This is why we write things down

Original post:  Oct 15, 2014

Nina Pham is a nurse in Texas who recently contracted Ebola after treating a patient. She was wearing full personal protective gear and knew that she was treating a highly infectious patient with the disease. How could she have been so careless?

It turns out that while there are specific procedures for treating these patients, it isn't always so easy to follow the protocols exactly. It is very complicated. There are also many sections where the directions are ambiguous or unclear. Here is an example from the actual CDC document:

Each of the five sections actually has a more detailed longer section with step-by-step instructions. There are specific instructions for what to do if your hands are contaminated, but nothing about what happens if some contamination infects another part of the body. There are also two examples shown for removing personal protective equipment with no preference stated for one over the other.

An article in Vox quotes CDC director Tom Frieden acknowledging the difficulty in following the protocol:

"The care of Ebola can be done safely but it's hard to do it safely," Frieden said in his Sunday press conference. "Even an innocent slip-up can result in contamination."

There is a 49 slide PowerPoint which gives more detail. It is only a slice of what is available:

These presentations are summaries of a longer, more official set of guidance, the 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.

This 225-page document (145 pages without footnotes) is arguably the United States' most comprehensive guide to wearing protective health care equipment. One section, on page 52, talks about the challenges of finding the right mask:

Since procedure/isolation masks are not regulated by the FDA, there may be more variability in quality and performance than with  surgical masks. Masks come in various shapes (e.g., molded and non-molded), sizes, filtration efficiency, and method of attachment (e.g., ties, elastic, ear loops). Healthcare facilities may find that different types of masks are needed to meet individual healthcare personnel needs.

How does a hospital choose the right mask after reading that paragraph?

The article closes with a few quotes from Atul Gawande, one of the leading proponents of checklists:

Protocols can be incredibly powerful and important documents in healthcare. Atul Gawande has written extensively about the importance of checklists, and how a simple set of guidelines can go a long way. In one experiment he writes about, intensive care units who followed checklists decreased infections rates by one third in just three months.

"It's true of cardiac care, stroke treatment, H.I.V. treatment, and surgery of all kinds," Gawande writes. "It's also true of diagnosis, whether one is trying to identify cancer or infection or a heart attack. All have steps that are worth putting on a checklist and testing in routine care."

It is undeniably good that the CDC has a checklist for how to put on the protective gear needed to treat Ebola patients. It's less good, however, that the protocol is difficult to follow and leaves space for human decisionmaking — and thus space for dangerous human error.

Here is the link to the full article:  How does an American nurse contract Ebola? With directions like these. - Vox

The secret to innovation? Winning hearts and minds....

Original post:  Nov 14, 2013

This post is linked to part one.

As the article goes on, Dr. Gawande discusses simple innovations to combat infant mortality in rural hospitals. One of the simplest methods is to keep newborn infants warm. While high-tech incubators exist, the most effective tactic is using the mother's own body warmth. Yet even this simple advice is consistently ignored.

The author goes on to discuss why people struggle to adopt new ideas. He writes:

The most common approach to changing behavior is to say to people, “Please do X.” Please warm the newborn. Please wash your hands. Please follow through on the twenty-seven other childbirth practices that you’re not doing. This is what we say in the classroom, in instructional videos, and in public-service campaigns, and it works, but only up to a point.

Then, there’s the law-and-order approach: “You must do X.” We establish standards and regulations, and threaten to punish failures with fines, suspensions, the revocation of licenses. Punishment can work. Behavioral economists have even quantified how averse people are to penalties. In experimental games, they will often quit playing rather than risk facing negative consequences. And that is the problem with threatening to discipline birth attendants who are taking difficult-to-fill jobs under intensely trying conditions. They’ll quit.

The kinder version of “You must do X” is to offer incentives rather than penalties. Maybe we could pay birth attendants a bonus for every healthy child who makes it past a week of life. But then you think about how hard it would be to make a scheme like that work, especially in poor settings....

Besides, neither penalties nor incentives achieve what we’re really after: a system and a culture where X is what people do, day in and day out, even when no one is watching. “You must” rewards mere compliance. Getting to “X is what we do” means establishing X as the norm. And that’s what we want: for skin-to-skin warming, hand washing, and all the other lifesaving practices of childbirth to be, quite simply, the norm.

In his eyes, here is the solution:

But technology and incentive programs are not enough. “Diffusion is essentially a social process through which people talking to people spread an innovation,” wrote Everett Rogers, the great scholar of how new ideas are communicated and spread. Mass media can introduce a new idea to people. But, Rogers showed, people follow the lead of other people they know and trust when they decide whether to take it up. Every change requires effort, and the decision to make that effort is a social process.

This is something that salespeople understand well. I once asked a pharmaceutical rep how he persuaded doctors—who are notoriously stubborn—to adopt a new medicine. Evidence is not remotely enough, he said, however strong a case you may have. You must also apply “the rule of seven touches.” Personally “touch” the doctors seven times, and they will come to know you; if they know you, they might trust you; and, if they trust you, they will change. That’s why he stocked doctors’ closets with free drug samples in person. Then he could poke his head around the corner and ask, “So how did your daughter Debbie’s soccer game go?” Eventually, this can become “Have you seen this study on our new drug? How about giving it a try?” As the rep had recognized, human interaction is the key force in overcoming resistance and speeding change.

As we develop our own innovations, it will be important to keep this in mind. We must never forget the human factor in change management.

You've got a great idea. Now how do you get it adopted?

Original post:  Nov 13, 2013

I like to think that the world is logical. In this idealized version of reality, simply making the case for a good idea is enough. Everyone agrees that this new method is the right thing to do and it gains adoption. Unfortunately, that is rarely the case. Most of the time, the good idea itself is only the first step. Then comes the long slog of convincing those who are vested in the status quo that the change will be worth all of the disruption it takes to get there.

If you've ever sat in a monster traffic jam as they work to expand a freeway, you will know exactly what I am talking about.

Atul Gawande has another great article on this very subject in the New Yorker. "Slow Ideas" discusses how some (medical) innovations spread more rapidly than others. He opens with two clear-cut examples of revolutionary innovations in medicine:  anesthesia and infection control in surgery.

Anesthesia spread more quickly. Prior to its invention, surgeons were judged for their speed. Even minor procedures like tooth removal still required restraints and struggle. Once William Morton demonstrated the idea and Henry Jacob Bigelow published an account in a medical journal, the idea spread like wildfire. Within two months, the idea had already spread to London and Paris.

Despite this rapid uptake, there were still skeptics:

There were forces of resistance, to be sure. Some people criticized anesthesia as a “needless luxury”; clergymen deplored its use to reduce pain during childbirth as a frustration of the Almighty’s designs. James Miller, a nineteenth-century Scottish surgeon who chronicled the advent of anesthesia, observed the opposition of elderly surgeons: “They closed their ears, shut their eyes, and folded their hands. . . . They had quite made up their minds that pain was a necessary evil, and must be endured.” Yet soon even the obstructors, “with a run, mounted behind—hurrahing and shouting with the best.” Within seven years, virtually every hospital in America and Britain had adopted the new discovery.

Infection control took a more torturous path. It was the leading killer of surgical patients. It was so common that oozing pus was considered a sign of healing! Dr. Joseph Lister read a paper by Louis Pasteur about how microorganisms could cause fermentation and spoilage. He had an idea to use small amounts of carbolic acid to improve surgical infection rates. By 1867, he published the results of years of study showing that the common use of his method dramatically reduced the rates of sepsis and death. Despite these findings, his ideas faced a much colder reception than anesthesia. Gawande reports:

....The surgeon J. M. T. Finney recalled that, when he was a trainee at Massachusetts General Hospital two decades later, hand washing was still perfunctory. Surgeons soaked their instruments in carbolic acid, but they continued to operate in black frock coats stiffened with the blood and viscera of previous operations—the badge of a busy practice. Instead of using fresh gauze as sponges, they reused sea sponges without sterilizing them. It was a generation before Lister’s recommendations became routine and the next steps were taken toward the modern standard of asepsis—that is, entirely excluding germs from the surgical field, using heat-sterilized instruments and surgical teams clad in sterile gowns and gloves.

Why did one innovation have such an immediate impact while the other took decades to take root?

We'll discuss Gawande's insight into the answer tomorrow.
Here is a link to part two.

The link to the full article is in the title above and here:  http://www.newyorker.com/reporting/2013/07/29/130729fa_fact_gawande

Lessons from the Cheesecake Factory

Original post:  Aug 8, 2012

Atul Gawande is a Boston area physician who writes extensively about healthcare. His latest article will appear in the upcoming issue of the New Yorker magazine. I found the article to hold some amazing insight about the future of healthcare. It is a long article, but well worth the time. Here is the link to the full article:  Big Med (The New Yorker)

The author opens with an explanation of how the Cheesecake Factory is able to bring high quality food at reasonable prices to a mass audience. The chain is wildly popular and the food is quite good. Through a combination of standardization and relentless quality control, they are able to take complicated recipes and reduce the variation dramatically. The result is a perfect wasabi-crusted ahi at any one of their restaurants all for the same moderate price throughout their chain.

He then compares that to our current healthcare system. In his words, we are getting "greasy-spoon fare at four-star prices." Proven medical innovations can take, on average, fifteen years to become the new norm. Expensive treatments that are proven to have little or no clinical value are routinely ordered. He wonders what might happen if healthcare could adopt some of the best practices of the restaurant industry.

To give one example, he cites the fact that controlling food waste is extremely important to a restaurant. The Cheesecake Factory is able to project demand so well that they only throw away about 2.5% of their food (on average)!

He goes on to discuss his mother's experience with a knee-replacement surgery. John Wright, a surgeon at Brigham and Women's, is reshaping the orthopedic department. He is taking best practices and creating new, standardized procedures for joint replacements. He says, "Customization should be five per cent, not ninety-five per cent, of what we do."

Those changes have not been easy for the staff to accept, but the results have been positive:

...He told me that about half of the surgeons appreciate what he’s doing. The other half tolerate it at best. One or two have been outright hostile. But he has persevered, because he’s gratified by the results. The surgeons now use a single manufacturer for seventy-five per cent of their implants, giving the hospital bargaining power that has helped slash its knee-implant costs by half. And the start-to-finish standardization has led to vastly better outcomes. The distance patients can walk two days after surgery has increased from fifty-three to eighty-five feet. Nine out of ten could stand, walk, and climb at least a few stairs independently by the time of discharge. The amount of narcotic pain medications they required fell by a third. They could also leave the hospital nearly a full day earlier on average (which saved some two thousand dollars per patient).

Gawande then discusses the virtual ICU concept as practiced by the Steward hospital group. There are ten hospitals serving 8,000 patients per year. The centralized command center is not meant to replace the staff on site. They can augment the staff on hand by ensuring that the protocols have been followed and that important warnings are given proper attention.

These changes will bring savings but they will also create a great deal of disruption and uncertainty.

Those of us who work in the health-care chains will have to contend with new protocols and technology rollouts every six months, supervisors and project managers, and detailed metrics on our performance. Patients won’t just look for the best specialist anymore; they’ll look for the best system. Nurses and doctors will have to get used to delivering care in which our own convenience counts for less and the patients’ experience counts for more. We’ll also have to figure out how to reward people for taking the time and expense to teach the next generations of clinicians. All this will be an enormous upheaval, but it’s long overdue, and many people recognize that. When I asked Christina Monti, the Steward tele-I.C.U. nurse, why she wanted to work in a remote facility tangling with staffers who mostly regarded her with indifference or hostility, she told me, “Because I wanted to be part of the change.”

He closes with an interesting flourish:

The critical question is how soon that sort of quality and cost control will be available to patients everywhere across the country. We’ve let health-care systems provide us with the equivalent of greasy-spoon fare at four-star prices, and the results have been ruinous. The Cheesecake Factory model represents our best prospect for change. Some will see danger in this. Many will see hope. And that’s probably the way it should be.