Tuesday, July 17, 2012

Quality without science and research is absurd

If there were something called a Nobel Prize in Medicine, it would be awarded to Peter Pronovost for the number of lives he has saved by his applied research in quality improvement.  Oh wait, there is a Nobel Prize in Medicine, but they will never award it to Peter because the way he saves lives is based on the scientific method.  Oh, wait the Nobel Prize in Medicine is based on applying the scientific method to questions of broad human health import and is awarded "to the person who shall have made the most important discovery within the domain of physiology or medicine." So, they will never award it to Peter because he applies the scientific method in clinical settings and saves lives today as opposed to engaging in reductionist research in laboratories that may never save any lives.

Who knows?  Maybe someday the Nobel Prize committee will review the evidence and decide that scientifically conceived experiments and programs in clinical process improvement are worthy of their attention.  When that day comes, they need only read Peter’s book Safe Patients, Smart Hospitals to find the source material for the award presentation.

But in the meantime, every person involved in the delivery of care in hospitals should read this book.  I am not so keen on the subtitle--”How one doctor’s checklist can help us change health care from the inside out”--because that is a highly simplified shorthand for the many lessons contained in the book.  Sure, there is the checklist story, first applied to eliminating preventable central line infections.  But, as Sullenberger notes, "A checklist alone is not sufficient. What makes it effective are the attitude, behavior and teamwork that go along with the use of it."  A checklist applied to an organization that has not engaged in a cultural change that promotes respectful relationships among the clinical staff--described by Peter as a comprehensive unit-based safety program--will fail.  Peter’s contribution is explaining how to create such an environment and in telling the story of his successes and failures along the way.

My favorite story is about the CEOs of the Michigan hospitals and how they learned they could help in the statewide effort to eliminate central line infections.   One CEO said, “You do not get to be CEO without having answers to questions.  Yet I do not have a clue what to do to improve safety. I am not comfortable admitting that.”

Peter admitted that he did not have all the answers either, but that a show of commitment from the CEOs was essential to programmatic success.  “What if I made this easy for you?  What if we were to send you one simple task for you to do each month, would that help?”

They liked the idea.  Our first trial run came when we learned most of the hospitals used an antiseptic solution called Betadine to clean the skin prior to placing a central line . . . [but] chlorhexadine had been proven to be 50 percent more effective at reducing infections.  Even though the two cost about the same, only 20% of the hospitals in Michigan stocked chlorhexidine....

We went to the doctors and nurses and encouraged them to change the antiseptic solutions . . . but the staff didn’t know how to make this happen. . . .  So we sent all the CEOs a memo asking them to make sure that, within on e month, every hospital stocked chlorhexidine in their central line kits. . . .  In one month it was done.

Every hospital can accomplish the kinds of changes described by Peter in this book.  But they have to want to.  To quote Jim Womack, "Whether you think you can or you think you can't -- you're right."

But accomplishing change is not the same as wishing it were so.  Process improvement is a discipline.  At one point in the book, Peter expresses frustration at the lack of data collected by several hospitals participating in the improvement program.  A colleague says, “This is not how quality is done in this country.  Quality is a concept that has never been viewed as research or science.  As long as hospitals are doing projects they think will make patients safer, they believe patients are safer.”

Peter makes the case strongly:  This is unacceptable.  “Quality without science and research is absurd.”

Right.  Now let’s get back to that Nobel Prize committee. 


DKB said...

Until there is more capacity than demand ... then there will never be meaningful quality improvement between competitors.

Paul Levy said...

In other fields, I might agree. But consider the Ohio hospitals, where they say, "We compete on everything except quality." Consider, too, the Michigan hospitals, who banded together to eliminate central line infections.

Anonymous said...

Nobel prizes are given for fundamental advances in a field. Dr. Pronovost should be a serious candidate for this prize not only because of his well-founded insistence on scientific rigor in safety/quality research, and for the stellar outcomes of that research, but even more fundamentally, because he is showing that the currently broken culture of medicine underlies essentially everything in it - and is providing a blueprint for changing it.
As Lou Gerstner said, "I came to see, in my time at IBM, that culture isn't just one aspect of the game, it is the game."

nonlocal MD

e-Patient Dave said...

"Oh wait..."

Woah, Paul veers toward Snarkytown! :)

I know it's serious business - I just notice an occasional drift in your tone lately, sometimes.

To the topic: in the (mere) 3+ years I've been trying to sort out healthcare improvement, if I had to point out two lessons that are most impactful and powerful, they'd be:

1. Information alone doesn't change behavior. So many hearts have been broken by people who believe that telling people some accurate info will solve a problem, but it doesn't work for patients and it doesn't work for physicians. It's a massive error with vast consequences if someone believes they're solving a problem by delivering the right answer, as they used to in their school days.

2. Culture trumps strategy every time. I know you know that.

To me #1 parallels the difference between science and engineering. A pure scientist wants (and only wants) deeper and deeper scientific truth, regardless of whether there's practical impact; an engineer wants practical results, regardless of whether we deeply understand WHY it works. And it seems to me that Nobel pays attention to the science, and you're pointing out that this misses the chance to honor practical results.


e-Patient Dave said...

DKB said "Until there is more capacity than demand ... then there will never be meaningful quality improvement between competitors."

Sounds like yet another great reason to reduce utilization of existing facilities!

Bruce Ramshaw said...

I enjoyed Peter's book a lot(almost as much as Goal Play). I saw him speak at the Planetree conference last year and he said the key to patient safety was loving our patients. I think sometimes the emphasis on CQI/systems science takes the focus off of the need to develop human, caring relationships with patients (who are regularly de-humanized in our current system). One other need for the application of systems science is to define a patient's entire cycle of care. When CQI is applied to a portion of the care process and the whole cycle of care is not defined and measured, there will be predictable unintended and unknowable consequences from a genuine attempt to improve care.

jonmcrawford said...

...and, time to replace the betadine in my medicine cabinet with Hibiclens...thanks!

Michael Pahre said...

They don't just pull people out of thin air to award them a Nobel Prize: somebody has to nominate them first.

Anybody can nominate someone they consider worthy.

If you really think him worthy, then nominate him to the committed for the Nobel Prize in Physiology or Medicine. And please write a blog post here to tell us you did it.

Anonymous said...

I'm a first time visitor to your blog. As I scanned your entries, I noted your enthusiasm for Dr. Pronovost; I have not read his book but his name was familiar. I came across it when putting together an educational talk on burn care; in 2001 a little girl (Josie King)incurred a burn injury, was on the mend but subsequently died from medical mismanagement at Johns Hopkins. That event along with Mrs. King's crusade, fueled Dr. Pronovost's quest to improve patient safety. I applaud his efforts and believe it (pt safety) is the shared responsibility of all providers. Primum non nocere.

Paul Levy said...

That case was an important event in Peter's professional career, and he tells the entire story in the book.