On Wednesday Gawande talked at a Scripps Quality Summit in San Diego about how the 19-point system he and others developed is proving every day that its use can reduce surgical deaths, complications, surgical site infections, and unplanned reoperations.
Death rate dropped from 1.5% to .8%; complication rate from 11% to 7%; surgical site infections, from 6.2% to 3.4% and unplanned reoperations, 2.4% to 1.8% as measured within the first 30 days in eight hospital sites globally, after his surgical checklists were adopted, he said.
He also talked about how hard it is to get providers to adopt those checklists, that they are controversial, and listed some of the reasons many providers are resistant, even with so much evidence that they improve care. Gawande told his audience that providers largely think they alone are responsible for the treatments they administer to one patient, but in fact, it takes 19.5 full-time equivalent positions to make that process happen.
Gawande recounted one bone-chilling example of how the failure to perform one thing – the administration of a simple vaccine that should have been part of routine medical procedure – caused the system to disastrously fail for one young man.
It was the story of Duane Smith, a 34-year old grocery store worker from Texas, who got in a terrible vehicle collision while driving in Boston.
"He'd had a broken leg, broken pelvis, broken arm, bilateral lung collapse and internal bleeding from an unknown source. The team that took care of him worked like clockwork. The EMTs got on the scene immediately. They extracted him, gave volume resuscitation, and kept him alive. They transported him rapidly to the nearest level one trauma center.
"There in the emergency room, they enumerated and found every injury, identified bilateral lung collapse and needed chest tubes, confirmed the bleeding was not coming from his chest and moved him to an operating room so that his ruptured spleen (could be) removed."
Smith spent the next two weeks in the intensive care unit and survived. And was grateful for how hard so many people worked to save his life, Gawande recalled.
But the hospital team missed a crucial step. The spleen functions as part of the immune system to fight bacteria, and when it is removed, patients have to have vaccines to protect against infection.
"The surgical team thought the ICU should have given it and the ICU thought the surgeon should have done it and both thought the primary care provider should have remembered. Maybe they all just forgot. But it didn't happen," Gawande said.
Two years later, Smith was on the beach with his family when he got an ordinary strep infection that landed him in the intensive care unit at the tether of his life.
"He survived, but not before losing all his fingers and all his toes, his livelihood, and the ability to care for his family and simply be the person he wanted to be. It was, he said, the worst vacation ever."
Then Gawande clicked the next slide. There was Smith, sitting on a curb, without those portions of his limbs.
As much as the doctors and healthcare executives in the audience sat in rapt attention, that wasn't Gawande's punchline.
"The damning thing wasn't that this happened. The damning thing was that no one learned anything from it. The story is repeated. We had the exact same thing happen in my hospital, with a worse outcome. And it's happening all over the country. We missed this basic unglamorous step about half the time when the spleen gets removed. Why?"
A Rhodes Scholar, MacArthur Genius award winner, Harvard Medical School Graduate, and author of books about healthcare and topical essays that are frequently published in the New Yorker, Gawande has emerged as a healthcare rock star.
He flies around the country a lot giving inspirational talks to leaders of systems trying to improve, even while still pushing the research envelope trying to find better ways to prevent mistakes, improve care and lower costs.
These days, when he's not in the operating room removing endocrine tumors, Gawande works on checklists. "It's a gamble. But I want to do something that might make a difference," he said.
In "The Checklist Manifesto," he describes his work with the World Health Organization's project to reduce surgical errors through the use of a 19-point checklist, which could be adopted in poor hospitals in developing countries as well as wealthy hospitals in the developed world.
Today, only 25% of American hospitals have adopted surgical checklists, Gawande told this Scripps audience. For whatever reason, he says, to get surgeons to make such a change in their approach "has been immensely hard."
For starters, the most controversial idea for teams to accept is perhaps the simplest item in the checklist. Require all team members say their names prior to the launch of the procedure.
"This has been one of the most important things that help people feel comfortable speaking up" if they're unsure or unclear, for example, that this is the right patient, right site, right procedure.
"It acknowledges that you're part of a team and are allowed to speak."
Gawande says that there has been resistance to accepting checklists at another level. "The concept has forced us rethink what it means to be great at what we do. And I hadn't grasped this until I saw it recur over and over again. There's a set of values in the idea of a checklist, and they're in distinct conflict with some of the values we have in medicine.
"We value physician autonomy, which works well when there are just two full time equivalents providing care, but when we have 19.5 FTEs trying to make things work, it becomes a problem."
His three values that he thinks providers should embrace are these:
1. Humility. "Recognize that no matter how smart we are, how well-trained, no matter how much experience, you will fail. You won't have it all together every time, every day.
2. Discipline. The way you overcome failure is by doing the same thing the same way, every time, over and over. Appreciation of that second value, he says "could save us."
3. Teamwork. "The belief that other people, no matter their station or specialty or background, can save you from an error."
Gawande is not slowing down. Now, he's busy developing more checklists for various procedures in neurosurgery, and then there's another project for checklists when surgeries start to go wrong. Anaphylactic allergic reactions, cardiac arrest, malignant hypothermia, hemorrhage are a just a few of the things that can and do go wrong.
He's also working on a checklist to help physicians and other care providers know how to discuss end-of-life care with terminally ill patients, perhaps the one topic physicians are most likely to avoid having, even when it matters most.
Gawande participated in a panel discussion with some Scripps leaders, and as the questions started to run their course, he brought up the topic of healthcare reform, and the fate of the Affordable Care Act legislation, now awaiting another year's worth of debate before the Supreme Court decides to weigh in. Or not.
"We go outside now to a deluge of negativity. And I find it depressing, this national debate on FoxNews or MSNBC. The reform bill is a disaster or the alternatives are a disaster. And it can feel like there's no way forward.
What we will brace ourselves for is a year of fighting over whether we will repeal or defend, and neither of which I where I want to be, or where you want to be.
"Where we want to be is we want to improve, because whatever comes out of Washington will be imperfect.... And none of that debate is by people who are making care for people better day in and day out.
"We need one community, just one, that will lower costs and make care in their system better. And the rest will follow. Washington and Sacramento won't be those communities, but this one could be," Gawande said.