A Checklist That’s Saving Lives

The best ideas are often the simplest.

When Peter Pronovost was a fourth-year medical student at Johns Hopkins, he worked briefly in a mission hospital in Ogbomosho, Nigeria. On any given day, hundreds of people lined up outside the clinic. While treating cases, he realized many problems—infections from bad water, burns from people carrying lighted oilcans on their heads to see at night—could have easily been prevented.

“Every day there was this line of people. No matter how hard I worked, it would not go away,” says Pronovost. “That’s when I realized that you can’t fix a health care system without also addressing social policy—in this case introduce electricity and water purification.”

Pronovost was no stranger to problems with the health care system. Before traveling to Nigeria, his father passed away from cancer that was misdiagnosed. By the time the correct diagnosis was made, it was too late for treatment.

“These and other experiences led me to believe that to improve healthcare, you have to affect policy,” says Pronovost. “That’s when I got the idea for the checklist.”

The checklist is as brilliant as it is simple. In a modern hospital, countless critical and complex procedures take place every day. In some cases, a single mistake could mean the difference between life and death. So how do you make sure all the t’s are crossed and the i’s dotted? Create a simple checklist and make sure people use it.

Checklists have been used for years by the airline industry. As technology advanced and planes became increasingly more complicated, there were literally too many individual steps that pilots needed to perform in order to safely operate an airplane. Pilots began to forget key procedures and—as is true for medicine—these mistakes proved fatal.

Enter the checklist. You’ve seen it in countless movies, two pilots sitting in the cockpit: “Landing gear—check; fuel—check; stabilizers—check.” Once introduced, checklists greatly reduced pilot-related errors and, in turn, saved lives and money.

Medicine, like aviation, has grown increasingly complex. Gone are the days when doctors would arrive at the doorstep with a black leather bag containing a handful of medicines and limited ability to diagnose and treat disease. Today, doctors use thousands of medicines and billions of dollars worth of complicated medical apparatus. Procedures have grown infinitely more involved and the complexity of diagnosing a condition has increased exponentially.

Realizing this parallel between hospitals and the airline industry, Pronovost produced his first checklist for medicine in 2001—a simple sheet of paper with five steps for doctors to follow in the intensive care unit (ICU) at Johns Hopkins Hospital. He chose the ICU because as an intensivist—a doctor who specializes in the techniques and procedures used in a hospital’s intensive care unit—he treats patients in the ICU and knows they undergo close to 200 procedures a day. Since most patients are on the edge of survival, he also knew that a missed step could be lethal.

Targeting all the moving parts of a busy ICU would have been almost impossible. So as a test case, he chose a simple but vital procedure—the placing of central venous catheters. This is a common procedure in which a doctor places a needle into a large vein in the neck, chest or groin. The catheter is used to administer medication or fluids, obtain blood tests, and directly gauge cardiovascular measurements such as the central venous pressure. At the time, Hopkins, like most hospitals, had a high rate of catheter-related bloodstream infections and far too many deaths associated with these infections. If his checklist was successful, Pronovost knew that he should see a drop in this infection rate and deaths.

While he knew potentially many factors contributed to these infections, he also knew that he had to keep the checklist simple in order for it to work effectively. Therefore he simplified the checklist to the five steps that he thought could most likely lead to infection if neglected. Doctors had to (1) wash their hands using soap; (2) wear sterile gloves, hat, mask and gown and cover the entire patient with sterile drapes; (3) avoid placing the catheter in the groin if possible (these have a higher infection rate); (4) clean the insertion site on the patient’s skin with chlorhexidene antiseptic; and (5) remove catheters when they are no longer needed.

This was nothing new: it’s exactly what is supposed to occur. However, in a place as demanding and hectic as an ICU, it’s easy to occasionally miss a step. To monitor the list, Pronovost asked nurses to observe compliance for two weeks and record whether or not each step was completed.

The results? At least one step was skipped 38 percent of the time—putting one out of three patients at greater risk of infection and possible death.

For the next phase of the study, Pronovost authorized nurses to inform doctors if a step was missed. Pronovost monitored results for 15 months, and what he found was astonishing. The infection rate dropped from 11 percent to zero. The hospital saved an estimated two million dollars, prevented 43 infections and eight deaths.

“My overall impression about the new measure is, it keeps everyone focused—it keeps everyone on target,” says Johns Hopkins neurosurgeon Alfredo Quiñones. “It brings all the different teams together, and that will undoubtedly lead to better outcomes. I really think it’s the best environment when nurses feel they can collaborate with surgeons. I welcome suggestions; it improves the atmosphere.”

The study was such a huge success that in 2003 the Michigan Health and Hospital Association asked Pronovost to apply his checklists to the entire Michigan State Healthcare System. Budget cuts and staff cuts had lowered morale and put a significant dent in healthcare outcomes—catheter-related bloodstream infections and related deaths were higher than the national average. The project was called the Keystone Initiative.

In December 2006, after 18 months of implementing checklists across the state of Michigan, a landmark paper appeared in the New England Journal of Medicine citing the results. Quarterly infection rates dropped to zero, placing ICU performance ratings in the 90th percentile nationally. Administrators estimated that the system saved $175 million and more than 1,500 lives, all due to five simple steps on a checklist.

“It made a big difference,” says Mary Ann Adamczyk, nurse manager in the critical care medicine unit at the University of Michigan Hospital. “It really boosted morale. The numbers went up in staff satisfaction. They could voice concerns and communication improved with doctors. Overall it was a very positive change.”

Today, Pronovost has the green light to expand the program to 10 states. In addition, four nations are adopting the checklist. In a seemingly endless series of papers, editorial and articles published in the New England Journal of Medicine, Journal of the American Medical Association, and other prominent medical journals, Pronovost has outlined checklists for a wide variety of hospital procedures. He has also developed questionnaires that plumb the roots of hospital culture. His goal? He wants to eliminate preventable harm and costs by improving what he calls the “knowledge market.” He wants to encourage the sharing of ideas and information so that healthcare workers have all the tools and information at their disposal and patients receive the best care available.

It doesn’t just apply to hospital systems and aircraft, according to Pronovost. He believes checklists can be applied anywhere there’s a need to improve the knowledge market.

“Everything you do, every decision you make, is based on the knowledge you have about the subject,” says Pronovost. “If you don’t have access to all the information, you have a clear disadvantage.”

Recently, Pronovost spoke to a gathering of top executives at Barclay’s Bank. Instead of talking about hospitals, he addressed something they could relate to—the subprime mortgage crisis. According to Pronovost, it’s a perfect example of what can happen when you have an inefficient knowledge market. It’s a simple parallel. In an ICU, you need to make sure health workers have access to and are using all the medical knowledge available to prevent infections. Similarly, when estimating risks from mortgages, all the players—the bankers, investment professionals, agents, and the home owners—need equal access to the same information. Without this information, decision makers will likely get it wrong with dire consequences.

Pronovost is now working to create an online checklist-maker that could be applied to an infinite number of different situations.

“This theory can be applied to any situation where knowledge is linked directly to performance. It’s all about creating an efficient method to tap the ‘wisdom of crowds’ sharing information, making sure everyone has all the tools they need to do the best job and make the best decisions,” says Pronovost. “Obviously there is no way to completely prevent negative outcomes, but it’s imperative that you have access to all the tools and information available.”

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October 29, 2008