An audacious solution for primary care
From the opening page of the first chapter, entitled ‘The problem of extreme complexity,’ it is clear that Atul Gawande does not take lightly the problem of improving healthcare. He describes how even the best of clinicians in the best of organisations can make a small assumption and care is compromised – or ask a small question and a mistake is narrowly averted. These aren't grandiose musings – but actually the most pertinent. As a researcher, and surgeon, Gawande relates the science of making healthcare better and suggests that predictable processes (well-honed checklists) can be applied to prevent the most uncertain of possible errors. Every day people like us go to work hoping to make people better. Professional discipline, experience, knowledge and practice are put to the test with every patient encounter. A well-read author in the USA, Gawande vividly teases out what we can learn from the realities of healthcare and how to decrease the risk of mistakes that could be made, and are made, at every level.
Improvement of a healthcare system is indeed a science, and this author relates data and lessons learned from the airline and architecture industries, where slight errors may cost many lives. He discusses his role with the World Health Organization trying to implement and study the impact of surgical checklists around the world, including at St. Mary's Hospital in London. His assertions are not easy assumptions, however, that a simple checklist solves all problems. The checklist is not just an administrative process to be imposed on unwitting staff. It is a communication tool, which connects members of the interdisciplinary team to each other and to their complex task at hand. Going through a checklist at the beginning of a multi-faceted process empowers a process for every professional to ask the right questions at the right time, and to identify and address concerns. Are we all seeing the same need for care in the same way? Are there any problems at this step? Can we now move to the next phase of care? The author explores how checklists have been shown to be an elegant vehicle of culture change in other fields, and now in healthcare, with dramatic statistics for quality improvement, including patient mortality and morbidity. Checklists can be applied in a wide variety of settings and tailored to local needs, even in primary care. Research like this can, and should, provide insight for us all.
Dr Gawande goes further though and steps beyond the checklist. He questions our assumptions of the hero as an audacious expert, in medicine and in many other fields. The outstanding doctor as a keeper of all knowledge and wisdom is no longer realistic, if it ever was. There is so much information, so many facets of humans, modern technologies, and the changing healthcare system. How adaptable is the healthcare professional, how disciplined, when the system of care is increasingly complex? With great clarity, Gawande describes the realities of many professionals working together to help patients, and how to avoid error, even when response is needed in the face of innumerable permutations of unpredictable events. He suggests that checklists provide order, not human leaders, and that no single individual can know enough to solve every problem. Medicine is a dynamic practice of high risk, great complexity, and expected uncertainty – errors happen every day. Decentralising leadership – sharing expertise for truly patient-centred care – this is an updated model for improving healthcare, continuously. What would it look like – a system for learning from current data, adapting to unique situations with intelligence, problem-solving with a variety of colleagues, and serving each unique patient? Not a physician gatekeeper, but a valued member of a team – are doctors ready to see themselves in this role? We describe goals for being more efficient in order to lower costs – but best care demands that we are also more effective. Is primary care ready to move forward together with this sort of collaborative vision?