What does it take?

I take a short break from my travelogue to get back to medical issues. A vacation is supposed to help you get perspective and calm down, but I find myself pretty upset.

What follows is not criticism of any particular hospitals. I repeat, it is not criticism. It is an observation about this medical system in which I find myself a participant. It is a statement of frustration about the lack of will within this profession to change itself in a timely fashion.

Here's the setting. There is a great story by Liz Kowalczyk in today's Boston Globe about the work that Atul Gawande and others have done to document the effectiveness of a pre- and post-surgical checklist. They were able to show that use of the checklist has real benefit in reducing the likelihood of medical errors during surgery. Atul himself said "that in his own operations, the checklist catches a potential problem about once a week."

A number of commenters to the Globe story expressed surprise that surgeons had not previously adopted this approach. One person noted, "It is quite shocking that something like this is considered an innovation. I would have thought that it was a common practice long ago. It makes me wonder what else is going on in hospitals that could use the application of common sense."

A good point.

So, the question I raise is, what does it take to implement changes like this in a profession that is so steeped in the practice of giving individual physicians the prerogative to do their work the way they want to?

Here at BIDMC, we learned the hard way about the importance of this kind of checklist and instituted it after a bad experience with a wrong-side surgery. I think it is fair to say that institutional and personal embarrassment, along with our decision to be very open about this error, stimulated the change.

But even at the Brigham, where one of the world experts in this field has carried out this important work, the progress is evolutionary: "The Brigham, which was not part of the study, began using the checklist a month ago in general and cardiac surgery and plans to roll it out to other specialties over the next several months."

And of course the story implicitly raises the question about the other hospitals in Partners HealthCare (e.g., MGH, North Shore, and Newton Wellesley), a system characterized as an integrated delivery system? Where are they on this matter?

But this is not just a Partners issue. Look at the non-response to my challenge to all the Massachusetts hospitals on this matter a few weeks ago? I don't think I am being egotistical to expect at least one hospital administrator or someone from the state hospital association to contact me and say, "Yes, let's try it." Or even have one of them say, "That's a dumb idea." No, the response is silence.

Meanwhile, I hear public officials and insurance companies and businesses express concern about the high cost of health care. They say we need new models of compensation and regulation to control those costs. Everyone in the field knows that a major contributor to costs is preventable harm that occurs in the hospitals. It should not take a new alternative contract from Blue Cross Blue Shield or from anybody else to institute these kinds of changes. Failure to implement is not the result of economic pressures or the design of reimbursement. The check list takes about 90 seconds, not enough time to make a whit of difference in the day's OR schedule -- and, I am guessing that it will even accelerate a number of cases.

No, the imperative must come from within the profession. It has to be based on the underlying set of values to which doctors pledge their lives: avoiding harm to patients. The story about Atul's study unfortunately says, in so many words, that there is much lacking within.