Wednesday, July 14, 2010

Does Pronovost wear Kevlar?

A friend of mine once said that Dr. Peter Pronovost deserves a Nobel Prize for the work he has done to improve patient safety and reduce harm. Of course, that won't happen because the Nobel Committee does not recognize lives saved through process improvement. (Hmm, maybe someone could start a prize for that.)

The latest contribution is an article in JAMA today entitled, "Learning Accountability for Patient Outcomes." An excerpt*:

Each year, an estimated 100 000 patients die of health care–associated infections, another 44 000 to 98 000 die of other preventable errors, and tens of thousands more die of diagnostic errors or failure to receive recommended therapies. Physicians are overconfident about the quality of care they provide, believing things will go right rather than wrong, assuming they provide higher-quality care than the evidence suggests, and thinking they alone have sufficient knowledge and skills to provide care. Teamwork failures are common contributors to harmful errors. In many cases, someone knew something was wrong and either did not speak up or spoke up and was ignored. It is unclear how many teamwork and communication failures result from arrogance. Most clinicians have personal stories of arrogance causing patient harm.

I have seen two responses among physicians to the things Peter says and does. One reaction is resentment and anger -- ironically often proving thereby the very points he has raised. The other is a respectful recognition and acceptance and desire to learn and improve.

Kudos to Peter for willing to take the heat from those in his own profession for saying the things that need to be said. It cannot be a lot of fun.

Kudos, too, to those in the profession who have taken his lessons to heart and are saving lives every day. They are the ones who provide the "Kevlar" vest, offering Peter the protection of actual clinical outcomes that prove his worth every single day.

*Wouldn't you love to read the whole thing? Maybe, someday this influential journal will understand that it would be still more influential if it permitted free access to articles of public import like this.


Anonymous said...

Paul, thus the NIH Publication Policy!


e-Patient Dave said...

This Talk Of The Nation piece yesterday is probably relevant for the anger/resentment component. It's a politics piece, not health policy, but look:

"New research suggests that misinformed people rarely change their minds when presented with the facts -- and often become even more attached to their beliefs..."

It leaves us with the usual question: what do we do about it? I continue to think people (especially scientifically trained ones) are able to respond to evidence (despite this evidence!), but not when it's presented to the lymbic system, e.g. via attack.

Anonymous said...

I had to obtain the full text of Dr. Pronovost's commentary via shady connections, but now I feel qualified to comment on it. I urge all those with access to JAMA to read it and share it with others; it is very powerful, especially for physicians. Dr. Pronovost cites central line associated infections (CLABSI) as the bellwether for learning accountability, and he directly addresses our weaknesses:

"Moreover, many physicians have not accepted that fallibilities are part of the human condition. Therefore, when a nurse questions them, it causes embarrassment or shame. Clinicians are sometimes arrogant, believing they have all the answers, dismissing team input, or responding aggressively when questioned. The line between autonomy and arrogance is fine and nuanced."

But he does not let the administration off the hook either:

"Hospital leaders must be accountable for infection rates, monitoring rates, and supporting prevention initiatives."

His central point echoes Paul's post from yesterday, namely, that CLABSI's are entirely preventable and yet are still happening in unacceptable numbers. It is a call to action that we in the profession should heed.

nonlocal MD

Anonymous said...

I need to make a second comment to issue a public apology to you, Paul. You addressed this very issue of CLABSI and why it wasn't improving way last year, Feb. 12 and 13, 2009, to be exact. The posts generated 72 comments in all. My response to your posts was - resentment and anger. Our exchange terminated with your comment:

"...Then, what seems to upset you the most is my suggestion that a failure to engage in such work is a really serious problem that would be called something more dramatic in other industries. And that I pointed out that very often, MDs respond to all this by saying, "Well, there is something wrong with the data."

Sorry, but these are ALL truisms."

I stopped reading your blog for 2 months. But I will say it now - I was wrong, and you were right. Not only right, but way ahead of the game. Kudos to you as well as to Dr. Pronovost.

nonlocal MD

Anonymous said...


Of course you make a good point. But then again, presentation of argument is largely a cultural thing. A lot of Russian expat scientists struggle with the more "genteel" debating style in the West -- as opposed to a more aggressive and ad hominem debating style among Russian scientists. They might argue that U.S. professionals should have thicker skins and make allowance for passionate critiques...

e-Patient Dave said...

Anon 12:33 - point taken; twice in my career I've worked with Russian engineers, and MAN the bombastic style of argument was annoying for people from the American culture.

(Otoh, I worked with another Russian who was all about beauty and elegance. Hm.)

Anyway I'm increasingly thinking the issue is that the lymbic brain screws up our ability to reach good conclusions. The more people feel attacked or Glenn-Beck-emotional, the more they may get activated (for better or worse), but the less likely they are to think things out. (This isn't specific to Glenn Beck - he's just the in extremis poster child these days.)

Anonymous said...

Dear nonlocal,

Thank you for the apology, which is very gracious indeed. For my part, I will confess to impatience and intolerance on this issue in that earlier post. I had trouble understanding why a profession that takes an oath to do no harm would find it so hard to admit when it is doing harm.

But, by all means, please keep me honest when you disagree!

Barry Carol said...

This looks like another issue where both leadership and incentives are important.

By leadership, I mean the organization, starting with the CEO, must create a culture that includes minimizing preventable harm as an important priority. As Paul notes, public disclosure of central line infections can help to hold the organization accountable as well as to inform patients about how good a job the hospital is doing in this area.

Nurses need to feel empowered to speak up without fear of adverse consequences if they notice a problem or see a doctor making a mistake. At the same time, doctors need to perceive the likelihood of adverse consequences for persistent arrogance and for too many mistakes. As more doctors become hospital employees, this approach might get easier to implement. Hospital executives need to assume the risk that there may be revenue losses if doctors who generate a lot of business for the hospital leave or are asked to leave. Finally, insurers, including Medicare, need to stop paying for care resulting from central line infections and other preventable harm.