Visiting Kaiser Permanente's Garfield Center for Innovation, a 37,000-square-foot testing ground for health care innovation in San Leandro, California, is a bit like stepping into a well-equipped hospital 10 years into the future. Telepresence technologies seem to lurk around every corner, and robots occasionally cruise the hallways.
When I visited on a sunny afternoon in early May, a group of surgeons, anesthesiologists, and nurses were preparing to put on the largest ever simulation at the Garfield Center: an operating room that would test how various technologies—Google Glass, telepresence, voice-controlled tablets, big wall-mounted screens—could make crisis checklist procedures more effective. The strikingly realistic facility was decked out with a $40,000 robot/patient, lots of fake blood, a smoke machine, and a "fire lamp" to represent the patient catching on fire (check it out in action in the video below).
In 2010, Atul Gawande, an author and surgeon, brought the idea of operating room checklists to the masses in his book The Checklist Manifesto: How to Get Things Right. In aviation, detailed checklists are a key reason why co-pilots are so reliable. But the idea has traditionally been foreign to surgeons. Gawande explains in an interview with Time:
We evolved from a world where the operating theater—we called it a theater—was a stage for the surgeon. Now it is a stage for an entire team of people to work in sync. The most important component [of the checklist] has turned out to be making sure that everybody in the room has been introduced by name and that people just take a minute to discuss the case in advance. I introduced the checklist in my operating room, and I've not gotten through a week without it catching a problem.
In the past several years, checklists have been shown to dramatically reduce errors in the operating room. One study, published in the New England Journal of Medicine in 2009, found that checklists lowered infection rates in patients from 6.2% to 3.4% (a more recent study calls this data into question).
Kaiser has taken checklist implementation seriously, even contracting with Boeing, which has plenty of aviation checklist experience. The organization—made up of hospitals, clinics, and its own health care plan—is now rolling these paper checklists out en masse. But at the Garfield Center, anesthesiologist Paul Preston and user experience designer Erica Yamada are already thinking about the next steps. "The problem with paper is that we have to pick it up and use it," says Preston.
Which brings us back to the OR simulation—actually a series of short simulations examining how well different checklist-related technologies fit into a crisis situation.
The first simulation featured a young guy (the humanoid robot, in reality) with malignant hyperthermia, an allergic reaction to anesthetics that has a 90% mortality rate if untreated. In this scenario, a doctor wore Google Glass, while a remote doctor beamed in on a screen provided guidance from a checklist. The remote doctor could see through the eyes of the Google Glass-wearing doctor, as well as via a series of cameras in the room. A second simulation featured the same technology, but with a patient that was on fire.
In a debriefing afterwards, the doctors and nurses had some criticisms and a number of useful suggestions. One person suggested that there needed to be a leader in the room to delegate tasks. Another thought Google Glass would be more useful if the wearer could pull up the checklist and see it in their peripheral vision.
More scenarios were explored as the afternoon went on. There was the touchscreen checklist, where one of the participants checked off tasks as they were completed, with the results showing up on a big monitor in the back of the room. And there was the voice-activated checklist, where a nurse verbally noted when a task was completed via a tablet (in the final version, this would be hands-free).
For the most part, everybody liked the big-screen checklist. But there were still practical considerations to think about: what happens, for example, if blood splatters on on a screen? And how well will voice activation work in the middle of a fire? The group also spent about 10 minutes hashing out the legal implications of using a checklist where steps are individually checked off.
Preston, who has been conducting simulations with Kaiser for over a decade, was pleased with the results. "I think we've already got one and a half fails. It's great," he told me about halfway through the afternoon. Those fails will ultimately ensure that Kaiser doesn't develop expensive applications and protocols that don't work.
Implementing a digital checklist system will take time—even the afternoon of simulations took a year to plan. But if moving past paper makes it easier for doctors to follow checklists, it will all be worth it.