Why You Should Care About The Pit Crew: Lean Healthcare and the Checklist Manifesto

Atul Gawande, the author of several books on Healthcare such as The Checklist Manifesto, Better, and Complications recently gave the Commencement speech at Harvard Medical School. In his speech, he mentions a few things worth noting, because he gives credit to the quality movement and its influence on the current practice of healthcare.

First, Atul Gawande notes the high cost of healthcare and presents an interesting finding that the places that get the best results are also not the most expensive – in other words, effective, elegant, and practical solutions aren’t often the most expensive and those examples have one thing in common – they are healthcare teams and facilities that work most like a system:

Another sign this is the case is the unsustainable growth in the cost of health care. Medical performance tends to follow a bell curve, with a wide gap between the best and the worst results for a given condition, depending on where people go for care. The costs follow a bell curve, as well, varying for similar patients by thirty to fifty per cent. But the interesting thing is: the curves do not match. The places that get the best results are not the most expensive places. Indeed, many are among the least expensive. This means there is hope”for if the best results required the highest costs, then rationing care would be the only choice. Instead, however, we can look to the top performers”the positive deviants”to understand how to provide what society most needs: better care at lower cost. And the pattern seems to be that the places that function most like a system are most successful.

Then, Atul Gawande introduces the notion of a Pit Crew in his explanation of a system within the context of healthcare:

By a system I mean that the diverse people actually work together to direct their specialized capabilities toward common goals for patients. They are coordinated by design. They are pit crews. To function this way, however, you must cultivate certain skills which are uncommon in practice and not often taught.

Atul Gawande then describes a few needed metrics by all systems, but especially systems within healthcare:

For one, you must acquire an ability to recognize when you’ve succeeded and when you’ve failed for patients. People in effective systems become interested in data. They put effort and resources into collecting them, refining them, understanding what they say about their performance.

Second, you must grow an ability to devise solutions for the system problems that data and experience uncover. When I was in medical school, for instance, one of the last ways I’d have imagined spending time in my future surgical career would have been working on things like checklists. Robots and surgical techniques, sure. Information technology, maybe. But checklists?

In what follows, Atul Gawande explains that the tools needed by these formal healthcare systems are the basic quality tools. He further explains that almost every other field has adopted the 7 basic quality tools, except healthcare.

They turn out, however, to be among the basic tools of the quality and productivity revolution in aviation, engineering, construction”in virtually every field combining high risk and complexity.

Then, Atul Gawande introduces his insight on Checklist and their practical application in healthcare:

Checklists seem lowly and simplistic, but they help fill in for the gaps in our brains and between our brains. They emphasize group precision in execution. And making them in medicine has forced us to define our key aims for our patients and to say exactly what we will do to achieve them. Making teams successful is more difficult than we knew. Even the simplest checklist forces us to grapple with vulnerabilities like handoffs and checklist overload. But designed well, the results can be extraordinary, allowing us to nearly eliminate many hospital infections, to cut deaths in surgery by as much as half globally, and to slash costs, as well.

But implementing something as simple as Checklists is apparently a challenge to do at scale. Why? Primarily because of resistance from the healthcare industry itself:

Which brings us to the third skill that you must have but haven’t been taught”the ability to implement at scale, the ability to get colleagues along the entire chain of care functioning like pit crews for patients. There is resistance, sometimes vehement resistance, to the efforts that make it possible. Partly, it is because the work is rooted in different values than the ones we’ve had. They include humility, an understanding that no matter who you are, how experienced or smart, you will fail.

Then he introduces, in passing, the notion of Standard Work in Healthcare:

They include discipline, the belief that standardization, doing certain things the same way every time, can reduce your failures. And they include teamwork, the recognition that others can save you from failure, no matter who they are in the hierarchy.

But what are the root causes of the resistance within the healthcare industry to adopt simple quality tools that could increase patient outcomes?

These values are the opposite of autonomy, independency, self-sufficiency. Many doctors fear the future will end daring, creativity, and the joys of thinking that medicine has had. But nothing says teams cannot be daring or creative or that your work with others will not require hard thinking and wise judgment. Success under conditions of complexity still demands these qualities. Resistance also surfaces because medicine is not structured for group work. Even just asking clinicians to make time to sit together and agree on plans for complex patients feels like an imposition. I’m not paid for this! people object, and it’s true right up to the highest levels.

Indeed, medicine itself is not oriented or structured around the patient. Clearly, we must start there – even at step 1:

I spoke to a hospital executive the day after he’d presented to his board a plan to reorient his system around teams that focus on improving care outcomes, improving the health of the community, and lowering its costs of care. The meeting was contentious. The aims made sense, but hospital finances are not based on achieving them, and the board wasn’t sure about asking payers to change that. The meeting ended unresolved. These aims are not yet our aims in medicine, though we need them to be.

You can see a video of Atul Gawande below explaining the Checklist Manifesto and its applications in healthcare: how such a seemingly simple tool can dramatically improve patient outcomes – and, yes, a tool that comes in large part from the quality movement and is widely used in both Six Sigma and Lean Manufacturing.