Checking it twice: Lists help improve client service and patient care

Patients receiving improper doses or medications. Doctors making surgical and lab errors. Hospital staff failing to communicate about follow-up care. The trends, concluded Atul Gawande, MD, were more than a bit disturbing. Despite all of the advancements in human medicine—revolutionary technology, groundbreaking research and multimillion-dollar facilities—the human error rate in patient care hovered at unacceptable levels. And no one could figure out why.

Dr. Gawande’s idea for his book, Checklist Manifesto (Metropolitan Books, 2009), came from trying to understand how medicine could be made better. Dr. Gawande, an associate professor at Harvard Medical School and a Boston-area surgeon, says the healthcare industry improves by training people longer and introducing new technologies to get better results. “But despite all the training, human error continued to climb, and we didn’t have any answers,” he says.

Dr. Gawande had his suspicions. As human healthcare had grown more complicated, more chaotic, and more technology-driven, the people in the trenches were losing their way. He had experienced this firsthand through a series of near-disasters in his and other operating rooms.

Investigating human error

What the medical establishment needed, Dr. Gawande was convinced, was a tool to keep it on course—a road map. A complex surgery is like a long drive down a dark and windy road, and doctors need markers to help them complete the journey. As Dr. Gawande investigated, he confirmed his theory. Most human error came not from the technical, complicated part of patient care, but from the mundane side. Poor bandaging, erroneous medication doses, central lines inserted incorrectly—all were errors resulting from tasks that should have been second nature to those performing them.

So what went wrong in those situations? The answer was simple. “A lot of the struggles in our healthcare system arise because we’ve had a vast increase in the amount of knowledge, capability, and complexity we’re expected to manage day to day,” Dr. Gawande says. He began to look at how other highly technical, complex industries handled similar issues. “Areas like aviation and skyscraper construction require lots of training and use lots of technology,” he says. “But they also have a fundamental tool that they’ve adapted to help them—a checklist.”

The airline industry utilizes detailed checklists for almost every aspect of an airplane’s maintenance and use. Skyscraper designers create checklists for virtually every step of a yearlong construction project. So why couldn’t the healthcare industry do the same?

That became Dr. Gawande’s goal. By mapping out the steps involved in a procedure, making sure each team member knew his or her role, and ensuring that the process was followed through and accounted for, could the industry expect to see an improvement? Yes. Every hospital that tested the checklist concept saw a reduction in complications and deaths—anywhere from 18 percent to 47 percent. "A large component of what we do is not about how smart or skilled we are,” Dr. Gawande says. “It’s about how well we manage complexity with a group or chain of people who are all responsible for patients.”

How this applies to veterinary medicine

Midway through the book, Dr. Gawande describes his observations at a bustling, high-end restaurant in Boston. He noticed that certain customers received special consideration from the staff.

“Any customer who had been in the restaurant three times received their own checklist," Dr. Gawande says. “Every aspect of their previous dining experiences was catalogued and available to the staff prior to the customer’s visit—seating preference, special dietary requirements, favorite server, and so on. There’s no reason the same method couldn’t be applied to the top clients at a veterinary practice."

Dr. Gawande says veterinary medicine is a natural fit for the checklist concept. “Checklists can be successful in any industry where there’s a high level of complexity,” he says. In veterinary medicine, people are highly trained and expected to do a great deal of work—which means there’s potential for mistakes. “Human medicine is clearly a field like that, and veterinary medicine is highly parallel,” he says.

A reduction in complications and deaths would obviously be a good thing for a veterinary hospital. But what other benefits might a practice owner expect from implementing a checklist system? This higher standard of medicine would no doubt seep into the community, enhancing the practice’s reputation. Practice owners could also expect to see an increase in staff morale, better overall client service, and, as a result, a more efficient and profitable practice.

Putting checklists to use

Here’s an example of how you could use a checklist with clients at your veterinary practice. Let’s say Mrs. Harris, one of your clinic’s top clients and best referrers, makes an appointment for her dog Henry. The client care coordinator prints off a checklist for Mrs. Harris’s upcoming visit and gives it to the staff that morning. It highlights Mrs. Harris’s preferences and needs and Henry’s healthcare requirements (see page 3). The No. 1 goal of using the checklist is to ensure that Henry receives top medical care. The other main goal is to ensure that the client’s visit is pleasant and efficient.

Euthanasia is another area of veterinary practice that would benefit from construction of a checklist. With clients’ and staff members’ emotions running high in these situations, having a checklist in place would help the process go as smoothly as possible given the circumstances. (Click here to download Dr. Gawande's "A checklist for checklists.") You could also use a checklist for practice management processes, such as hiring or firing employees.

The overall goal, Dr. Gawande says, is to make your business a better one. “Look at your own failures and measure where they are,” he says. “Ask yourself what’s important to your patients and if you’re delivering it. You’re going to be embarrassed at how badly you do. I was with my own practice.” Once you’ve identified these weaker areas, pick the most important ones to address. Maybe it’s a key customer service moment, such as how clients are greeted when they come in the door. Some other interesting points from the book:

> Those who use the system should be sure to fine-tune checklists. “We have not made a checklist with less than 50 revisions before it finally seems like it starts to work well,” Dr. Gawande says.

> Dr. Gawande insists on having team introductions prior to a surgery. Why? “The phenomenon that people observe in committee rooms—and this is true in operating rooms as well—is that people need permission to know that they are allowed to speak,” he says. “And allowing people to hear their name in the room and the role they’ll play activates them for participating. They feel responsible. They feel they have permission to speak up later if there’s something they feel uncertain about.”

> What are the downsides to a checklist? “You run the risk as a clinician of turning off your brain rather than turning it on,” he says. “You want a checklist that puts you through a deliberate process that ensures you’re thinking through everything you need to. It’s not meant to be a recipe for surgery.”

Dr. Gawande, owner of a rambunctious 3-year-old Labrador retriever, is confident veterinarians can implement the concepts behind Checklist Manifesto. “It would be fantastic to see this concept save animals as well as people. If I could have that even remotely be a part of my legacy, it would be amazing.”

For more details on the career of Dr. Atul Gawande, including his books, articles, and more checklist examples, visit gawande.com.

Preferred client checklist sample

Name: Janet Harris

Pets:Henry, 10-year-old black Lab

Scully, 7-year-old yellow Lab

Alice, 12-year-old Collie

>Client likes morning appointments between 10 and 11 a.m.

> Unless it’s an emergency, she sees Dr. Katherine.

> Client needs assistance getting from parking lot to waiting room.

> Client drives black Lexus SUV.

> She brings a leash.

> Client prefers Ted as a technician. If Ted is unavailable, she prefers Mary Beth. Have one of them waiting outside for her.

> Client prefers to wait in the exam room. If one is not available, set aside a corner of the waiting room for her.

> Have Ted or Mary Beth stay with the client until the doctor is ready.

> Ask about her other two pets.

> Ask her if the dog is staying for the day or overnight.

> If the dog is staying, give it a complimentary bath.

> Have Ted or Mary Beth discuss invoice discount with Dr. Katherine.

> Client’s credit card is on file. Do not ask for one.

> Have the bill ready when Mrs. Harris leaves.

> Per client, verbal authorization is sufficient. No signature is necessary.

> Confirm the client’s next appointment.

> Have Ted or Mary Beth escort client and pet to car.

> Dr. Katherine calls the following morning to check in.