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The value of checklists in ensuring that basics are followed…

by
01 March 2015, at 12:00am

PERISCOPE continues the series of reflections on issues of current concern

THE Government has announced an initiative whereby the cases of 2,000 patients who later died while in NHS care will be reviewed annually. The purpose is to expose deaths that were avoidable and for hospitals to be ranked according to their avoidable mortality rates.

This will ultimately allow the public to make informed choices about where they want to receive their care and presumably drive the worst hospitals to change their procedures with a view to improving their success and patient survivability.

It is estimated that there are about 12,000 avoidable deaths each year in the NHS, more than six times the number of people killed on the roads annually.

If 12,000 people died on the roads each year, or in plane crashes, there would be a national outcry. So why has this state of affairs been allowed to continue up until now?

I suspect one of the prime reasons is that not many people know about it. Whilst most of us can probably recount an incident where a friend, family member or acquaintance has died unexpectedly whilst receiving care, we are probably not aware of the sheer scale of the problem.

And when one considers the millions of people who are treated by the NHS each year, perhaps 12,000 deaths does not seem like poor odds. But millions of people travel on the roads and fly in planes each year too and the safety record of both is continually improving. It is timely that the Government has decided to step in to try to improve the situation.

Coincidentally, I happened to listen to the BBC’s Reith lectures a few weeks ago. This year they were given by the eminent American surgeon Atul Gawande. I recommend them wholeheartedly to you and they are available on the BBC iPlayer on the Radio 4 website.

Atul Gawande is currently a Harvard professor of medicine and at only the age of 26 became adviser on health and social policy to Governor Bill Clinton when he ran for President. In addition to his career in hands-on medicine and surgery, he is a writer, thinker and political analyst on medical matters.

You only have to hear him speak to realise that he has a powerful intellect and a real grasp on the big issues and wide picture. And he is not afraid to challenge and sometimes upset the status quo.

The reason I bring up his lectures is that some of what he was saying is very relevant to the issue of avoidable deaths in the NHS.

In his first lecture he spoke about an essay he had read, written in 1976 by two philosophers, Samuel Gorovitz and Alasdair MacIntyre.

The essay was on the nature of human fallibility and they proposed that there were two main reasons why humans might fail.

The first was ignorance, i.e. the fact that at any given point in our development we have a limited understanding of all the relevant physical laws and conditions that apply to any given circumstance.

The second reason they called “ineptitude”, meaning that the knowledge exists, but an individual or group of individuals fails to apply that knowledge correctly.

Fear of self-reflection

It was this issue of “ineptitude” that Professor Gawande spoke about in his first lecture. He spoke about our reluctance to look into our own fallibility and ineptitude through fear and perhaps a feeling of shame or guilt if we are found not to have got things right all the time.

And he suggests that exposing this ineptitude can make people angrier than exposing the fact we are simply ignorant. Which, he says, is why there is frequently resistance to having greater transparency about what goes on in medicine, perhaps through the presence of audiotapes or video cameras in hospital clinics or operating theatres.

Imagine what would happen to an airline if it became known that all its pilots refused to have black box recorders on the flight deck. Who would voluntarily fly with such an organisation that must clearly have something to hide?

And that, of course, is why so much effort is put into finding the “black box” whenever there is a crashed plane. Firstly, it is to satisfy our curiosity as to what happened; but, more importantly, it is so that we can learn from the incident and rectify any mistakes/failings/ ineptitude in the future to prevent a repeat occurrence. Such is the way that air safety is constantly improved so that it is now one of the safest forms of transport.

So Professor Gawande argues that there are lives at stake from not turning on the video cameras or through keeping data on the complication rates at different hospitals locked behind closed doors. And he argues that to embrace such transparency might lead to miraculous improvements in results.

Complexity of disease

His second lecture focused on the complexity of disease and the sure fact that large percentages of people (the majority in most cases) diagnosed with things like asthma, hypertension and mental health conditions receive inappropriate or incomplete care.

He suggests that this complexity occurs across the board outside medicine from software, the banking system, the police investigation of murders, to name a few. He says that the real problem facing us is that there is so much knowledge out there that it has exceeded an individual’s capability to retain and implement it.

This century, he says, is the century of the system. And to improve the care given in medicine, systems such as checklists need to be developed in order to ensure that even the most expert and skilled of doctors follow the basics that are known to give good outcomes.

He gives a concrete example of how he helped developed a checklist, with the help of experts from the airline industry, to reduce the number of deaths as a result of surgery. It was trialled in eight cities around the world, in the USA, Canada, the UK, India and Tanzania, and in every hospital where it was used the experts found their complication rates fell by an average of 35%.

The average reduction in deaths was a staggering 47%. Apparently the system has been replicated in Scotland where it is taught at the front line and it’s been demonstrated that 9,000 lives have been saved over the last four years as a result.

Professor Gawande went on to say that when surgeons were interviewed three months after adopting the checklist, 20% said they really didn’t like it. But when questioned as to whether they would want it used if they were having an operation themselves, 94% said yes. As Professor Gawande says, discipline makes daring possible.

So perhaps the annual review into NHS hospital deaths that is now to take place will result in a substantial drop in avoidable mortality and we will all surely applaud that.

The challenge for us as vets is how we start to implement similar systems in our own practices and become more transparent about our own successes and failures.

I have no doubt that there is much we can learn if we adopt this approach but I suspect it would be a huge challenge to overcome the resistance that such change would inevitably create.