I’m not sure if the checklist themselves were the valuable thing in the article, so much as the change to organizational processes that gave nurses the right to overrule doctors any time the doctor deviated from best practices, despite the nurses having fewer years of education and a lower salary. What if the real trick was allowing low status people to other-optimize high status people for deviating from formalized but relatively trivial adequacy standards? I don’t mean to be too Hansonian here, but it seemed just kind of glaring to me.
Maybe the lesson to learn really is the checklists… but it kind seems like those might have been a safe way to implement the social hack rather than the essential thing to latch onto. If the checklists are a red herring for a status manipulation then maybe a more effective performance improvement path for someone who can think clearly and accept emotionally complicated truths might be “make it safe for low status people to other optimize you on obvious stuff”.
I pulled quotes from the document and the status issues and role adjustments seemed significant. Think of this like the methods section of a scientific paper… what else might be going on here?
Pronovost asked the nurses in his I.C.U. to observe the doctors for a month as they put lines into patients, and record how often they completed each step. In more than a third of patients, they skipped at least one.
The next month, he and his team persuaded the hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask them each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. Nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder (“Um, did you forget to put on your mask, doctor?”) to more forceful methods (I’ve had a nurse bodycheck me when she thought I hadn’t put enough drapes on a patient). But many nurses aren’t sure whether this is their place, or whether a given step is worth a confrontation. (Does it really matter whether a patient’s legs are draped for a line going into the chest?) The new rule made it clear: if doctors didn’t follow every step on the checklist, the nurses would have backup from the administration to intervene.
Pronovost and his colleagues monitored what happened for a year afterward. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from eleven per cent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period.
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Pronovost truly believed in was that checklists could save enormous numbers of lives. He took his findings on the road, showing his checklists to doctors, nurses, insurers, employers—anyone who would listen. He spoke in an average of seven cities a month while continuing to work full time in Johns Hopkins’s I.C.U.s. But this time he found few takers.
There were various reasons. Some physicians were offended by the suggestion that they needed checklists. Others had legitimate doubts about Pronovost’s evidence. So far, he’d shown only that checklists worked in one hospital, Johns Hopkins, where the I.C.U.s have money, plenty of staff, and Peter Pronovost walking the hallways to make sure that the checklists are being used properly. How about in the real world—where I.C.U. nurses and doctors are in short supply, pressed for time, overwhelmed with patients, and hardly receptive to the idea of filling out yet another piece of paper?
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I accompanied a team on 7 A.M. rounds through one of the surgical I.C.U.s. It had eleven patients… The doctors and nurses on rounds tried to proceed methodically from one room to the next but were constantly interrupted: a patient they thought they’d stabilized began hemorrhaging again; another who had been taken off the ventilator developed trouble breathing and had to be put back on the machine. It was hard to imagine that they could get their heads far enough above the daily tide of disasters to worry about the minutiae on some checklist.
Yet there they were, I discovered, filling out those pages. Mostly, it was the nurses who kept things in order. Each morning, a senior nurse walked through the unit, clipboard in hand, making sure that every patient on a ventilator had the bed propped at the right angle, and had been given the right medicines and the right tests. Whenever doctors put in a central line, a nurse made sure that the central-line checklist had been filled out and placed in the patient’s chart.
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Pronovost also insisted that each participating hospital assign to each unit a senior hospital executive, who would visit the unit at least once a month, hear people’s complaints, and help them solve problems.
The executives were reluctant. They normally lived in meetings worrying about strategy and budgets. They weren’t used to venturing into patient territory and didn’t feel that they belonged there. In some places, they encountered hostility. But their involvement proved crucial. In the first month, according to Christine Goeschel, at the time the Keystone Initiative’s director, the executives discovered that the chlorhexidine soap, shown to reduce line infections, was available in fewer than a third of the I.C.U.s. This was a problem only an executive could solve. Within weeks, every I.C.U. in Michigan had a supply of the soap. Teams also complained to the hospital officials that the checklist required that patients be fully covered with a sterile drape when lines were being put in, but full-size barrier drapes were often unavailable. So the officials made sure that the drapes were stocked.
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Pronovost remains, in a way, an odd bird in medical research. He does not have the multimillion-dollar grants that his colleagues in bench science have. He has no swarm of doctoral students and lab animals. He’s focused on work that is not normally considered a significant contribution in academic medicine. As a result, few other researchers are venturing to extend his achievements. Yet his work has already saved more lives than that of any laboratory scientist in the past decade.
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We have a thirty-billion-dollar-a-year National Institutes of Health, he pointed out, which has been a remarkable powerhouse of discovery. But we have no billion-dollar National Institute of Health Care Delivery studying how best to incorporate those discoveries into daily practice.
I asked him how much it would cost for him to do for the whole country what he did for Michigan. About two million dollars, he said, maybe three, mostly for the technical work of signing up hospitals to participate state by state and coördinating a database to track the results.
I’m not sure if the checklist themselves were the valuable thing in the article, so much as the change to organizational processes that gave nurses the right to overrule doctors any time the doctor deviated from best practices, despite the nurses having fewer years of education and a lower salary. What if the real trick was allowing low status people to other-optimize high status people for deviating from formalized but relatively trivial adequacy standards? I don’t mean to be too Hansonian here, but it seemed just kind of glaring to me.
Maybe the lesson to learn really is the checklists… but it kind seems like those might have been a safe way to implement the social hack rather than the essential thing to latch onto. If the checklists are a red herring for a status manipulation then maybe a more effective performance improvement path for someone who can think clearly and accept emotionally complicated truths might be “make it safe for low status people to other optimize you on obvious stuff”.
I pulled quotes from the document and the status issues and role adjustments seemed significant. Think of this like the methods section of a scientific paper… what else might be going on here?
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