2015 Atul Gawande – On removing the pumphandle: innovation and implementation

The 23rd annual Pumphandle Lecture was given on the 8th of October 2015 by Dr Atul Gawande, Professor of Surgery and of Public Health at Harvard, well known author (eg The Checklist Manifesto and Being Mortal), and Executive Director of Ariadne Labs, a joint centre for health systems innovation, as well as Chairman of
Lifebox, a UK-based nonprofit devoted to making surgery safer globally.

Dr Gawande began by referring to Snow’s work on cholera, and the subsequent evolution of the complex health care systems of today.

He highlighted the effectiveness of a simple checklist approach in three key areas – surgery, maternal and childcare, and primary healthcare – emphasising that a checklist is not a protocol, but a list of the most common things that experts miss, and which should be tailored for particular activities and institutions.

Drawing from experience in the airline industry, the checklist approach was adapted by Dr Gawande’s team and
recently introduced, first in surgical practice. The explicit checking of a list of just 19 items, in theatre, has led to
important reductions in surgical mortality in many countries. He emphasised the necessity of monitoring the system through setting targets, continued contact and data feedback.

In the case of maternal and child health, he emphasised the importance of identifying a set of ”minimum required guidelines” and the collection of data to identify what is missing in the real world. He described
studies in areas of India where one in 20 newborns die in utero or soon after birth. Critical analysis led to agreement on a series of actions before admission, during birth, after birth and when the mother was being discharged. Improved results were not from additional skills training or supplies but the use of a 30-item checklist at different stages.

In assessing primary healthcare, it is common to consider four S categories: staff; stuff; structure and systems.
However, users typically ask about four C’s: contact (is there a place to go that is open); continuity (do staff recall medical histories); coordination (is information transmitted to add to wider public health discussion) and comprehensiveness (can a primary healthcare institution take care of the majority of medical needs). To address these concerns, Dr Gawande and colleagues have recently launched the primary healthcare performance
initiative, which has been approved by the UN General Assembly, in order to identify which is the simplest system to follow to close the gap between aspiration and achievement.

All these are examples of innovative ways by which to remove crucial pumphandles confronting public health.

The vote of thanks was proposed by Professor Dilys Morgan, using a checklist, and Dr Gawande was invited to remove the handle of the pump to close the lecture. Society members then adjourned to the John Snow pub in Soho for the Annual General Meeting of the society.