How to Fix Health Care Delivery
in the United States
Recently Dr. Atul
Gawande* describes what he thinks is one of the greatest breakthroughs
in healthcare in history: The checklist.
It is borrowed from
aviation. When planes became too complex for one person to fly without
memory help, the checklist was introduced. To this day, the pilot in
the cockpit of every passenger jet checks that all the systems in the
plane are working and that the aircraft is good to go.
Why not make
checklists for healthcare delivery?
In 2001, a critical
care specialist at Johns Hopkins, Dr. Peter Pronovost, identified all
the steps that were necessary to avoid infection when an intravascular
line was put into a patient. Here are the steps:[i]
1.
Wash hands with soap.
2.
Clean the patient’s skin with chlorhexidine antiseptic.
3.
Put a sterile drape over the entire patient.
4.
Wear a sterile mask, hat, gown and gloves.
5.
Put a sterile dressing over the catheter once the line is in.
In addition, nurses
were asked to stop doctors if they saw them skipping a step in the
checklist, and also to ask them each day whether any lines ought to be
removed.
The results were
dramatic. The ten-day line infection rate went from eleven percent to
zero in one year. In fifteen more months, only two infections
occurred. Using historical data, they calculated that they had
prevented forty-three infections and eight deaths.
Checklists are not used only in aviation and
healthcare delivery. Checklists are used everywhere it is important to
make sure that “right things are done, in the right order, and in the
right way, all the time.” So checklists are used to ensure
productivity, and between the quotes in the preceding sentence, you will
find the very definition of productivity.
For a physician,
there are thousands of tasks that must be done in a certain order, and
in a certain manner, for the results to be satisfactory. No human being
can remember all these steps every time a task needs to be done. Add
the fact that every patient is different and likely needs a unique set
of procedures (read: sequence of tasks) done, and the problem
seems overwhelming.
When Tor Dahl &
Associates introduced checklists in our own productivity improvement
practice, anonymous evaluation scores of our work performance soared,
the bottom lines of our clients increased by hundreds of percent, and
both the satisfaction of our staff and that of our clients improved
dramatically.
Being a “company
doctor” and being a physician specialist in an Intensive Care Unit (ICU)
(read: “intensivist”) have a number of things in common. For one
thing, an intensivist in a hospital reduces death rates in the intensive
care unit by one-third. Each engagement for us is like an intensive
care episode for an organization, and none of our “patients” have died.
Stock-registered companies have a life span of forty-four years, which
means that mortality rates for companies are far higher than mortality
rates for people.
Health care
delivery is considered more of an art than a science. Each year
billions of dollars are being spent for research on diseases, treatments
and new drugs, but only a pittance is spent on the actual delivery of
healthcare. Yet here is the root cause of the rising cost of health
care: The productivity of healthcare delivery in the U.S. is negative!
Over the last ten years, the health sector has gotten worse every year —
by approximately 2.3% annually. This does not stem from a
lack of medicine, equipment, facilities or people. It is not doing the
right thing, in the right order, and in the right way all the time, that
has caused healthcare costs to skyrocket, unnecessary deaths to occur,
and outcomes that — compared to those of other countries — are simply
embarrassing.
The fact that one doctor at
Johns Hopkins (with a Ph.D. in public health) could cause hospitals to
save lives in the most obvious and self-evident manner, is proof that we
have ignored the most important part of good health care: That it should
be delivered in the best possible manner, all the time. That also
implies that all care that is unnecessary or harmful to any patient
should not ever be delivered; therein lies the greatest potential for
savings in the U.S. health sector today. |
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Doctors
hate what they call “cookbook medicine.” But this is
not cookbook medicine. This is not
interfering with the most demanding task in medicine:
Diagnosis and the devising of an effective treatment.
Doctors reign supreme in these specific areas, where years
of study and experience combine with intuition and
creativity for physicians to perform miracles at times.
But
just like the complexity of flying is mastered through the
use of extensive and detailed checklists, so should be the
preparation of a surgical suite, the intubation of a
patient, the administration of drugs, the process of
rehabilitation, the instructions for home care, and the
teaching of self-care to patients who live alone.
It
could all be made available on a portable personal digital
assistant — or a clipboard. And the results from applying
any procedure should be studied so that even better
procedures could be devised.
Do you
agree that this makes sense for the health sector to do at a
time when we know that many people needlessly die in
hospitals, overall healthcare costs are threatening the
international competitiveness of U.S. business, and a recent
Health Affairs study rated the US last among industrialized
countries in preventing unnecessary deaths?
If so,
you are wrong, says the Office of Human Research Protections
(OHRP) in the U.S. Department of Health and Human Services.
According to this office what Dr. Pronovost did was
unethical and illegal, and the federal government used its
power to close down the effort and stop the plans to expand
it to the ICUs of New Jersey and Rhode Island.[ii]
This
was done in spite of the fact that in the state of Michigan,
the average ICU on this program cut its infection rate from
4% to zero. Over eighteen months, the program saved more
than 1,500 lives and nearly $200 million.
Here is
what was considered unethical: According to the OHRP, a
checklist is an alteration of medical care at par with the
introduction of a new experimental drug. That is illegal
without federal monitoring and explicit written permission
from each patient. The justification for the shutdown
included an explanation that without such close monitoring,
not only patients but also doctors could be put at risk —
the latter by exposing how poorly some of them had followed
basic infection-prevention procedures.
I guess
we should be thankful that this kind of lunacy is not
practiced by the FAA. If a pilot’s checklist were to be
improved, I doubt whether written permission from every
passenger would be required by the Feds.
Would
future Michigan ICU patients be treated in the same way as
before unless they specifically request the new five-step
regimen? Would more patients be subject to the older, more
hazardous procedure for inserting an intravascular line than
the safer procedure, even when it has been proven to be
superior? What would be the ethical logic for such an
outcome? What does common sense dictate?
A
strict interpretation of this ruling could also shut down
the efforts by the Institute of Healthcare Improvement that
are designed to reduce avoidable complications in 3,700
hospitals in the U.S.
For
productivity improvement to occur, change must happen. If
there is no change, productivity improvement goes to zero.
By making change difficult, if not impossible, the Office of
Human Research Protections may have stopped healthcare
delivery improvement dead in its tracks in this country.
The
techniques used by Dr. Pronovost and his research team have
worked in every other sector of the economy. Because
healthcare has not been very much exposed to these ideas we
should expect that healthcare delivery would become a
fertile field for positive change when these techniques are
introduced.
Before the OHRP closed down Dr.
Pronovost’s work, he was expanding his checklist for
stopping infections from occurring in the ICU, to dealing
with heart attacks, drowning victims and surgery patients.
We should welcome Dr. Pronovost’s
efforts to improve health care delivery in the United
States.
Do we need an Act of Congress for this to happen?
[i] Gawande, A. The Checklist..
The New Yorker. December 10, 2007. 133 (39). 86-95.
[ii] Gawande, A. A Lifesaving
Checklist. The New York Times. Op. Ed. December 30,
2007.
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