Hospitals vs. Doctors: Can They Work Together to Avoid Medical Errors?

Last week, I briefly noted a spirited conversation over at Paul Levy's blog Running a Hospital over the question of how -- and even whether -- hospitals can find and implement innovative ways to avoid medical errors. This is a huge problem for the healthcare industry both in human terms -- the Institute of Medicine found a decade ago that wrong-side surgery, adverse drug reactions, hospital-acquired infections and a host of other preventable medical mistakes cause roughly 100,000 deaths a year -- and on economic terms as well, because both the errors and follow-up care cost a lot, with the result that such slip-ups are one of the leading sources of wasteful healthcare spending.

I'd urge anyone interested in the subject to read Levy's post -- he's got a ringside seat, given that he's the CEO of Beth Israel Deaconess Medical Center -- and its long comment thread, because it's a perfect illustration of the tensions that can flare between hospital administrators and fiercely independent doctors over well-intentioned reforms that should be at the heart of medical care. It's also notable for the participants, including several BIDMC officials, healthcare-quality experts like Don Berwick and Jim Conway of the Institute for Healthcare Improvement, Virgina Mason Medical Center CEO Gary Kaplan, surgeon Atul Gawande and a number of other doctors and patient advocates.

Since it's a long discussion, though, here's a summary for BNET Healthcare readers. (It's not particularly short, but it's a lot faster than reading the entire thread at Levy's blog.) Although I haven't verified the identity of any of the participants, I'm taking commenter self-identification at face value for the purposes of this post.

Levy first notes a recent study authored by Gawande that found a simple checklist -- similar in certain respects to the preflight checklist used by pilots -- can reduce surgical deaths and complications by roughly one-third. While such checklists sound like a common-sense measure, they're not widely used at most hospitals, in part because hospitals haven't had much incentive to address medical errors (at least until recently, they got paid for botched surgeries the same as for any other procedure) and in part because surgeons and other doctors are resistant to what they consider burdensome and usually ineffective administrative fiats.

Levy asks:

[W]hat 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?

And then the commenters weigh in. Berwick, who is CEO of IHI, suggests Levy is being too hard on doctors, noting that they're trained specifically to believe that they are solely responsible for patient care, and that as a result, "[t]hey are pursuing the form of excellence and responsibility that they have been told to pursue." Concerning the checklist, he adds:

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

An anonymous commenter -- an ER physician, apparently -- chimes in:

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".

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?

Another anonymous commenter chides Levy for taking an "adversarial, finger-shaking approach" to entrenched medical culture and suggests that checklists still require further study, lest they turn out to be yet another medical fad whose usefulness isn't what it's cracked up to be. The same commenter suggests that Levy teach a course at Harvard Medical School on safety issues. Yet another anonymous commenter agrees that med school is the place to begin inculcating safety-consciousness on the part of doctors, noting:

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.

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.

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.

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 [in order to fight] 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.

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.

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.

Update: My BNET Healthcare colleague Ken Terry has just posted a followup item on IHI's new campaign to get all U.S. hospitals to try the surgical checklist in at least one operating room by April 1.