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dispatches from the new world of work

Beyond Belief!
(Not!)

In my ever-changing, annotated "Implementation" Presentation, version 0119, at Slides 137-145 you will find a riff on the power of "simple" checklists in reducing hospital errors. My presentation drew this incredible—ever so credible!—Comment by Manoj Pawar, M.D.:

Regarding the slides based on information described in the excellent New Yorker article by Atul Gawande, "The Checklist": [checklists] are ever so important.

The next chapter in this story is extremely important, as described in the NY Times Op-Ed piece by Dr. Gawande.

I urge you to read the Op-Ed piece.

The gist: A simple checklist, similar to pre-flight checklists used by pilots, has been proven to reduce ICU deaths. People die less ... much less ... as a result of this. Plans to spread this nationally in the US were underway. Simple. Elegant. And primed for implementation on a broad scale, BUT ...

The Office for Human Research Protections (OHRP), upon learning of this, stopped the project immediately.

Why? The OHRP treats this as research (despite the fact that results are proven). Because they see it as research, they feel that it was unethical that patients were not informed that a checklist was being used, and that its use was being measured. In essence, they treated this in the same way that they would a study in which patients were being given a medication with unknown efficacy.

Can they really do this? Sure. And in fact, they can cut off all federal funding to groups (hospitals, researchers, etc.) that fail to obey.

Since that 12/30/07 decision, health care institutions and quality improvement specialists across the country have been running scared, fearing the wrath of the OHRP and the subsequent loss of funding. They've asked their quality improvement folks to stop doing what they're doing immediately, based on these legal and regulatory concerns.

A number of prominent healthcare bloggers share their concerns. Check out healthbeatblog.org to see Maggie Mahar's blog.

We all are left asking, "WHY?"

With such great results, who would want to stop this work? Maybe it's the folks who fear exposure of how truly bad our hospitals currently are. Imagine the loss in market share for those that don't use the checklist! Maybe it's about money.

Analogy: We've done process improvement work to look at and improve compliance with ideal handwashing guidelines (yes ... not all doctors wash their hands as much as they should). But imagine if we had to get informed consent for patients to participate in this work! "You may be subject to an intervention ... your doctor may actually wash his/her hands, and, as such, you may be exposed to something that isn't consistently done."

Innovation isn't common when it comes to healthcare operations and processes. When it happens, (even if it's something simple like a checklist), do we really want to squelch it? The lesson for implementation: Watch out for the barriers to implementation. And when barriers sometimes seem insurmountable, there are times when radical action is necessary. When our Denver-based healthcare think tank met last night, I suggested civil disobedience as one approach. Do it anyway, and worry about the consequences later. Be radical ... be remarkable!

Manoj Pawar, MD, MMM
Posted by Manoj Pawar at January 19, 2008 12:13 AM

Tom Peters posted this on 01/22/08.

Comments

All I have to say is ... holy smokes, is this what we have come to? If so, how sad and tragic.

Posted by Dean at January 22, 2008 9:34 AM

Isn't this story just amazing?

Note, the post where the comment by Dr Pawar appears is this one, where Tom posted an update to his Implementation PowerPoint:
http://www.tompeters.com/entries.php?note=010220.php

But Tom had also expressed incredulity in this post, when he first read the New Yorker article by Dr Gawande:
http://www.tompeters.com/entries.php?note=010132.php

Posted by cathy mosca at January 22, 2008 10:17 AM

And we are surprised why?
Ridiculous.
Sadly, I am not shocked.
Our government dollars at work again!

Posted by Leonard Klaatu at January 22, 2008 10:17 AM

Like Leonard I am, sadly, not in the least surprised. I spent years in my healthcare career trying to understand ethical approval for research. There is a tortuous process in the UK healthcare system to even gain permission to interview patients if it is labelled research. Best to beg forgiveness than pray for permission is my own view. I remember working with a Dermatologist â€“ now sadly no longer with us - who was a real cage rattler against silliness of process. He wrote a new acronym when requesting tests to be carried out by the lab. His acronym, in those days on handwritten test request forms to the lab was â€˜JFDIâ€™

â€˜Just Fâ€¦.. Do Itâ€™

Dr Pawar is a hero for promoting civil disobedience â€“ good luck to you Sir.

Posted by Trevor Gay at January 22, 2008 12:04 PM

I seem to recall an interview on NPR with this Dr. recently. He saved a Michigan hospital a ton of cash with this simple approach

Posted by Mike Neiss at January 22, 2008 12:16 PM

It's not research if it's just "common sense"

The 14th century - William of Ockhams razor - "All other things being equal, the simplest solution is the best."

Office for Human Research Protections (OHRP) brought to you by the same bureaucrats that gave us Federal Emergency Management Agency that well oiled responsive machine.....not

Posted by Tom F at January 22, 2008 12:28 PM

Ouch! This post hurts and scares. Hurts because my oldest son likes to mimic me by using bureaucratic tone. Scares because you'd think surgical teams would already have had the importance of checklists drilled in to them.

The clear message for business in general is to adamantly oppose blind obedience to process and to make process improvement / change flexible and easy.

Posted by H. Peter Schiller at January 22, 2008 5:03 PM

and so what is new, mediocrity rules, it does not rock...

Posted by Steve Gray at January 22, 2008 5:58 PM

Exactly, Steve. Mediocre doctors complained to the regulators, and the rest is travesty.

Posted by Joe Marier at January 22, 2008 7:29 PM

You guys clearly don't understand this at all - the OHRP was quite correct to do what it did. I mean, how would you feel if a famous management guru (perhaps even one with the initials TP) was to run a website saying, "Look, I've acquired a bit of experience and I've observed business all my adult life and now I've got a few ideas I'd like y'all to try out and discuss. I've not run them past Harvard Biz Skool and they haven't been rigorously scrutinised by a review panel of my peers, nor do they conform to any ISO standard or recognised legal statute, but they're based on common sense, insight, judgement and experience and are they're to be used as appropriate in your situation." I mean, this would be just nuts... wouldn't it?!?

Posted by Mark JF at January 23, 2008 11:37 AM

Here's a post fom the NIH responding to the Op-Ed piece as well as associated blog posts:

http://www.irbforum.org/forum/read/2/161/161

Posted by TroyTurner at January 23, 2008 7:11 PM

Tom:

I'm confused. You are obviously a very bright guy. So why are you using PowerPoint software still? You must know about Apple Keynote software and that by any measure it is far superior to PowerPoint? Are you actually not using one of Apple's laptops? Hard to believe that someone like yourself hasn't at least taken a drive down to an Apple store and checked-out the newest Apple Macbook Pro or taken a look at the Macbook Air online.

Did you not see an Inconvenient Truth with Al Gore using Keynote to give his presentation?

The content of your slides speaks for itself but the presentation of that information is so 1990's. Time for an update.

Posted by Timothy Post at January 27, 2008 12:37 AM

The pursuit of logic within healthcare is normally seen as being very radical and not the done thing, just look at the changes in the NHS in the UK and you will go slightly mad.

Itâ€™s all no logic and re-organise the last organise without letting the first one settle.

Where health care thrives in WOW and gaspworthy and succeeds is via the organic change from the bottom up!

I bang my head every day for the NHS

Posted by James Batchelor at February 6, 2008 9:55 AM

Checklists don't improve outcomes people do. There is a bigger story behind every medical error, blood borne infection, or bedsore. I have a checklists out the wazoo (Morse Fall Scale and Braden Scale) to give you just two examples. Those checklists don't improve the care I give, they meet an accreditation mandate. Turning your patient every two hours and being present takes care of the above two checklists. Does anyone in the U.S. want to know why I can't turn my patient every two hours or tend to basic needs? The answer to bad care is so simple. Let me do my job!!! and yet everyone is looking to policy, procedures and technology. The Nursing shortage and the undocumented causes of job dissatisfaction is where America needs to begin
Kellyann Curnayn RN

Posted by Kellyann Curnayn at October 9, 2008 3:25 PM

This is testimony to why you should not blog until you have read the article related to your comments. "The checklist"
Checklists with accountability are great as the example of line insertion proved. Accountability at the bedside is a self governed attribute. No one really knows if you give could care except you. How do we tap into the conscience of health care workers to serve the needs of their patients first? Checklists without accountability are just checks on a paper.

Posted by Kellyann Curnayn at October 9, 2008 9:36 PM

Kellyann - how wonderful – at last - to see someone from front line healthcare commenting on TP Blog.

You prove what I have been saying on this Blog and elsewhere for the last thousand years or so. Front line employees are where it’s at!! ...Simple common sense - front liners being accountable ... they know how to do stuff and they know the answers – the last thing they need is more process to take them away from patient care!

They certainly don’t want more complexity and they do not want managers who have not seen a patient in the last decade or two breathing down their necks. They just want to be left alone to care for patients using all the skills they’ve acquired and have leaders to support them.

It is music to my ears to hear someone else saying this stuff.

I spent 35 years in a health care management career and Kellyann - you say it so much better than me!

The following two extracts from your comments are just fantastic:

“Checklists without accountability are just checks on a paper”

“The answer to bad care is so simple. Let me do my job!!! And yet everyone is looking to policy, procedures and technology.”

Keep saying it as it really is Kellyann – I pray that one day the managers making the job of front liners more difficult must just read words like yours.

Best wishes from England.

Trevor

Posted by Trevor Gay at October 10, 2008 9:34 AM

I so appreciate your words of encouragement and yes prayers. No one speaks the truth because they want to climb the ladder, bucking the system stall mates the little promotions we get, in the form of charge Nurse, mentor, preceptor or Nurse manager. Unfortunately the managers now serve executive staff and are subject to making sure their unit looks good for accreditation process. Which means charting to the letter of the law. Our charge Nurses spend hours making sure everyone charts restraints correctly and then she must fax the sheet of paper to the CNO. At the end of the shift I was personally reprimanded for not having my restraints charted in a timely fashion. I pointed out that it was probably because I was to busy taking care of the patient. Could the time spent ensuring accurate charting been better spent assisting with patient care? Someone needs to stand up to JCAHO and the power they hold over institutions. Just like this economic plunge we are in, no one listens until the floor falls out from under them. The job is grueling and there are so many processes that need changing.
Kellyann Curnayn RN

Posted by Kellyann Curnayn at October 10, 2008 8:16 PM

No problem Kellyann - just keep saying what you are saying - you are 100% right. Someone will listen.

My view is we spend big money and many years training nurses, doctors and other practitioners to become brilliant health care professionals and then managers try to turn those same highly skilled people into ‘office workers’ – removing them from direct patient care – simply and only to make sure all the boxes are ticked for some crazy process. This is a no brainer!!

Your voice needs to be heard above the management ‘clutter’ and wasteful chatter.

One of my Simplicity principles is ‘front line employees know all the answers all the time’ …. I stick by that in spite of many people telling me I am far too simplistic and that I really don’t understand the complexity of these things … ‘they would say that wouldn’t they’ is my usual response :- )

Posted by Trevor Gay at October 11, 2008 4:41 AM

Kellyann...it is terrific to hear another voice from the front line on these pages. The "value" that makes the checklists described in the New Yorker article effective was "added" by the engagement of the front line care teams in their development and execution. The Nurses are enabled to stop and correct errors or deviations made by the doctors or others involved. The power of this oversight from a front line provider makes the process produce the results that it does. This approach and many other success stories in health care past and present work because they are as un-JCAHO as possible. They recognize the role of any management/administrative team is to continuously increase the capacity of those on the front line to excel by giving them the time, tools, training, and other resources they need to do their jobs. They also use the knowledge and expertise of the front line team in developing the policies and processes they work by. Again, not a checklist for accreditation, a team oriented approach that has proven to work in every type of industry, healthcare included!

Trevor is 1000% correct. Keep on saying what you're saying! I'm a front line manager in a different industry and know you will find allies and advocates who share your point of view! Tom Peters being one of them!

Posted by Dave Wheeler at October 11, 2008 11:50 AM

Yes I agree!!! and would love to take a Unit/floor and let the employees restructure the entire thing. If we have a population of employees (bedside care providers) that are continually given non value added (for the patient) tasks to do. They begin to resist any and all ideas with the fear that one more thing will be added to the already full plate. The mantra currently is "I can't do my job right now and you want me to consider what list". "added" requires engagement, that is where everyone needs to start. Nurses punch in, punch out and do the best they can under the circumstance. How do we get Nurses re-engaged? Start by changing work environment hinderances. Everyone writes about the Nursing environment "Among Nurses under the age of thirty who were employed outside nursing 91% cited workplace concerns. Lisa Black Phd. from NSSRN (2004) study. Those 'concerns' are never documented, and people leave year after year. Working environment is politely mentioned throughout Nursing literature and yet the dysfunction is not documented, defined or addressed. Which means no action plan to change it. And you want me to do what? So engagement is a crucial first step.
Kellyann Curnayn RN

Posted by Kellyann Curnayn at October 11, 2008 3:51 PM

Kellyann...my daughter is a nurse oncologist and the hospital she works with now was voted on the annual Fortune magazine list of the Best Companies to work for. The previous hospital she worked at was exactly the type that you describe above. I work in a Customer Service Call Center and we have an annual turnover of about 65=70%...mostly caused by "environmental" charecteristics as well.

I have attached a link to an information resource that can get one to a frontline focused hospital.

http://www.baldrige.nist.gov/PDF_files/2008_HealthCare_Criteria.pdf

Most states have a "Quality" award program that use this criteria for business, non-profit, education and healthcare organizations. I was a member of the Board of Examiners for the Arkansas Quality Award and had the occasion to audit three hospitals and saw first hand this system makes a difference. Results has a way of changing the closed minds of managers and admistrators!

Posted by Dave Wheeler at October 11, 2008 4:44 PM

I have attached a link to an information resource that can get one to a frontline focused hospital.

http://www.baldrige.nist.gov/PDF_files/2008_HealthCare_Criteria.pdf

Posted by Dave Wheeler at October 11, 2008 4:45 PM

Kellyann...I posted another comment earlier that got caught in "comment moderation"...hopefully it will appear later because it had a link to some information that would be helpful to you. I'll check later...if it oesn't post, I'll try again.

Posted by Dave Wheeler at October 11, 2008 7:22 PM

Thank you so very much Dave, I can't believe I haven't heard about this program!! I will go over it today. I also worked within the field of Oncology for 10 years and became a better person through my work.
Kellyann Curnayn RN

over night delivery viagra Posted by Kellyann Curnayn at October 12, 2008 2:11 PM