, who had lost his own father to a medical error, was upset enough to do something beyond the call of duty. He designed a 5 step checklist in 2001 to combat JUST the unacceptable number of central line infections he observed in the hospital’s critical care areas. He outlined five general steps to perform, from evidence-based medicine, to avoid infections when putting a central line in. Physicians were supposed to, as a minimum standard of care:

1. wash hands with soap,
2. wipe patient’s skin with chlorhexidine antiseptic,
3. place sterile drapes over entire patient,
4. don a sterile mask, hat, gown, and gloves, and
5. place a sterile dressing over catheter site after line insertion.

The steps sound pretty easy to do, but when JH nursing staff informally observed physician behavior against the checklist, the physicians typically missed steps and infections resulted. When the checklist was formally put into place, only two central line infections appeared during 15 months. Dr. Provonost calculated that their checklist alone had prevented 43 infections, 8 deaths, and saved $2 million in treatment expense. Dr. Pronovost also tackled problems with pain management and incidences of pneumonia in ventilator patients. Physicians and nursing staff were encouraged to write down steps versus intrinsic current “wisdom”, which drastically improved care. Eventually, Dr. Provonost’s dropped the length of stay in a Johns Hopkins ICU by almost 50%.

Provonost’s checklists provided two primary benefits to clinicians:

1. Checklists establish a higher standard of baseline performance, if achievement was previously measured against an informal or loose standard.
2. Checklists help clinicians remember routine care plans in patients undergoing more emergent or multiple disease processes (helps in not forgetting the ABC’s).

I did a little more research on Dr. Pronovost. He recognized a checklist’s power to save not just one life at his hospital, but many lives at other institutions. In that vein, he helped design the Keystone ICU project after health insurers inevitably got wind of his results. Dr. Provonost and others wrote an article in the New England Journal of Medicine (Dec. 28, 2006) about “Keystone ICU”, undoubtedly the largest patient safety collaborative in the world. Building on the Johns Hopkins checklists, the Keystone ICU program was initiated in March 2004 to reduce preventable medical errors, like central line infections and ventilator-prompted pneumonia, in 120 of Michigan’s hospital ICU’s. The Keystone ICU program saved more than 1,500 lives and $165.5 million in health care costs in 15 months by translating simple checklists into applicable interventions for patient safety improvements directly at the patient bedside. Truly a physician-nursing bipartisan effort.

Dr. Provonost was also recognized as one of Time Magazine’s 2008 Time 100 under “Scientists and Thinkers”. He’s been profiled in the New York Times and his checklist methods are being adopted by the entire country of SPAIN. Not too shabby.

Here’s how checklists can help your veterinary practice:

1. Performance measurements are standardized
2. Goals are measurable
3. Generally requires just commitment
4. Initiatives are evidence-based

But potential drawbacks to checklist usage are the typical:

1. Resistance to change
2. Lack of support from veterinarians
3. Eventual lack of follow-through
4. Lack of a culture of patient safety and staff accountability

I have often noted we seem to talk alot about practicing “good” medicine, but how can we prove it?

Here is a way to start. I suggest you start with small steps and work from there. Maybe begin with surgical complications, pharmacy dispensing errors, or even making sure that discharge care instructions are both given and explained to each surgical patient owner. You could then publish your results, and demonstrate your commitment to quality veterinary care to colleagues, staff, and pet owners. Don’t think of checklists as taking away your clinical diagnosing skills, just the repetition of “stuff” your brain is cluttered with that may interfere with a good diagnosis.

This topic won’t go away either. I just heard a broadcast on NPR the other evening highlighting Dr. Gawande’s article and it’s forward-looking template for how all healthcare organizations should operate. You cannot escape checklists now. Good luck.


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