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Health Care Rocket Science: Better Human Delivery Systems & Checklists
Dr. Jim Yong Kim will become the 17th president of Dartmouth College next week. A guest on Bill Moyers’ Journal last Week, Kim is an internationally recognized physician and humanitarian. His goal at Dartmouth is to tell young people that “a few committed souls can change the world.”
Yong says that in his 25 years working in global health what he’s learned is that the fundamental challenge the American health care system faces is not about finding new drugs or new treatments. It’s about how to make our human systems work effectively:
In my view, the rocket science in health and health care is how we deliver it. And unfortunately, there’s not a single medical school that I know of that actually teaches the delivery of health care as one of the essential sciences
In other words, what we’ve learned about organizations is that it is very difficult to get a complex organization, a group of people, to work consistently toward a goal. In the business world, if you don’t do it well, the market gets rid of you. You go out of business. But many hospitals executing very poorly persist for a very, very long time. So my own view of it is that we have to rethink fundamentally the kind of research we do and the kind of people we educate, so that they’ll think about the complexity of delivery as a topic that we can take on and study and learn about as a science… What we know is that transfer of information is critical. Now to me, again, that’s the rocket science. That’s the human rocket science of how you make health care systems work well
What we need now is a whole new cadre of people who understand the science, who really are committed to patient care. But then also think about how to make those human systems work effectively. We’ve been calling it, aspirationally, the science of health care delivery. And we do it at Dartmouth.
I am reminded of an outstanding piece in the December 2007 New Yorker by Atul Gawande, The Checklist, If something so simple can transform intensive care, what else can it do?
In 2001, though, a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give it a try. He didn’t attempt to make the checklist cover everything; he designed it to tackle just one problem, the one that nearly killed Anthony DeFilippo: line infections. On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting a line in. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in. Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years. So it seemed silly to make a checklist just for them. Still, Pronovost asked the nurses in his I.C.U. to observe the doctors for a month as they put lines into patients, and record how often they completed each step. In more than a third of patients, they skipped at least one.
The next month, he and his team persuaded the hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask them each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. Nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder (“Um, did you forget to put on your mask, doctor?”) to more forceful methods (I’ve had a nurse bodycheck me when she thought I hadn’t put enough drapes on a patient). But many nurses aren’t sure whether this is their place, or whether a given step is worth a confrontation. (Does it really matter whether a patient’s legs are draped for a line going into the chest?) The new rule made it clear: if doctors didn’t follow every step on the checklist, the nurses would have backup from the administration to intervene.
Pronovost and his colleagues monitored what happened for a year afterward. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from eleven per cent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs. [...]
The checklists provided two main benefits, Pronovost observed. First, they helped with memory recall, especially with mundane matters that are easily overlooked in patients undergoing more drastic events. (When you’re worrying about what treatment to give a woman who won’t stop seizing, it’s hard to remember to make sure that the head of her bed is in the right position.) A second effect was to make explicit the minimum, expected steps in complex processes. Pronovost was surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions. In a survey of I.C.U. staff taken before introducing the ventilator checklists, he found that half hadn’t realized that there was evidence strongly supporting giving ventilated patients antacid medication. Checklists established a higher standard of baseline performance.
If something so simple works, why aren’t we using them?
Tom Wolfe’s “The Right Stuff” tells the story of our first astronauts, and charts the demise of the maverick, Chuck Yeager test-pilot culture of the nineteen-fifties. It was a culture defined by how unbelievably dangerous the job was. Test pilots strapped themselves into machines of barely controlled power and complexity, and a quarter of them were killed on the job. The pilots had to have focus, daring, wits, and an ability to improvise—the right stuff. But as knowledge of how to control the risks of flying accumulated—as checklists and flight simulators became more prevalent and sophisticated—the danger diminished, values of safety and conscientiousness prevailed, and the rock-star status of the test pilots was gone.
Something like this is going on in medicine. We have the means to make some of the most complex and dangerous work we do—in surgery, emergency care, and I.C.U. medicine—more effective than we ever thought possible. But the prospect pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity—the right stuff, again. Checklists and standard operating procedures feel like exactly the opposite, and that’s what rankles many people.
It’s ludicrous, though, to suppose that checklists are going to do away with the need for courage, wits, and improvisation. The body is too intricate and individual for that: good medicine will not be able to dispense with expert audacity. Yet it should also be ready to accept the virtues of regimentation.
The still limited response to Pronovost’s work may be easy to explain, but it is hard to justify. If someone found a new drug that could wipe out infections with anything remotely like the effectiveness of Pronovost’s lists, there would be television ads with Robert Jarvik extolling its virtues, detail men offering free lunches to get doctors to make it part of their practice, government programs to research it, and competitors jumping in to make a newer, better version. That’s what happened when manufacturers marketed central-line catheters coated with silver or other antimicrobials; they cost a third more, and reduced infections only slightly—and hospitals have spent tens of millions of dollars on them. But, with the checklist, what we have is Peter Pronovost trying to see if maybe, in the next year or two, hospitals in Rhode Island and New Jersey will give his idea a try.
Business Week advised that business executives have a lot to learn from Peter Pronovost’s “humble self-discipline.” Pronovost’s Wikipedia entry.
29 Responses to “Health Care Rocket Science: Better Human Delivery Systems & Checklists”
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While I was in the Navy and went to work on the bridge, I was amazed to see checklists laminated and grease pencils being used constantly for evolutions (that's what they call them), such as landing a helicopter. I was also amazed to see how well they worked.
Back in the civilian world again, I rarely see them. This was not peculiar to shipping, either. I didn't see lists much among civilian shipping. People are expected to keep all these things in their heads, but they don't do that very well, do they?
Why the difference, I don't know. I expect that checklists weren't being used in the Navy 50 years ago. Somewhere, in that time, somebody ordered their use. I think they are required in training exercises. So I would suppose there would be some resistance to them, especially if there are only 5 steps as in the example cited by Pronovost.
I have helped implement ITIL (Information Technology Infrastructure Library) processes and procedures for several Fortune 1000 companies. And it's maddening how “the right stuff” attitude gets in the way of structured procedure. And once ITIL processes are implemented right and are working, it makes a WORLD of difference.
In health care, procedure HAS to be followed. Lives depend on it. The example you show Joe proves it. Line infections reduced to zero! That speaks for itself. These are the type of things that government should be involved in regarding health care that are low cost but have far-reaching impact.
Checklists in medicine and other checks are nothing new. They're also not novel; aircraft flight displays for years have had some versions that include entire screens consisting of checklists whose elements change color as the steps are checked off, literally.
Just don't have naive faith in techno-toys. More realistic is the future fear that as these things become standardized, by default they'll become a de facto legal requirement, and failure to adhere faithful to the checklists (which will be based on best known practices and outcome studies, etc.) will be lawsuit fodder.
“it is very difficult to get a complex organization, a group of people, to work consistently toward a goal”
It's even more true in bureaucracies, in government, which makes naive or worse faith in it today so amazing.
“More realistic is the future fear that as these things become standardized, by default they'll become a de facto legal requirement, and failure to adhere faithful to the checklists (which will be based on best known practices and outcome studies, etc.) will be lawsuit fodder.”
Yeah, so what?
If using a checklist can reduce infections, do you have ANY idea how much money that would save? Billions. I'm not kidding, either. Billions, maybe tens of billions.
Agreed, vey9. If the doctor — for whatever reason — doesn't wash his hands and the patient ends up with a line infection, isn't that negligence? If anything, strick adherance to the lists will cause many fewer law suits, not more.
“Yeah, so what?”
You can choose to be “challenged” about the obvious, but some of us prefer to be thoughtful. There is a dark as well as a bright side to improvements (that can become de facto standards) in this world.
“If anything, strick adherance to the lists will cause many fewer law suits, not more.”
That's aside from the need for tort reform and a new, separate (non-civil or criminal court-based) system for medical fault finding and “corrections” that should be mainly within the medical profession.
Just don't be naive about standardization. Innovation and divergence from any de facto standard is legally dangerous.
Another thing to think about: if one list used at one hospital can save $2million over one year, what other super simple, non tech based solutions might be out there? My company makes large, complicated machines that perform to very tight specs and cost a few million dollars each. Almost every subsystem has a set BKMs (Best Known Methods) that is meant to head off the potential problems. We still need engineers to design and test these devices, we still need creativity, we still need people who know how to improvise. However, we also know that if the steps aren't followed during manufacturing and installation, the tool will almost certainly perform poorly, sooner or later. Why the root cause/corrective action methods and BKM methods haven't been followed in health care just makes no sense.
“doesn't wash his hands”
And they DON”T! I have stood right there watching doctors go from patient to patient in the ICU without washing hands between touching patients. And then there is this huge mystery as to MRSA infections in hospitals.
To treat someone for a MRSA takes about three weeks in the hospital with 24/7 IV's of strong antibiotics. This “only” adds 10's of thousands to the bill and some people die from it.
If I were to pull a stunt like that and someone died, I would EXPECT to get sued. Why is a doctor any different?
I answered your “challenge.” I said so what? Your “concern” is so inconsequential it shouldn't need an answer because the benefits outweigh any cost you can think of. Why don't you think doctors should be sued if they don't follow a checklist? It would be hilarious if there wasn't a small group that knee jerks against lawyers and lawsuits.
DLS — First, I don't disagree with the idea of tort reform; never said I did. I think we need to look at *why* this country has such a problem with litigation against doctors when compared to other industrialized nations. It's not hard to see that if a doctor makes a mistake that can and will be corrected at no cost to the patient, it's less likely that patient will sue than if that mistake costs the patient tens of thousands of dollars and the possibility of losing their job due to not being at work. Since it's become increasingly clear we're not going to do away with the stupid for-profit health care system we have in this country, the only fair way toward tort reform is to decrease the need for litigation by *decreasing the mistakes made*. How can you just throw out the term “tort reform” without that component? Are you suggesting that patients just eat the potentially billions of dollars a year in easily preventable mistakes? Sorry! I messed up but you have to pay not only out of the pocket but in pain and suffering! And you can't sue!
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“I think we need to look at *why* this country has such a problem with litigation against doctors when compared to other industrialized nations.”
This is where tort reform comes into play, as well as going out of courts completely with medical fault-finding and disciplinary practices. (This in fact is fully compatible with “single-payer” federal health care, even if not with the trial lawyer lobby and related activists; tort reform was acknowledged by a proponent of “single-payer” who was bitterly critical of the Clinton plan years ago, who said the model for non-judicial medical discipline is a desireable alternative.)
“the only fair way toward tort reform is to decrease the need for litigation by *decreasing the mistakes made*. How can you just throw out the term “tort reform” without that component? “
We all know what true tort reform is (along with the medical disciplinary model). That there may be standardization of care in addition to what we have now is a
separate issue
having nothing truly to do with tort reform itself. (It is associated instead with standardization and quality control.)
As to checklists (which I've benefited from, medically, already) and the idea of “prevailing generally accepted or preferred standard of care,” it's obvious additional lawsuit fodder (as is the general case of federalization of health care that keeps providers nominally private, so they have no sovereign immunity — which I've elaborated on to note already that we could see ratcheting-upward minima for liability insurance by providers, and even taxpayer-boosted insurance, to keep the lawsuits going).
“I said so what?”
What was no real answer, of course, but I responded, anyway. What I had to say is about an obvious threat or dark side to standardization, that isn't as great as the benefits from the checklists — did I say anything wrong about having checklists themselves on aircraft or in medicine? [sigh] — but which is a threat. It's a crippler for truly experimental medicine (that it is at the same time that pharma firms and the doctors have pushed meds for off-label purposes does not change that fact), and for innovation in general. It's no different than any government trying something new and better with the roads but that is not in the Manual on Uniform Traffic Control Devices. Even something not in a checklist but in an algorithm is “prevailing practice” fodder for use against any deviation from it.
Example — I'm personally familiar with it but hell, it's obvious and should be well-known by now:
(See especially “Guidelines and Commentaries”)
http://www.kidney.org/Professionals/kdoqi/
* * *
Roro, if you're ever able, get your hands on the following book. Melvin Konner is a liberal academic and a medical doctor, who was greatly opposed to “corporate HillaryCare” at the time it was tried. (You may remember him for his capitalism-bashing “Medicine at the Crossroads” TV show in addition to a book by that name.)
http://www.amazon.com/Dear-America-Concerned-Do…
He has his own Web site and blog now, by the way.
http://www.melvinkonner.com/
“It's a crippler for truly experimental medicine … and for innovation in general.”
Yes, just like financial “innovation” is being threatened. This is a complete canard, in the vast majority of cases things should be done to best known practices and standards (as long as there is leeway for the practitioner to deviate on a case by case basis if they have a compelling reason) and deviations from that standard have proper channels already established. For health care if you want to have experimental techniques then you make an IRB proposal and go from there.
“Yes, just like financial 'innovation' is being threatened. This is a complete canard,”
I could have said “risk-taking” instead, and would still not have committed any blunder.
tort reform is a red herring. The cost of malpractice is 0.5% of health care cost. Of that cost, I doubt if half is “frivolous”. So how much energy shall we spend trying to shave 0.25% off the cost of health care, when private insurance v.s. Medicare is 37% ?! THAT is the low hanging fruit. The GOP wants tort reform because they want to escape liability for incompetence, fraud, negligence and errors. When the doctor screws up, the PATIENT suffers. Spare me your crocodile tears for the doctor who HURT his patient, or killed her.
“tort reform is a red herring.”
Not at all. What you could truthfully say, though, is that it is not about a problem solely concerning medicine.
Hey, keep on blustering…….it's been………what 4 months? Need another 4? Obama gives his big speech and barely moves the ball two yards. Dems are still stuck at the 50. Better call in the punting squad.
I am told swallowing the herring can taste better when you add sour cream and onions!
What a genius DLS is.
He should immediately tell these doctors how hosed up they are:
http://pookiemd.wordpress.com/2008/10/22/checkl…
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“Dems are still stuck at the 50. Better call in the punting squad.”
Actually, Baucus is trying now. So far, three yards and a cloud of dust; he's being hit by his teammates as well as the other guys.
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