Thursday, January 15, 2009

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.

53 comments:

Keith said...

Paul:
I'm fairly new to your blog and enjoy it. In the interest of full disclosure, i work for the Brigham.

I agree with just about everything you have said here on this topic and wholeheartedly agree with the poster from the Globe that you quote.

The issue that I have is that you say this is not a criticism of any particular institution, but then you go on to question why the Brigham is evolving to using a checklist system only now (and then add conjecture about the other Partners locations). Yet, BIDMC only implemented this policy in July 2008 (correct me if I'm wrong), a mere six months ago and in response to a major medical error (that I applaud you for getting out in front of rather than letting the press rip BIDMC). Given
that there are multiple institutions involved and there are variables that can be debated on any checklist and its appropriateness for use in certain areas discussed, isn't six months (with an incremental rollout) after learning from BID's unfortunate incident reasonable for implementing use?

Looking forward to your comments.

Paul Levy said...

In simple terms, no. I don't really think there is much to debate about with regard to this kind of checklist. As we learned to our dismay, BIDMC doctors should have been doing this months before as well. Instead, our staff was inappropriately comfortable with the level of care they were providing to patients.

That's the issue, whether at BIDMC, Brigham, or dozens of other hospitals in the state. It is a lack of self-awareness of the danger to which we subject patients.

Anonymous said...

Just think something as simple as a checklist improves patient care.

A hospital environment is a tough place to work. They are full politics and ego issues. While the BI is able to preach and practice transparency well, I am not sure the medical profession as a whole likes the pragmatic process.

The profession needs a change and you are leading the way. How do you propose to outside competitors that transparency is a good thing if they are scared of it?

Many people share your frustration.

Don Berwick said...

You're being a tiny bit too hard on the MD's, I think. As "duh" as the checklist looks (and it's really "duh"), this is still a "good people - bad system" thing, mostly. The "system" at issue here is the one that prepares and shapes young professionals. It is somewhat broken. It does not prepare these generally wonderful emerging professionals for active citizenship.

To blame a doctor for a self-image of heroism, autonomy, and artistry when he or she has had it drummed into them for their whole career that the buck stops with them - that the patient's fate is in their hands - that they personally and individually are responsible for excellence is a set-up for deep misunderstanding. They're not being dumb. They are pursuing the form of excellence and responsibility that they have been told to pursue.

I also think that 90 seconds is not a trivial investment. Believe it or not, it will feel onorous and wasteful much of the time. "Pause and reflection" are not seen as "productive" in health care. So the message that might work is: "I know that in the busy pace of the work, this minute-and-a-half to pause, prepare, and reflect will likely feel burdensome. But, we'll need the maturity to realize that, in interdependent systems, time to learn and communicate is a crucial investment - not a luxury - if we are to grow together. As CEO, I need to translate that commitment to learning into my own daily work and to encourage and support it among the good people who work with and for me. When you are spending time to synchronize and coordinate your work, you are being 'productive.' If I send mixed signals on that, tell me."

You know better than I do: a checklist is simple; changing a culture isn't simple.

Paul Levy said...

Many thanks, Don. Beautifully put.

On the other hand, sometimes I am really impatient -- in that I see little interest in the medical schools to teach this stuff -- and then we are left with having to excuse smart people for their lack of training. Regulators and legislators are likely to be more impatient than I -- and we know their remedies can be crude, misplaced, and ineffective.

Also, I think it gives insurers unwarranted support for ill-conceived plans to shift risk from the insurance companies to the providers. That, too, can be a crude and misplaced approach to process improvement.

henry r said...

Thank you for your comments and thoughts.In my training as an anesthesiologist I witnessed the adoption of a pre-anesthesia check list involving the anesthesia machine and equipment. Although not everyone agreed with the concept it has worked very well and been incorporated into the accreditation review process.

Carl said...

I think we also need to recognize the huge amount of paper work and tasks that are already done in healthcare. There should be a check list, and there should also be twenty other checks and each one of them only takes 1 to 2 mins. So that's an extrat 20-40 mins filling out paperwork and doing tasks. The problem comes with the inability of administration, CMS, Joint Commision, Medicare, etc., not looking at the big picture of care. Everyone has their interests in patient care, however the dilivery of that mandate can be unrealistic in the current process. I believe that this is one of the reasons there are so many medical "mistakes". Not because of the skills or intellegence of the healthcare staff, but because of the process is so disjointed and time consuming.

Anonymous said...

Paul, As a former pilot I generally understand your frustration but Don Berwick is right; we are not trained to operate this way.

Carl's point is also very good. Telling us "it only takes 90 seconds" is insulting. In the ER, we work in an environment where we are short of many things and time is at the top of the list. Each of these initiatives is viewed as another time-waster forced on us by someone who does not understand what we do.

This checklist is probably a very good idea but it will take more than someone telling us "this is a good idea, do it".

Anonymous said...

Innovation is in the eye of the beholder.

After all, think of something as simple as a child proof safety cap. I mean really, it aint rocket science, and poof, countless lives saved. It only seems obvious (and trivial) after the fact.

Brad

Paul Levy said...

Dear Anon 1:10:

To imply that a well-designed time-out is "another time-waster forced on us by someone who does not understand what we do" suggests a very bad attitude on your part. This procedure was designed by clinicians, not by some industrial engineer or administrator from another field.

And why is it that 'telling us "it only takes 90 seconds" insulting'? That's how long it takes. Is that not worth avoiding a wrong-side error or some other significant harm?

I am sorry to say that you are making the case more strongly than anything I have stated. To those without medical training, you appear recalcitrant and stubborn. What, in fact, will make you want to do it? Does Atul's research mean anything to you? What further level of proof do you need?

Anonymous said...

Paul,

When I referred to "time wasters" I was referring to things like screens for domestice violence and fall risk on every ER patient. The time I saw both of those screens done on the semi-pro football player with a broken ankle illustrated that well.

I support a well-designed time-out although I recently had to correct the mis-application of the time-out in my ED. We now do it correctly.

When I said it was insulting to be dismissive of "only 90 seconds" I simply meant that by saying that you imply that we have 90 seconds to spare. In an ER that sees 160 patient per day, what happens when you add a 90 second screen to every patient? Do the math. That extra time comes from somewhere else. How refreshing it would be if someone added "... and here is how we will eliminate 2 minutes per case."

I agree with you that this concept is good. I'm trying to point out that years of bad ideas and lack of understanding have made front-line people skeptical.

One further personal example of a good idea gone bad: I'm recovering from surgery. Just once I would have appreciated someone not asking me to express my pain on a 0-10 scale. What's wrong with "how is your pain?" or "do you want some pain medicine?"

You misunderstand me. I agree with you. The problem often comes in the application of a good idea. What starts out as a good idea (do a better job of asking about pain) has become a joke ("my pain is 20/10"). I can only imagine what that check list will look like after it goes thru the JC and all the committees in my hospital system.

Anon 1:10 (an ER doc)

Paul Levy said...

Got it. Many thanks. Sorry I misinterpreted.

And I certainly agree that the ER is a different kind of place than the OR. A fast-paced, high stress environment.

By the way, in the OR environment, we find that the 90 seconds spent before a case can actually make the whole thing proceed more efficiently and reduce wasted intraoperative time (e.g., discovering that a certain piece of equipment or instrument is not where it should be).

Our folks designed their own check list, modeled after the WHO one, but they are constantly refining it as they learn how to do it better. It was a great team-building exercise among the nurses, MDs, surg techs, and so on.

They also designed the training program for all the OR staff.

Carl said...

Paul,

I also agree with what the ER doc mentioned above. These are great ideas, however there are a lot of them. Some make sence, some are repetative and some just are old and out of date but are still required.

I used to work in mental health and we were asked to get a pg test on every female that came on the unit. Never mind the 65 year old woman who had a historectomy 15 years ago written in her history on the previous page, it had to be done.

There is a lot of skeptical clinician who are well intended that become frustrated with additional checks no matter how well intended.

e-Patient Dave said...

Good discussion. Here's an email I sent to a friend this morning, when he sent a link to his local paper's coverage of this. I knew him in one of the first online peer communities I ever joined, the Desktop Publishing Forum on CompuServe. (20 years ago this month!) He worked in production for the Calgary Sun, and in those days we found that PostScript users needed to band together to figure out how to make the damn stuff print right, because bad output was costly and time-consuming. (The answer that evolved was, um, a checklist, which we likened to a pilot's pre-flight checklist. The entire industry came to call it pre-flighting a job.)

Note: we couldn't count on the vendors to give us the information we needed so we banded together using electronic forums (known today as social networks) to share information, and we evolved a solution ourselves. (This was even before the Web was born.) It's a perfect metaphor for what's in process now as e-patients use the Internet.

He sent me the link today, and I responded:

=======

Brian,

The general subject of checklists is getting a lot of press, and for good reason.

The more I learn about healthcare, the more I see that some of its practices are very archaic, and will benefit as they get more common-sense participation. For instance, checklists? Hmmmm, let me think - pre-flighting a PostScript file?? Pre-flight checklists on airplanes? Not EXACTLY a new concept. And yet medicine, for all its technical brilliance, is just starting to open its doors so we can see in and contribute.

There is a movement starting, Brian. A movement in which medicine shares its knowledge and invites contributions from us.

That's why it says at the top of the e-patients blog, "because health professionals can't do it alone."

====

Don's point about changing a culture is well said. But at some point people need to STOP BEING ATTACHED TO OLD WAYS THAT COST LIVES.

Sorry for shouting, but this is no time for saying "But I don't WANNA do it different. It's too HAARRRD."

Anonymous said...

Paul;

You know that I admire you and your efforts, and that we share some views about physicians' culture as sometimes obstructive of patient safety/quality progress. However, taking an adversarial, finger-shaking approach as with anon 1:10 will only diminish your credibility with medical staff - even albeit that once he/she responded fairly and reasonably, you did apologize. Dr. Berwick's comments are also very pertinent. Impatience is entirely understandable, but even Peter Provonost was skeptical of the huge decrease in post-op deaths reported in the article, and there is evidence that implementation of the WHO time-out procedures has done little to decrease wrong site surgeries.
So I am on the fence here - while I am sympathetic to your do-it-now response, I also recognize anon 1:10's point that checklists could just be another medical fad which is discredited over time. Medicine is unfortunately littered with such fads. Certainly I would agree the surgical checklist should be implemented, but ability to replicate the positive results in the study should be carefully followed up at multiple institutions over time. Don't just assume this is a "duh" moment, implement it, and move on to the next thing.
As Warren Buffett supposedly says, it takes years to build up a good reputation, but only minutes to destroy it - and so goes the administrator-physician relationship.
If you disagree perhaps we can continue the debate via email rather than clogging up the comment section. (:

nonlocal

Anonymous said...

Addendum: Actually, I have a serious suggestion. Since you have a prior relationship with Harvard Medical School (am I correct?) I believe you should approach those in charge of the curriculum for you to teach a course on these issues to medical students. One would have to carefully think through at which year of medical school this would have the most impact - my theory is that it would be during the 3rd year, after the students have had a taste of how things really work (or don't) on the wards. Dr. Berwick is correct that physician re-education really needs to begin at the student level, and obviously current physician-teachers would not be the best ones to teach it. You would be perfect - good speaker, excellent role model, a wealth of real-world material on which to draw.
Now how you find the time, is another question - but this is important stuff.

nonlocal

Anonymous said...

All this circles back to the craft and autonomy element of medical training. Watching medical students in training is not so heartening. They may be learning good detective skills, but not good scientific skills. They do not learn to deduce from summarized information, to follow data - but to follow directions. And be right. Or face intense criticism. Who wouldn't be avoidant? This is how they make As.

Learning to learn - to be open to improvement - is a culture shift that requires intense attention and reinforcement by leaders. Everyone top down must pay attention to what is required: culture change. You are doing it, Paul. But there have to be a lot of carrots with the sticks. Advertise the innovators! Marginalize status quo.

Charlie Kenney said...

Cincinnati Children's instituted a pre-surgical timeout/checklist a while back. Dr. Steve Meuthing realized that it was one thing to have the procedure in place but quite another to have the culture that would ingrain the practice. Early on a surgical group jumped the gun and a child life specialist halted the process noting that there had been no timeout/checklist. It was an important moment. There surely would have been places where the surgeon would have leveled an icy stare at the woman and plunged ahead. But Uma Kotagal, Jim Anderson, Lee Carter and their team at Cinn Children's had worked long and hard to create a culture where the patient came first and where everyone on the staff -- by their actions -- acknowledged that. In this case the team realized its mistake, took the timeout, and all went well. The story of what happened made its way around the institution and sent an important signal of empowerment to the staff. A good procedure in the right culture can really work.

Stephi said...

From the patient side...bring on the check lists!

I had to go for day surgery last summer (St. Paul's Hospital, wonderful people there). It was my first time having surgery so I was nervous to begin with. Terrified actually. Well, it didn't help that I was asked, about 10 times, what my full name was including my birth name, and what surgery I was having. At first it horrified me - partly because it was a traumatic surgery and I had to repeat the reason for it 10 times - until I realized why they were asking me and I was SO grateful.

I don't know if St. Paul's has adopted a checklist policy, but I'm eternally grateful that there was no mistaking what I was "in for".

I have no idea what it takes to implement a policy in a hospital, I have no idea what the administration must do to get it rolling, but, as a patient, I'm a HUGE checklist fan!

BTW: the checklist article was in The Vancouver Sun today as well.

Paul Levy said...

Dear Nonlocal and others,

I am very lucky to work in a hospital with lots of doctors who are taking real leadership positions on these kinds of quality improvements, and they know that our Board and I are very proud of their efforts and support them. Your advice that I should ease off and be more patient with regard to the general pace of cultural change, however, is misplaced in that society as a whole is even more impatient than I. Please reread what I say about the likely kinds of actions that governmental authorities will take place in these arenas if the medical profession doesn't accelerate the pace of change.

e-Patient Dave said...

I'll second what Stephi said. (btw, anyone who hasn't seen her fabulous Pregnant Stephanie blog is in for a treat! Subtitle: "A completely self-involved blog dedicated to my pregnancy. Because, you know, I'm the first person ever, in the history of the world, to be pregnant!") And she's 38 weeks pregnant now, so get it while you can.

I too was at first irked when these apparent fools kept asking me the same things over and over. Same for when they keep asking me to bring in my prescription list. "You fools, it's all in YOUR system - don't you know?" But the more I've learned about healthcare in the past year, and from reading this blog (thank you for the transparency), the more I see that these practices evolved from analysis of past failures. And like Stephanie, I've ended up grateful.

I wonder how many patients, understanding this, would say "If the doctors don't think they need checklists, don't make 'em." Maybe some would. But me, well, I put a thousand blessings on what Charlie Kenney said: "But [the] team at Cinn Children's had worked long and hard to create a culture where the patient came first and where everyone on the staff -- by their actions -- acknowledged that."

I wanna know, who puts anything else above that?

Who?

Lachlan Forrow, MD, FACP said...

Paul:

I hope that no one here is saying "be more patient" when people are being injured and too often dying at our hands unnecessarily, or if they are then I hope they can stop and ask themselves if that's what they really would want if their own loved one was about to enter a dangerous environment where effective safety improvements were slowed down by people who valued superficial niceness over quality.

I'm not sure I can even see how there could be such a thing as 'too impatient' here. I hope that everyone can agree that the question is not about patience, but rather how we can _maximize_ the pace of improving safety-improving change. In some of the comments to you people might be right to worry that the wrong tone will create resistance that slows change down, or that too-fast adoption of measures that may not be as good in practice as they sound will actually delay true improvements in safety. Both may be true, though sometimes those expressed worries are just covers/excuses for resisting change that is uncomfortable (I've for sure been guilty of that myself!).

But please, please don't anybody think that "patience" here is a virtue! I think we need to vigorously encourage much more impatience here than we have yet mustered, and focus/limit our disagreements to the question of what the best and fastest ways to achieve positive and enduring change will be.

And for that, Paul, I agree with you that Don Berwick's comments above, as usual, are worth reading two or three times.

--Lachlan Forrow, MD
Director, Ethics Programs, BIDMC

Gary Kaplan said...

I very much appreciate the dialogue about this very interesting challenge.

I agree with the comments made by all and often find myself as a physician and CEO having to resist the temptation to both defend and demonize my own colleagues for their initial resistance. At Virginia Mason we have made great progress improving receptivity to "standardization". We have approached it from many different angles as even amongst physicians there is variation in learning styles, psychological anchors, and aversion to change. Our training to only trust ourselves to ensure our patient's well being is deeply rooted but ultimately maladaptive for today's complexities in diagnosis and treatment.

We often consider these things in terms of respect. I am talking about ultimately respect for our patient's but also respect for our colleagues and team members and even respect for oneself.

Following standard best practice is a form of respect and ensuring that all non value added and even harmful (in situations like the surgical checklist) variation can and should be eliminated. This then allows for the value added variation that must distinguish the individual physician or caregiver-patient relationship and interaction. Initial reaction from my academic colleagues within our organization was that standardization was "cook book' and a sure path to mediocrity. They now however resonate to Taiichi Ohno's (the founder of TPS) wisdom that "without standards there can be no improvement"and "you cannot improve a process until you have a process". Today we have our surgeons and all clinicians championing "standard work" in the name of safety, ability to measure, and as an impetus to improvement and creativity.

It is all about cultural change and building on the clinicians' desire to always do the right thing. As a leader, I have found that the time and iteration required to make this happen is well worth it and the cycle times shorten as the journey continues.

Thanks to all.

Gary S. Kaplan, MD
Chairman and CEO
Virginia Mason Medical Center

anon md said...

Atul's research is not very rigorous in showing that it helps. His comment that he catches something once a week is not very scientific.

And so the questions is, does the checklist really accomplish something? It sounds like a good idea, but that doesn't mean that it is.

In my hospital there's already a checklist. Nobody pays any serious attention to it, and just checks off all the items automatically. The checklist mentions that all the implants are available. But it gets filled out in the holding area, where the surgeon hasn't had the chance to see if the implants are really available. It's basically a form to make administrators happy, but it doesn't add anything to the safety of the patient.

And the 90 second thing? Come on. Every idea is 90 seconds, and now there's 100 of them. For every surgery there's 10 forms before, 10 forms afterwards, 10 forms for billing, dictation, editing, tumor registry, etc.... Eventually we'll only have time for the various "90 seconds" and not have time to take care of patients. This already happens with nurses. They're so busy "charting" and documenting, that they have no time to answer the call bell.

Another example: the instrument and needle count at the end of each case. It sounds like a good idea, and maybe it is. But is there data that it works? I know there are still foreign bodies being left behind - and the counts were correct in those cases. Half the time when I'm finishing a case, the scrub tech isn't paying attention anymore - because he's too busy counting. And when the count isn't right, it's invariably because they miscounted or someone dropped a lap pad on the floor. Then the "90 seconds" becomes 30 minutes and an x-ray.

I'm just suggesting you cut the critics some slack. It's not all because we're misfits who are too egotistical to care about patient safety. We just want to make sure there's a good reason before adding even more paperwork to the ever growing pile...

e-Patient Dave said...

Dr. Forrow, thanks for your additions to this. I shoot my mouth off sometimes but I hope it's clear that (speaking Bahston here) "I ain't no docta" and I'm still learning.

What your comment added for me is the reminder that an airplane take-off (or printing a PostScript file) is not done under the same circumstances as a medical emergency.

If I recall past discussions here correctly, it's always been agreed that in an emergency, you do what you gotta do. I don't know if there's realism in the TV scripts about using a ballpoint pen for an emergency tracheotomy, but it would illustrate that point.

So to me, all talk about policy and practice is inside a "whenever possible" proviso.

Paul Levy said...

Thank you so much, Anon MD. Your comment presents the ideal bookend to Gary's right above yours. The key to a useful checklist is not the checklist per se -- it is the process by which it is designed and implemented. If it is just checked without real involvement in the work flow, it has little value. What we have found, and what Gary has found, and what Atul has found is that properly designed and implemented, it improves the work environment for all those in the OR, as well as enhancing patient safety. In that sense, it cannot be an imposition of the administration: It has to be a product of the medical staff. However, sometimes the administration can be helpful in training MDs and other medical staff in the art and science of process improvement, something not usually taught in the medical schools but something used in many other industries.

Mark Zeidel, MD said...

I agree with your sentiments, Paul. Above all, I agree that we cannot look to the insurance companies to play a significant role in improvements like this. We must, must make these improvements an integral part of our profession, and we must view them as central to our responsibilities as professionals.

Mark Zeidel, MD
Chief of Medicine
BIDMC

Kenneth Sands MD, VP for Quality BIDMC said...

We will really start to make progress when clinicians recognize that the breakthrough concept here is not this specific checklist, but that implementation of more reliable processes leads to more reliable results. I fear that, as wonderful as this result is, if we have to transform healthcare one checklist at a time that we will still move too slowly. I agree with Don that the “blind spot” clinicians have to the importance of standardization relates to training and messaging, and it does not need to be that way. Other professions value standardization, and in fact physicians do too when it is a longstanding part of the culture (surgical scrub, H and P format).

Megan said...

As Paul points out, checklists work better when they are developed by the people who are going to be using them. Imposing illogical policies/standards, such as "all women must have a pregnancy test" (even if they have had a hysterectomy), is what makes people think policies/standards are useless.

Also, if people who must follow the standard don't know the logic behind it, they don't know when exceptions should be considered. And if there is no process in place for exceptions, patients can be harmed by the standard.

Bob Yokl said...

Paul as always a great commentary and just like your SPIRIT program you find out things that "Aren't Pretty" in any business and you work to correct them. Any best practice will take time to first be recognized then adopted by any level in your organization.

In the end the article has envisioned a best practice and now set the bar a little higher for surgeons/docs as well as learning something learned in other areas of hospital operations as well.

Great insight!

Bob Yokl

Atul Gawande said...

I love Don's suggestion for how to talk to surgeons and others about their work and the need to make changes that raise our own performance. Here's how I think
about the nature of the barrier we are up against.

We know that children in America are increasingly obese and eat terrible diets (with way too much sugar in particular). Parents know that. But if we proved that a daily diet checklist that put severe limits on soda pop reduced obesity, how far do you think we would get with persuading moms to use it? Moms will think such a checklist might be a good idea for everyone else. But when it comes to themselves, a checklist comes across as something like an accusation. You believe, as a mom, that you are doing the best you possibly can for your child. So they will be outraged -- OUTRAGED -- if you were to come along and mandate in law that the checklist be used.

Well, doctors feel the same way about their patients. Most of us go about caring for them with that strangely devoted but somewhat defensive and self-deluded way
a parent goes about raising a child.

I haven't completely resolved this issue in my mind. I understand the temptation to shake our fists and demand a law that makes every surgeon use our WHO checklist, or to fire them unless they use it. But all we'll have done is gotten them to tick off the boxes just to satisfy yet another paperwork requirement, and that's simply not the change that saved lives in the study. And we've failed to recognize that we who are in other lines of work are just as resistant to being told what to do, no matter how wise the advice is.

I am convinced that the most important force to bring people in medicine to adopt something as simple as a lifesaving checklist--and then reinvent it and improve it to make it even better for their operations--is cultural and not regulatory. We have to imagine that we've got mothers we're trying to persuade to stop giving soda pop to their children everyday. The intervention is simple. It is "obvious." And it is really really hard.

My approach in each country I'm working in is to start with one hospital. In that hospital, we start with one operating room, one surgeon, one anesthesiologist, one group of nurses. Once one room is going convincingly, we go to two. When we have two, we go to four. Then we go to the whole hospital. Then we go to two to three hospitals. Then we bring those people to the health department and try to use them as a basis for a nationwide roll out. We did this
in Seattle. Ramp up at U Washington to routine checklist use in every operating room took three months--a while, but it has stuck. And their success (complications fell by more than a third) has since made them almost evangelical about the effects. They've brought the checklist to 13 hospitals (with measurement no less). And it is rolling with such force that the Washington State Hospital Association appears to be on its way to reaching all 97 hospitals
by year's end. I've taken this same approach in Jordan. Same result. We're on our way to complete adoption in public hospitals by spring.

We're now trying China. We're in 3 hospitals in Hong Kong as of this month. I'm very keen to see what happens.

Atul

Brent James said...

Paul, you have put your finger on what I regard as THE core task of the present generation of the healing professions. It is very clear that we are in the midst of a transition. The term of art that is usually used to describe the present state – and which Don Berwick so eloquently explained (at least, at the level that an individual physician would experience it) – is “the craft of medicine.” It’s the idea that every physician (or nurse, or technician, or administrator, etc.) is a personal expert, relying primarily on their personal commitment to excellence. In a very real sense, every physician occupies his/her own universe, with its own reality, truths, physical constants. As a physician I might say to a colleague, “What works for you, works for you. What works for me, works for me. Let’s both stay focused on the patient – our core fiduciary commitment to put the patient first in all things – and that will guarantee the best possible results.”

David Eddy said it most eloquently: This core assumption of the craft of medicine is scientifically untenable.

As a direct result of some solid research around this fact, the healing professions are in the midst of a major sea-change, a once-in-a-century shift: We’re moving from “medicine practiced as individual heroism” to “medicine as a team sport.” The kinds of tools you’re talking about make perfect sense in a team setting, but almost no sense within the craft of medicine.

Don is right in calling it culture change. However, we are well past the tipping point. There is strong evidence that the professions have committed to a new course and are actively moving. It’s the difference between 5% of the profession “getting it” (where we are now), and moving to a point where it is standard, accepted, background business essentially all of the time.

The key change concept was perhaps best expressed by Winston Churchill: “People like to change; they just don’t like to be changed.”

I am also deeply impressed by Roger’s classic text on change: Diffusion of Innovation. He describes bottom-up change, by sharing results (both data and word of mouth) from initial thought leaders (his “early adopters”). That has worked very well for us, and makes the change fun – rather than something that a bunch of external “know nothings” are trying to do to you.

Jim Conway said...

Wow what an amazing conversation.

I want to introduce a perspective that is a little different--that of the consumer perspective. As Atul knows, Health Care for All has already submitted a request to the legislature to have this checklist made law in Massachusetts now.

In listening to consumers, what's driving them is not only suffering, harm, tragedy, and waste. They just don't get our notion in healthcare of time to implement or our ignorance of standard operating procedures. Many of them work in industries with they have SOPs, they are working in sigma 6 environments, they understand what it takes to produce quality, and they know there is no tolerance for variation. The expectation is set, it is known, you meet the expectation, or the deviation is immediately noted and dealt with. They don't understand why this doesn't apply to healthcare. I've believe I have heard Charlie Baker express similar sentiments at the MA Quality and Cost Council.

In an email exchange with Atul last evening, I noted that the public doesn't see the use of checklists as an "if" discussion but a "when and how" discussion. Just like in their life, there should be a "do what by when." We should set the expectation, train people to meet the expectation, manage to the expectation, and deal with deviation. Some is not a number. Soon is not a time.

In health reform I have also learned that this isn't just for the healthcare industry to decide--we are a vote but not the only vote. We will need to come to the right decision in partnership with all our publics (payers, regulators, employers, healthcare providers and organizations, patients and families, and all consumers.) No question in my mind--it won't be what we would have decided from within healthcare but it is absolutely the place we are going to go... so says the new law, payments system, etc. and the people we are here to serve.

Jim Conway
Senior Vice President,
Institute for Healthcare Improvement [IHI]

Lynn Nicholas said...

Paul, you’re not being egotistical and I’m not being defensive. But just to be clear, Massachusetts Hospital Association was specifically cited in Liz Kowalczyk’s article as supporting the IHI “sprint” effort and now that the WHO checklist study has been published in a peer-reviewed journal, we hope that many more organizations will adopt this voluntary approach. Given the literally hundreds of quality and safety measures Massachusetts hospitals are already voluntarily reporting, we anticipate that with these compelling, evidence-based research results, hospitals are in a good position to decide for themselves when and how best to take action on this initiative.

e-Patient Dave said...

So, all, this discussion has become all about checklists. What about Paul's point in the post, "What does it take?" What will it take to get hospitals to respond to Paul's initiative to share knowledge and work together to reduce harm?

What is the obstacle here? I can't imagine that hospital executives are against the idea of better care; that's silly. So what is stopping them?

On Paul's original post I said it's hard to imagine Albert Schweitzer not welcoming such an offer.

In a discussion about this on the e-patient blog, PsychCentral's John Grohol suggested that CEOs answer first to their boards. Paul's said many times here that such things require board support. Do we need to get the boards involved?

I mean, really. Lives are at stake. (Remember, I'm not talking about checklists here, I'm talking about his message in the post.) What is the obstacle to better care?

Anonymous said...

Gee, are pre-flight checklists in Massachusetts law too?

Robin said...

In my life, checklists actually save time in the long run instead of wasting time. Efficiency is always less chaotic than happenstance.

As a patient, I keep pushing for change which benefits me in healthcare. What seems so odd to me is the fact those who work in that business resist that so much. At least that's what it looks like to me. Without me, you don't have a job. Sadly, you know I have to take what I can get because I have no other option unless I am affluent enough to shop around (so-to-speak) with no regard to what insurance (if I can afford it) can pay.

I made a conscientious and life-saving choice in my life to do just that. That has financially limited other things in my life due to my adjusted priorities, but it has been worth it. Sadly, not everyone has that choice due to circumstances in his/her life.

When does the business of taking care of patients really become about the patient? It seems to me the connotations of the word "business" denote efficiency.

I have blogged several times about all the hype/talk about reforming healthcare, but no one is really doing anything but talking. Paul, it is refreshing to see someone actually putting their money where their mouth is.

As a friend of mine is always saying, "If you do what you always did, you'll get what you always got."

Regards....

Lachlan Forrow, MD, FACP said...

To what e-patient Dave said:

Albert Schweitzer taught: "Example is not the main thing in influencing others, it is the ONLY thing." Atul's report on Seattle confirms this once again. It's seeming clear that what Paul is saying on his blog has limited influence on other academic centers, at least in Boston. But if/when we at BIDMC have a demonstrably safer hospital than we do now, and medical, nursing, and other staff who are thus even more proud than of working here than they are now (and thus attract others), and if/when we are then attracting patients who trust us even more than they do now, THEN there would be no one in health care who wouldn't listen (or at least look!).

The different views expressed here are unlikely to be resolved through discussion. Schweitzer said "My LIFE is my argument". What Atul reports from Seattle and Jordan is a pretty powerful argument indeed.

Finally, I just learned yesterday of the great work of Sylvia Stevens-Edouard and others in Blue Cross on a childhood obesity prevention program "Jump 'N Go", which promotes a "5-2-1" approach -- 5 fruits/vegetables per day; max of 2 hours of TV per day; 1 hour of physical activity. What's interesting and relevant is how she says she/they succeeded. NOT by getting moms to start doing it. As I understand it, they started w. a monthly "2-s Day" (Tuesday) where moms and kids agreed that for one day there would be <2 hours of TV, just once a month for three months. (There may even have been a small prize for any kid/mom who succeeded.) That was doable. But of course to do that mom needed to figure out who was going to "babysit" the kid when the TV was off. The kid had to try out some other activity. When it didn't go well, there was a full month to figure out how to try again. Then any mom/kid who succeeded had figured out HOW to, and ideas could spread to others. Now, as I understand it, 5-2-1 has taken off far beyond Blue Cross (see http://www.healthynh.com/fhc/initiatives/ch_obesity/index.php ) for a Harvard Pilgrim Foundation-supported NH variant 5-2-1-0, where the 0 is "zero sugar-sweetened drinks".

--Lachlan

Lachlan Forrow, MD
President, The Albert Schweitzer Fellowship
Director, Ethics Programs, BIDMC

Anonymous said...

To me, the individualist approach to medicine is difficult to understand. Medicine MUST BE a team sport. Patients are not body parts, especially those with chronic illnesses. A great surgeon and poor aftercare still tends to equal a bad outcome. It doesn't matter how prettily the sutures were done.

Basic standards mean that basic things get done. I don't know of any profession where practitioners don't have automatic tools to make sure that they don't miss something -- from the litigator with her evidence chart to the accountant with audit tools. Part of being a professional is KNOWING that you are fallible and having tools handy to keep yourself in line. Many of us can attest that the people who make really big and really bad mistakes are those who believe that they don't make mistakes.

The medical profession is at a crossroads. It can choose to be a business, not take responsiblity for the quality of its practitioners, and have quality imposed on it by third parties or it can choose to take responsibility for itself. Websites reviewing the quality of services of health care providers are not going away; other fora for patients to discuss outcomes are not going away. More sophisticated "management" of health care outcomes by insurers is not going away. Which means that physicians will be accountable.

Anonymous said...

There is a virtue to practicing medicine consistently, especially as a specialist in a narrow field. When your patients confab about their visits, you don't get caught sounding like you don't know what you are talking about because you said completely opposite things about the same condition to two different patients -- ie. diagnostic criteria, preferred treatment, etc. Nothing kills a doctor's credibility more quickly than that. One well regarded doctor at Brigham is a very specialized area got caught claiming different diagnostic criteria as being necessary -- for every patient, the critical criteria was whatever test had not yet been run (and contrary to his published papers). Despite a distinguished career, he now has a reputation in the patient community of milking patients for insurance money rather that putting patients' interests first.

Anonymous said...

By way of analogy, here are a few quotes from today's WSJ article on the US Airways crash (P. A3):

"..despite years of prodding, it has been difficult for the FAA to bring changes to the flight-training regime, in part because airlines have resisted tougher rules as unnecessary and expensive."
"Stretching back to the 1990's the safety board (NSTB) has prodded the FAA to increase evacuation training and require more frequent maintenance checks of emergency slides and rafts to ensure they are in proper operating condition"
"....it has taken years to propose a comprehensive rewrite of training rule for pilots as well as attendants."

Perhaps we are dealing with just plain old human nature rather than some particularly obstructive group.

nonlocal MD

Jim Reinertsen said...

It seems to me that the message to doctors boils down to this: either we do checklists for ourselves, fast, or they will be done to us. We whine a lot about how we've lost autonomy, but this is a great example of how we will lose even more autonomy as a profession if we insist on hanging on to it as individual professionals.

I think this chain of effect could work in the other direction. I would frame it as a proposition to our colleagues: If we give up some individual autonomy (in this case, share it with our colleagues for standardized, simple practices such as checklists), we might regain at least some of the autonomy--the privilege of some self-regulation, granted by society--that we've lost as a profession.

John Norris said...

When the pilot of Flight 1549 figured out he had to put the plane in the Hudson river...he would have used a "ditching check-list".*

Surely, if a checklist is used in that time sensitive situation, others can find the time to use it elsewhere.

* http://tinyurl.com/8tt6hf

Anonymous said...

John;

Yeah, only one news report said the pilots said everything happened so fast they never did throw the "ditch switch" which helps render the plane watertight.

nonlocal

e-Patient Dave said...

Lachlan, thank you so much for your kind, informative and illuminating response.

I'm always humbled and grateful when a doctor takes time to teach me something. Sometimes I speak strongly because of my passion for a new world of healthcare, where patients and professionals collaborate in sharing responsibility and creating solutions. (See October discussion of the forthcoming Society of Participatory Medicine, and the recent discussion Embrace Knowledge Symmetry, as BIDMC's Danny Sands put it).

But I'm keenly aware that in absolute terms I don't know squat compared to the vast elephant-sized picture. So I'm always a little afraid to assert a position, and I'm always grateful when someone teaches me.

It's wonderful that social media and increasing transparency are letting lay voices in on the conversation. In developing the idea of participatory medicine, the e-patient scholars group has largely talked about patients participating in their care. But it's evolved beyond that: on his own blog, Ted Eytan MD led a discussion that defined Health 2.0 as "...participatory healthcare. Enabled by information, software, and community that we collect or create, we the patients can be effective partners in our own healthcare, and we the people can participate in reshaping the health system itself."

I participate with all humility, I hope, and I'm grateful for the chance.

--So, like, what is UP with hospitals (and perhaps their boards?) not "participating" in sharing information and ideas as the post suggests?? My guess is that whatever is stopping us, its causing as much harm as a disease.

Megan said...

That is a great article describing the procedure for an airplane crash landing, including the "ditching check-list". While it is great to have procedures and check-lists that help prevent disasters, this article is a reminder that systems are also needed for when things go wrong to protect the lives of the people affected.

Gary said...

wasteful healthcare spending is due to physicians practicing "defensive medicine".

your thoughts?

Richard said...

This may be is a case of 'just do it' and the snowball effect: One or two people start using a checklist. They talk about what worked and refine the list to make it better. Then they write about it, and talk some more to a larger circle, using tools like conferences, blogs, or twitter. Pretty soon, it may snowball into something that has the impact we all want.

Eva said...

A student's perspective on this fascinating dialogue:

...Are physicians prima donnas? Perhaps they are. But are they really to blame? Perhaps they are just a product of the current medical culture. A culture as Dr. Berwick shares in a comment that trains physicians to believe "a self-image of heroism, autonomy, and artistry...that the patient's fate is in their hands - that they personally and individually are responsible for excellence...They are not being dumb. They are pursuing the form of excellence and responsibility that they have been told to pursue."

In the dance world we excuse a prima donna attitude because of his/her talent. But, to achieve a fantastic show we need to stop making excuses. When we know that patient care could be better we need to stop allowing care givers to operate as lone individuals. The depth and breadth of skill necessary now to provide the best care to patients is too deep, too complex, and too wide to be a lone hero. As Gary Kaplan, CEO of Virginia Mason Medical Center said, "Our training to only trust ourselves to ensure our patient's well being is deeply rooted but ultimately maladaptive for today's complexities in diagnosis and treatment."

So what can we do to promote team work? As health professions students, I think we could start with better understanding of our patients and teammates. Spend a day with a patient and see how he/she sees the system. Spend a day with a nurse, spend a day with a physician, spend a day in the lab, spend a day with an administrator...and most importantly discuss your experiences with others. Any other ideas of how we can usher in a new culture of teamwork into health care?

I'll admit that I used to think that the tech crew helping with our shows were insensitive and incompetent. Didn't they know that red lighting flooded and overpowered pink costumes? Couldn't they hear the music and energy shift? That was until I went up to the tech pod and saw the large and complex switchboard that controlled all stage lights. Creating purple light didn't just require one button, but a pull here and a flick of this and a push on that. It was my impatience and lack of understanding that led to my frustrations with the tech crew. They were doing their best. After explaining what we wanted in advance and respecting their own artistic touches and expertise, I've never had difficulties with lighting. Since then, I've come to appreciate how lighting helps to set the tone of a piece and enhances our ability to express ourselves.

So, I guess the key to practicing like a rock star is to simply not practice like a rock star. Embrace the team and you'll see that practicing within a rock band is even cooler. If anything, you will always have your band mates with you to get through the bad and celebrate the good.

Click here to see the full blog post on the IHI Open School for Health Professions Blog

Dale said...

Hi Paul,

I apologize for reaching you via a comment to your blog, but did not readily see a way of contacting you. We are loyal readers because your blog is so well written and comes from such a credible voice ... and have commented on occasion to some of your posts.

My reason for this contact is to ask you to take a look at two blogs that should be relevant to your readers. "The Perfect Customer Experience" (www.perfectcem.com) now has about 1,000 articles on how to improve customer (and patient) experiences. "Better American Hospitals" is newer, just under a year old, but attempts to be a serious discussion to guide hospital leaders in their pursuit of becoming better hospitals (www.better-hospitals.com). I would be interested in any comments you might have regarding these two blogs and hope they reach the standards for inclusion in your blog roll. Many thanks.

Dale Wolf

MedicalBillDog said...

Brent James said (several months ago):

"As a physician I might say to a colleague, 'What works for you, works for you. What works for me, works for me. Let’s both stay focused on the patient – our core fiduciary commitment to put the patient first in all things – and that will guarantee the best possible results.'"

In response to that, after reading Dr. Gawande's The Checklist Manifesto, I would have to respond: "Fine. Show me that what you're doing protects as many lives as the WHO checklist has been shown to protect. Otherwise, get over yourself."

Looking at the WHO map I'm astonished at how many hospitals have apparently ignored this simple, straightforward approach to preventing life-threatening errors--to preventing iatrogenic infections, disorders, and deaths.

Hey, I understand that surgeons are proud of their skills, and everyone wants to be the hero who single-handedly save the day. If you can honestly say no patient of yours has ever died due to preventable complications, well I'm certainly not going to argue with perfection. If not, maybe you need to work on your OR teamwork. The WHO checklist might help.

Lisa researching hospital admissions said...

I find doctors and hospitals in general to be frustrating.

Lisa researching hospital admissions said...

@Eva, in my experience, most surgeon's are prima donna's . I know quite a few physicians that are just regular people with an above average IQ.