Atul Gawande says the key to hospitals staying resilient is slowing down

A simple step to improving outcomes.
A simple step to improving outcomes.
Image: Reuters/Mohamed Abd El Ghany
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Atul Gawande has his work cut out for him as a newly-appointed member of US president-elect Biden’s transitional Covid-19 advisory board. Nine months into the pandemic, hospitals across the US are stretched thin and resources are scarce. Healthcare workers are going to have to work with the systems they have.

But as a surgeon and public health researcher, Gawande has seen firsthand that big problems in the medical system don’t always require big solutions. Sometimes, a snowball effect can save thousands of lives with minimal effort.

That’s one of the ideas behind Lifebox, a nonprofit organization Gawande chairs whose mission is to make surgeries across the globe safer. Instead of opting for high-tech solutions, which would be inaccessible for many hospitals in low- and middle-income countries, Lifebox advocates for a thoughtful, low-tech approach, using simple interventions like surgical checklists.

Those kinds of tools can work in all healthcare systems: Research from hospitals in Scotland has shown that implementing a two-minute checklist increased surgical survival rates by roughly 36%. “I mean, that was more lives saved than die in car accidents every year,” says Gawande.

Quartz spoke with Gawande about how these smaller changes in behavior can contribute to hospitals’ overall resilience—especially in the time of Covid-19. The following conversation has been edited for length and clarity.

Quartz: How does a simple checklist help hospital teams communicate better? 

Gawande: The reality is when you have a complex set of things that you need to do, you don’t always confirm that you’re all communicating as a team. A communication checklist can make sure that some basic things are not skipped over.  You routinely catch stuff that people don’t all know and haven’t communicated. It’s a basic kind of briefing that occurs in cockpits.

It can feel annoying to have to walk through a series of checks. But what we see again and again is when people take it seriously and have a culture of communicating as a team, everybody knows what to do and what needs to be remembered. That’s important when there are more than 300 million operations done worldwide every year—when you do that many operations, you know, we have more deaths than occur from tuberculosis and malaria. This is as big as any other public health problem that’s out there. So these basic steps become very powerful.

In the low- and middle-income countries, there are even larger gaps. Some of that is about equipment, some of that is about procedures, some of that is about the culture of operating.

What does that kind of communication look like in a hospital setting?

There’s a backstory here. In 2009, I had led the World Health Organization and effort to define safety guidelines for safer surgery around the world. In order to implement those guidelines, we had established a 19-item, two-minute checklist checklist for surgical teams. That checklist was tested in eight cities, and in every hospital, it led to a 35% percent reduction overall in complications and 47% reduction in deaths.

It was about pausing before the anesthesia was started to make sure that certain safety procedures were in place, pausing before the incision was made, and then pausing before the patient left the room to make sure the recovery plan was in place.

How does operating room culture change with improved communication? 

It’s not as simple as a tick box exercise. We have definitely seen studies in places where the checklist is mandated and someone’s filling out a piece of paper, but there isn’t communication. You can tell the difference between an operating room where there was not great teamwork because there’s just one person talking.

When the checklist is implemented appropriately, there are equal voices in the room. So you hear everybody speak and raise any concerns they have and any doubts or issues or questions that they have. And you can see it within a minute. It’s the settings where the members reported that they were more likely to be listened to that were more effective in dropping their death rates.

How has open communication with a checklist become more important with the Covid-19 pandemic?

It becomes even more important because, first of all, the complexity of what has to be done in the operating room has increased.

In most Western hospitals, we now test every patient before they come to the operating room. But in the low- and middle-income part of the world, that is often not the case. There, the checklist is redesigned to treat everybody as if they have Covid-19. Everybody in the operating room has N95 masks, and are doing certain things to ensure precautions around infection control and avoiding infecting your staff.

If one person doesn’t get it right, then everybody is at risk. So that checklist we put out early in the pandemic has been very important for supporting operating rooms in low- and middle-income countries. We founded Lifebox to continue that mission, to support the capability of low- and middle-income countries to adopt this sort of very low-cost checklist tool.

Along with that, we found that there was an explosion in demand for oxygen monitors. The one thing that was a technology and resource investment on the checklist was that every patient should have safety monitoring that includes pulse oximetry monitoring, which measures the patient’s blood oxygen levels and pulse. And that actually was missing in much of the low- and middle-income world.

So it’s not always a question of communication—sometimes you just need the hardware.

Pulse oximeters are not manufactured for the low- and middle-income world for the most part. So we partnered with anesthesia networks around the world to identify the providers who didn’t have adequate monitoring available. We then partnered with Smile Train and their network of 1,100 hospitals doing cleft surgery, guaranteeing purchase of at least 2,000 of these units designed for the low- and middle-income world. They were portable. They had battery life that could last much longer than the Western ones for places that often had power cuts. And and we could get them delivered to these places and get and get training provided.

During the pandemic, we partnered with Smile Train to get 500 more units pushed out, because this was a way to detect in people who might have suspected Covid-19 whether they might have low oxygen levels and require additional support.

That was the original formation of Lifebox, to start with the pillar of safe anesthesia. We’ve since expanded the work to include training in approaches that adopt the safe infection part of the checklist and then the teamwork parts.

How does teamwork help when you are really strained for resources?

The culture of the operating room is traditionally one where autonomy is the highest value. The surgeon and their autonomy to do what they think is best is what we have traditionally maximized for. The approach of the safe surgery communications checklist is that you’re championing humility, discipline, and teamwork.

First, there’s the humility to recognize that no one, no matter how smart anyone is, can know everything. Errors will occur. Second, discipline is the belief that doing certain things the same way every time will lead to better results. And third is teamwork, the belief that ensuring the contribution of everybody’s ideas in the room is going to lead to much, much better results.

And that’s been seen in many fields, especially under complex and stressful circumstances, time and time again.

Is there any risk to losing time in the middle of an emergency, though? 

When it comes to resiliency in a pressured environment, one of the things that people raised was, geez, maybe that two minutes is dangerous. But it turned out that patients who had the largest benefit were the emergency patients, because the team was taking that pause to make sure just for 60 seconds at the start that that everything is in order.

In fact, you save time. You catch problems in the moments when you’re most stressed and things can go by the wayside. When you have a resilient team, they are much more likely to be effective in working together to rescue the person who has a complication. And that’s one of the marks of a more resilient team and hospital.