Gawande is enlisted by the WHO to participate in a committee to improve patient outcomes in developing countries. Part of the problem is that the volume of surery has increased. A group of specialists met at Geneva in 2007 to discuss possible options. The problem was how to make an impact in disparate environments and working conditions. They decided they should publish some standards of care but former attempts had mixed success. The key point was to keep things simple.

Gawande tells of Stephen Luby who enlisted Proctor & Gamble to help change washing behavior in Karachi, to teach appropriate use of soap, using a washing checklist. One hospital used a checklist of prevent surgical infections. Surgery has four major risk factors: infection, bleeding, anesthesia, and unexpected complications. The best way to resolve the unexpected is through team communication.

Psychologist Brian Sexton warns about “silent disengagement” resulting in a lack of accountability among surgical team members. Gawande had a difficult situation with a patient with a bad clot. The surgery had unexplicated complications but the team was able to work cohesively to bring the patient through. Sometimes teams just work like that.

Some checklists have a step where team members talk with each other. This step may increase overall team communication and individual accountability.

The WHO committee decided to work on a checklist. They organized a pilot study to test the efficacy of the checklist. When Gawande returned to his hospital, he found that the checklist was all wrong.