Problems With Protocols

April 12, 2010

Atul Gawande, a Harvard surgeon and New Yorker staff writer, has recently become a leading voice in public health policy. His essay last year on the high cost of care in McAllen, Texas—where entrepreneurial doctors overuse expensive imaging machines—helped explain why fee-for-service reimbursement systems may need to be overhauled. His 2007 essay on how stupid mistakes in surgery can be largely eliminated through the use of pre-operative checklists was a startling reminder of the big effects that simple reforms can have. He has now expanded the essay into a book, “The Checklist Manifesto,” in which he seeks, less successfully, to generalize the checklist lesson to many other human activities.

Dr. Gawande is at his best when telling stories from the operating room. A body cavity fills with blood because the surgeon—Dr. Gawande himself—has mistakenly cut an artery. But the nurse has dutifully complied with her checklist and has made sure that four units of blood are readily available. The public-health implications of formal checklists in surgery are remarkable. At Johns Hopkins, strict cleanliness protocols reduced central-line infection rates (for example, infections caused by inserting a catheter into a vein) from 11% almost to zero. When hospitals in Michigan tried the protocols, the results were equally dramatic, saving hundreds of lives.

Accomplishment is personal. That’s why giving people the freedom to take responsibility is so important. Organizational techniques can be useful—we all rely on checklists informally—but formal protocols can disrupt focus and undermine success in many life activities. Dr. Gawande is right to note that checklists are indispensable in situations where a small mistake can lead to tragic consequences, as in surgery. But his call for a broad checklist regime would be counterproductive—fraught with all the dangers of bureaucracy and excessive law.

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