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Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out (Pronovost, Safe Patients, Smart Hospitals)

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Having already read Dr. Atul Gawande's popular book, The Checklist Manifesto, I wondered whether or not Safe Patients, Smart Hospitals, by Peter Pronovost, M.D., Ph.D., would capture and hold my attention. After one chapter, I had no doubts.

As hard as it may be to believe in a country as advanced as the United States, thousands of people die each year from preventable medical mistakes. This book addresses why this happens and what can be done to save many of these people. Dr. Pronovost begins with the tragic story of 18-month-old Josie King, who was accidentally scalded at home and developed second degree burns. She acquired an all-too-common bacterial infection from a central line catheter while in the hospital, and then she got a secondary infection when the antibiotics administered to control the original infection killed helpful bacteria in her digestive system. Then there was sepsis and dehydration, but even all of this would not have killed the young girl were it not for lack of sufficient coordination and cooperation among the medical staff treating her. Just one chapter into this book you are already grieving, and you want to know more. By the way, if the term "central line catheter infection" sounds familiar, Dr. Gawande writes extensively about this problem in his book (and he characterizes Dr. Pronovost's book as a "tough-minded and revealing story of a leading doctor's crusade against medical harm").

It turns out that Dr. Pronovost's own father died in part because his cancer was not correctly characterized early enough--so Dr. P. finally enlists in the army of reformers. Along the way, he distills an unwieldy 120-page set of guidelines to reduce central line infections from the Center for Disease Control down to five key steps: (1) Wash your hands using soap or alcohol prior to placing the catheter, (2) wear sterile gloves, hat, mask and gown and completely cover the patient with sterile drapes, (3) avoid placing the catheter in the groin in possible, (4) clean the insertion site on the patient's skin with chlorhexidine antiseptic solution, and (5) remove catheters when they are no longer needed. Believe it or not, straightforward procedures like this ultimately reduce infections by over 50% in many cases.

Dr. Pronovost tells of an encounter (argument, really) with a surgeon who refused Dr. P's urgent request to perform additional surgery on a recent surgery patient. Fortunately, this surgeon walked away, and another surgeon was persuaded to take up Dr. Pronovost's request. It turned out that the patient's intestine and pancreas had been punctured in the first surgery.

Enough examples--you get the story. Oh, one more. Did you know that estimates are that about 30% of the time physicians operate defibrillators incorrectly?

The point of Dr. Pronovost's book is not that surgeons, physicians or other health care professionals are intentionally careless. Rather, as Dr. Gawande notes in his book, medicine has become enormously complicated, and the more complicated things are, the greater the chance of errors. Further, the protocols addressing the ways medical professionals communicate with each other need to be adapted in order to solicit and use the best inputs and observations available.

One of the famous dictums applied to medicine is, "first, do no harm." That can be easier to say than to do, but with people like Dr. Pronovost and many other medical professionals dedicated to improving health care, the outlook for better care is growing better every day. Thanks for writing this book and sharing your insights, Dr. P.

Peter Pronovost's father died early, primarily due to medical error; the 'good news' is that it galvanized Peter to ensure his own life made a contribution. He continued his education, becoming an M.D. and then carried on to become a researcher as well. Pronovost's PhD. dissertation summarized research on the value of intensivists (specially-trained ICU physicians) in hospital intensive-care units (ICUs) and found they reduced mortality by one-third, and length-of-stay as well. Soon after publishing his findings, providing ICU care via intensivists became medicine's 'gold standard' and spread across the nation. In 2008, Time magazine named him one of the 100 most influential people on earth, and that same year he won a MacArthur ('genius grant') Fellowship. Not bad for someone only 43-years old. But there's more!

Overall it is estimated that patients receive barely 50% of recommended therapies and only about 30% of those are administered as recommended. This despite the U.S. spending more on health care than any other developed nation, while leaving some 40 million uncovered by insurance, and medical costs being a major cause of personal bankruptcy. The result of medical errors, Dr. Pronovost estimates, is that hundreds of thousands needlessly die each year. He became focused on quality improvement after a young patient died in his hospital due to a catheter-caused infection. Pronovost then led a team effort that first created a five-step checklist distilled from a 120-page CDC set of catheter placement guidelines and underlying rationale. This improved protocol compliance to 38%. Compliance was limited partly due to difficulty finding needed supplies. Making them available on a special cart improved compliance to 70% and infection rates fell - impressive advances over what previously had simply been viewed as an unavoidable 'cost of doing business.' However, Pronovost recognized both that this improvement was likely to go away without ongoing reinforcement, and that more could be done. A culture change was needed - not only to maintain and improve the initial gains, but to spread these helpful attitudes to improving areas not already covered by checklists.

Studying liability claims and substantially harmful errors at various hospitals led to his finding that in nearly 90% of instances a team member knew something was wrong, and either kept silent (probably had previously been chewed out for speaking up), or spoke up and was ignored - similar to research on pilot/co-pilot communications prior to aviation crashes. An O.R. teamwork survey was then conducted, and found that almost all the doctors involved thought teamwork was good, while more than half of the nurses thought it was poor. A standard improvement approach evolved:

1)Form an improvement team (physician, nurse, ancillary staff-member, senior administrator) to address a problem. Survey members on safety attitudes - at least a 60% response was required to proceed. Discuss examples of good and bad practice within the hospital in general, and the unit in particular. Create a checklist to direct future actions in the targeted area, preferably with 7 or fewer items, and educate staff on the rationale for selecting those items.

2)Identify and mitigate local barriers. Actions might include clarifying primary and backup responsibility, preventing conflicting goals (eg. between a cardiologist and nephrologist regarding a patient's fluid levels) using a patient 'goal sheet,' insuring needed supply availability, using physical marks to encourage compliance (eg. cardiac catheter tubing marked at 60 cm. to help prevent over-insertion; ICU beds marked at 30-degree incline to help optimize ventilator therapy; marking initial surgical-site incisions in advance), and emphasizing the importance of resolving conflicts according to maximizing patient benefit. (Doctors would not longer be deities.)

3)Measure and track performance; provide feedback to those involved. This was often a problem with newly participating hospitals, sometimes cured with extra funding from insurers, other times by hectoring and pleading.

4)Ensure that all patients reliably receive the recommended treatment. Pronovost helped accomplish this by providing the appropriate checklists to patients and their families, and providing staff with his phone # and/or that of a senior administrator for immediate contact in the event the someone refused to follow a checklist.

Results included a 50% improvement in safety-culture scores, a 50% decrease in ICU lengths-of-stay, a decrease in nurse turnover from 9% to 2%, a 60% reduction in adverse drug events, and a drop in ten-day central-line infection rates from 11% to 0%. Expanding his central-line checklist approach to Michigan hospitals saved an estimated 1,500 lives in the first 18 months - "more than any laboratory scientist in the past decade," per Atul Gawande, M.D. (Lab research attracts many in medicine, mundane administrative tasks such as checklists and performance feedback - not nearly so much.)

Bottom Line: "Our current approach to solving (medical) mistakes is nuts," says author Pronovost. It commonly involves a hospital identifying a safety problem and attempting to solve it by telling doctors and nurses to be more careful - an approach akin to what W. Edwards Deming panned ("management by exhortation") in the early 1950s as he guided Japanese manufacturers to quality excellence. Fortunately, eventually the aviation industry caught on, and later yet, now health care. The 'bad news' is that Pronovost's efforts are not immediately and enthusiastically accepted and implemented - doctors don't like being told what to do, are primarily paid only for performing insurance-reimbursable patient services, and typically are reimbursed extra for errors anyway (as are hospitals). Fortunately, we now have Dr. Pronovost's efforts at Johns Hopkins, Dr. Donald Berwick's at Harvard, Dr. Brent James' at Intermountain Healthcare, Dr. Atul Gawande's at Brigham and Womens, Dr. John Wennberg's at Dartmouth, Dr. Gary Yates' at Sentara, and others, backed by outside efforts at The Leapfrog Group for Patient Safety. However, these pioneers cannot reform health-care on their own. It is essential that health care reform legislation force substantial quality improvement and reduced costs (the two go together, as Dr. Deming proved decades ago, and we then use those savings to provide increased insurance coverage.

As a book, it was a bit disappointing. Someone did a very poor job of editing; there were too many word, grammar, and punctuation errors to satisfy me. In addition, it is a prime example of a current fad in nonfiction that overemphasizes the "human" element in whatever subject is being discussed. The book opens, for example, with an extended recount of the admittedly very sad story of a little girl who died unnecessarily at Hopkins due to several shortcomings. This type of narrative continues throughout the book, including long discussions of Pronovost's experiences trying to get his ideas adopted.(How much of this was a literary technique and how much was ego I would not say without knowing the man.). There was way too much of this kind of thing at the expense of CONTENT.

That being said, there is a lot of good stuff here that applies equally well to safety, efficiency, and/or customer satisfaction in most fields, not just hospital care. The principles are the same, although different people express them differently. Pronovost's program has two aspects, TRIP and CUSP. Translating Research into Practice (TRIP) is the problem-solving part. It involves the checklists and other changes to practices, such as the simple idea of storing items often used together in the same cabinet and putting them close to the places where they are used, thereby both saving time and making it less likely that a busy provider will "not bother" with a particular safety item because it is too much trouble to go get it. Although the checklists are the item that grabbed attention, the other aspect, looking at an organization's specific procedures and making improvements, is also a component of CUSP. Every organization is different, and he does not give a lot of general guidance on how to approach this, although there are a number of standard techniques.

Comprehensive Unit-based Safety Program (CUSP) is really just a particular implementation of Pronovost's second principle, that of establishing a collaborative culture. He recounts how the traditional hierarchical culture in health care puts the doctors at the top of the totem pole, with surgeons the most insistent on their authority. This can keep other members of the team, such as the nurses who usually spend the most time with the patients, from speaking up even when they see something wrong. It also makes health care professionals often discount observations from patients' family members, even though family, who know the patients best of all, may notice important deviations from the patient's norm that would not be obvious to the health care providers. Another factor of the culture change, although Pronovost does not address this directly, is sensitizing team members to notice small things in their routines that seem inefficient or unsafe and to raise these as issues to be addressed.

Another item that Pronovost emphasizes, which I heartily endorse, is the importance of collecting data and measuring results. From daily experience health care members may know what things at a macro level they want to improve, but data will tell them how bad the situation is, perhaps suggest the best places to start making changes, and let them know how successful the change was. Pronovost does not, however, give much in the way of tips on how to get the data you may want or need, which is often not a simple task.

Pronovost clearly is a real believer in what he does, and I love his message. Given that the book is 271 pages long, though, he would have been much more useful if he had included more general guidelines or suggestions on how to implement TRIP and CUSP in a given environment and less narrative about Pronovost's cross-country speaking and consulting engagements.

Years ago a politician lost the presidential election by not focusing on the real issue--the economy. Here we see in Dr. Pronovost's book we see it's not the checklist, it's the culture of medicine that has created this problem. Checklists are instruments that may help change that culture.
Pronovost opens with the story of Josie King A 11/2 yr old baby who survives a long ordeal after sustaining severe burns only to die from a preventable central line infection. Mrs. King begins a crusade to prevent this from happening to anyone else's child. Two years later, nothing had been done. She is introduced to Dr. Pronovost who had made it his mission to improve patient care.
Together with John's Hopkins administrators they put in place a system which includes changing the hierarchical structure of care of this deeply entrenched medical system which now not only included checklists, but also empowered nurses, better trains residents to work as a health care team and enforces standards of care.
The practice of medicine has become unnecessarily complicated with a glut of information, most of which is superfluous, with everyone's hand in the health care pie resulting in a diffusion of responsibility, a lack of accountability, and failure of prioritization, add a touch of arrogance and entitlement, salt with physician persecution complex and stir. Together this is an incredibly noxious brew that is poisonous to all involved in the unhealthy careless system that plagues the practice of medicine today.
What a checklist does when properly implemented is to provide structure and establish priorities. It also creates a group of people who feel personally empowered to be dedicated to one ethos, "the patient must come first."
Dr. Pronovost takes us through this process from Johns Hopkins where incorporation of these principles with involvement at all levels from patient and family, to nurses, to residents and M.D.'s reduced the rate of catheter infection to almost zero to the state of Michigan where it was implemented throughout the state.
Very important here was his process as well as the process of the institutions. The beginning of the book is captivating, the middle is very sluggish (hence the 4 stars) and the reader almost drowns in a sea of acronyms (a glossary would be helpful in the next edition) and the end picks up.
This book is a must read for all health care professionals. Checklists work. Nonetheless, when Doctors Without Borders operating in some of the most disparate circumstances on earth with very sick patients with none of the modern technology and barebones surgical instrumentation can have a perioperative mortality equivalent to that in modern hospitals, we must truly examine what is really necessary for quality patient care.
Cudos to Dr. Pronovost for his role in this process. In a parallel universe Dr Gwande was going through the same process. The reader is encouraged to read The Checklist Manifesto.The Checklist Manifesto: How to Get Things Right Hopefully, these physicians will be key to right the badly listing ship of medical care in the U.S.

Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out outlines a leading physicians' crusade against medical harm and for improving health care quality in the United States. Hospital-acquired illnesses will affect 1 in 10 patients: this shows how the health care system can be fixed to improve the odds. It's recommended for any health collection.

I saw this book in the library and was intreuged by the title. As a nurse it peaked my interest. The preface was absolutely amazing and is a must to understand the concept of the book. I knew that this book was not something i would be able to read in 3 weeks that the library gives you and would want to pass on to others to read. I have not finished it yet but so far is very good. It is a good read for not just medical field people. Anyone who has ever been a patient in the hospital or just want to understand how things are done will enjoy this read..

Safe Patients, Smart Hospitals is likely to be to the health care industry what In Search of Excellence was to the broader business world. It's one of the most important books written about the medical profession and health care industry in many years.

Yet it's so simple.

On one dimension, it's about being among the best physicians in the world while appreciating that those around you are just as uncommon because of their rich ideas, feelings about patients and unique perspectives that may complement yours.

On another dimension, it's about the reality of businesses and managing organizational change. To create different results, you need to manage systems differently. The technical system includes formulas, techniques and measures. And the cultural system includes leadership, communication and respect for people. Both need to be managed to create the right results whether you're leading a hospital or a consumer products company. In Dr. Pronovost's case the right results are more lives saved through increased patient safety.

This book is for any business leader who must deal with outsized egos, smart people with poor social skills, stodgy bureaucracies or traditional hierarchies that impede open communication. And every medical student should be force fed Dr. Pronovost's book in their first and last years of school.

I first encountered Dr. Pronovost in a course I was taking where he did some lectures about improving the quality of health care. I loved his lectures and so purchased the book he co-authored. I'm so glad I did.

As someone who is involved in the healthcare industry, I'm always asking how we can improve things. With all of the changes we are seeing today related to this industry, I believe that, as the author said in the lectures I took, the patient should always be the north star. It was amazing to read about the process of making that happen and then taking this program to hospitals across the country. To see success in actually breaking down some of the barriers in the culture of health care and seeing teams get truly focused on patient safety was inspiring.

I highly recommend anyone involved in the healthcare industry who wants to learn about ways to improve patient safety read this book. I will continue to recommend it to anyone who will listen.

This is a phenomenal book. Peter Pronovost writes from the heart and the head. This book gives great examples of how small cultural and operational changes applied systemically can make huge differences in patient safety.

This book is a must read for anyone in healthcare. By working individually in the system and looking at it holistically, a complex system can be simplified and improved.

Everyone in the Health Care System, which has become an oxymoron since it is unsystematic and since too few people seem to care, should read this book. Dr. Pronovost's ideas are well established rules in many other industries. Health care is at least 200 years behind in accepting its responsibilities to the people it is supposed to serve,