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on February 18, 2010
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.
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HALL OF FAMEon February 23, 2010
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.
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VINE VOICEon July 4, 2010
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.
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on November 29, 2011
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.
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on May 2, 2011
I'm an RN and have practiced over 20 years. I have been around medicine my whole life since my father practiced surgery/general practice for 50 years and my mother is a retired anesthesiologist. Last week, after all the new regulations, etc. I went home dejected and really thought I needed to get out of healthcare. I randomly picked up this book that I had purchased several weeks ago and began reading it. The author is an anesthesiologist (and by the looks of his photo above, quite a good looking one,) so he is "one of us." This book changed my whole view on healthcare. Once you read the stories and it is pointed out how the hiearchy of the culture in healthcare is, you realize that having a standard way to do say, a central line placement, makes perfect sense. There is no way possible that healthcare practitioners can keep up with the most up-to-date way to perform a procedure as safely and effectively as possible. Lately, I have felt like going to the doctor is pretty much like Russian roulette. I wish I could give everyone I know a copy of of this book.
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VINE VOICEon July 4, 2012
Nice reference for you. Patient Safety seems to be that elusive target everyone seeks, but without a plan and appropriate strategies happens more by accident than by plan. Thee is no "one single way" of achieving & sustainlng safety but recognizing that ths is an ongoing process that requires frequent course adjustments. No one discipline owns responsibility, the demand for excellent, ongoing communication between disciplines and recognizing we are in this together! Many helpful hints / strategies including in this book.
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on August 13, 2014
This is a phenomenal book. Dr. Pronovost explains that what we need are major culture changes in health care to improve patient safety. The changes can happen and he show us how his pursuit for excellent and for dignity and honesty in health care can make these changes happen. This is not a book about learning to use a checklist. It is much more than that.

Similar good readings:

Management Lessons from Mayo Clinic: Inside One of the World's Most Admired Service Organizations

How to Win Friends and Influence People
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on May 18, 2010
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.
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on June 28, 2011
This book is excellent. It unveils in detail an honest assessment of patient safety and quality challenges in our hospitals. The challenge is not just in the protocols and techniques, and measures of change that are used; it is just as important to create the culture to make it successful. Peter's replication of his work from Hopkins in other institutions nationally shows what can be done when everyone in the hospital/healthcare system gets behind it.
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TOP 500 REVIEWERon October 7, 2013
Safe Patients, Smart Hospitals: How One Doctor's Checklist can Help us Change Health Care from the Inside Out by Peter Pronovost, Ph.D., and Eric Vohr

"Safe Patients, Smart Hospitals" is an important, and revealing quest to improve our health care system by reducing preventable mistakes. Dr. Pronovost takes the reader on journey from inside John Hopkins Hospital and shows us how checklists and cultural changes contributed to significant improvements to patient care. This insightful 304-page book includes ten unnamed chapters and a conclusion.

1. An accessible book on hospital administration. Presents an insightful overview of significant changes in patient care. A behind-the-scenes look.
2. Dr. Pronovost knows and cares an important combination that is felt throughout the book and an essential quality to a health care provider.
3. The power of putting a name to a patient. "There is no question you need to provide proof for your theories. But without the story, without emotion, there is no context, it's just words."
4. It all starts by identifying the problems. "One of the problems with health care that I knew was harming patients was the lack of a good mechanism for getting proven treatments to the bedside where they can improve care." There are a number of countless examples throughout the book.
5. Ingenious idea of simple checklists that captured the most important bits of knowledge on a need basis. Simple, effective and once the culture has changed much easier to enforce and be accountable.
6. Preventing infections. "Conversely, these catheters present a risk. It's estimated that the national mean rate of infections from central line catheters is four infections per thousand catheter days (a catheter day is one day that one patient has a catheter)."
7. Amazing facts, "That means each year roughly eighty thousand patients become infected as a result of placing central lines, and thirty thousand to sixty thousand die, at a cost of up to $3 billion nationally."
8. Makes it perfectly clear that the lack of standards are hurting the industry and thus patients. "This lack of standardization is entirely unacceptable and dangerous to patients, yet it happens every day, across the country and around the world. It's obvious that everyone should receive the same evidence-based training, yet there is no system in place to guarantee all doctors will learn how to do it correctly. "
9. Dr. Pronovost narrates in great detail how he helped prevent central line infections. "Our plan was to include what we thought was a manageable number of key steps for doctors and nurses to follow to ensure patients did not get infections from catheters."
10. Great quotes and practices that apply to many disciplines, "We also need to increase the efficiency with which we gather and share knowledge."
11. The TRIP (Translating Research Into Practice) model and its four key principles. "With this in mind we structured the TRIP model using four key principles (for central line infections): 1. Summarize evidence into checklists. 2. Identify and mitigate local barriers to implementation. 3. Measure performance. 4. Ensure all patients reliably receive the intervention."
12. A principle I live by at work, "Measurement is one of the most important aspects of our work. We are scientists and the cornerstone of science is measurement. Without hard scientific proof, we can't be sure something actually works." Had to share.
13. I really enjoyed learning about the-behind-the-scenes dynamics at hospitals. "Operating rooms are also exceedingly hierarchical. They have a pecking order that is stronger and stricter than the marines. The operating room is a world of ritual and privilege, a world of special favors for the elite."
14. Addressing culture. "What we needed was a program that focused primarily on this local culture, a program that worked at the unit level to help train physicians, nurses, and other staff to work together effectively as a team."
15. One of the great attributes of Dr. Pronovost is his ability to make his goals clear, "The goal of CUSP is to improve communication, teamwork, and culture in these individual units so they can focus more efficiently on the primary goal, improving patient outcomes." "Since the overarching goal in CUSP is to improve culture and learn from mistakes, the point here is not only to fix system problems, but also to fix teamwork problems by improving communication and cooperation. The idea is to create a culture of positivity and hope."
16. Safety is a science. "In the science of safety training, we share stories of real patient harm, like the Josie King tragedy."
17. Explains how he expanded his findings and new practices to other hospitals and countries. "Word got out about our work in Spain and other countries started to express interest. The World Health Organization's Patient Safety Program was already supporting our work in Spain so we asked them to help us implement the program across Europe and the world."
18. Federal recognition and support. "Our efforts in Michigan and Washington had gotten the attention of the new secretary of Health and Human Services, Kathleen Sebelius. Referring to our work, she called for a 75 percent reduction in ICU bloodstream infections within three years in all U.S. hospitals."
19. The need for oversight, "As a result of this absence of oversight on safety reporting, hospitals advertise erroneous and misleading information on Web sites, in glossy brochures, on billboards, and on TV. There is no assurance of the accuracy of their claims, because the measurement of quality in health care is neither standardized nor consistently reliable."
20. Excellent closing chapter that summarizes the practices demonstrated in this book through four fictitious cases. "Let's examine four relatively common diseases that likely touch everyone's life either personally or through a loved one--cancer, mental illness, heart disease, and stroke. With each of these diseases I will try to demonstrate patient safety efforts have either directly or indirectly made the patient experience better from admission to discharge to outpatient care."

1. As an industrial engineer and one that has made a living from improving processes I was hoping for more technical insights. I understand that this book was written for the masses and such things may have interrupted the main flow of the book but that's what appendices are for. Examples of process flow charts, organizational charts, graphs, etc...would have been of keen interest to some of us in administrative roles.
2. Surprisingly, poor editing. A book of such importance deserved better treatment.
3. Repetitive.
4. The narrative is accessible but at times dry.
5. No formal bibliography.
6. No notes or links to source material.
7. It always makes me cringe when subject-matter experts go out of their field of expertise to make erroneous comments about other fields. Dr. Pronovost made some comments regarding the housing bubble that wasn't really the complete picture. That being said, his comments regarding the aviation industry were accurate. Culture and the dogmatic respect of authority as in the Korean culture were factors that lead to more mishaps.

In summary, this is a must-read for hospital administrators and for anyone interested in how hospitals take care of patients. Fascinating subject material and such an important topic. Kudos to Dr. Pronovost for having the drive and vision of making a significant change for how hospitals are run all over the world. His simple but ingenious checklists, and the changing of a culture has resulted in many lives saved. His contributions to improved patient care far exceeds any shortcomings the book has. Too important not to read, I highly recommend it.

Further recommendations: "The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care" by T.R. Reid, "How We Do Harm: A Doctor Breaks Ranks About Being Sick in America" by Otis Webb Brawley, M.D. with Paul Goldberg, "Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer" by Shannon Brownlee, "Overdiagnosed: Making People Sick in the Pursuit of Health" by H. Gilbert Welsh, "Overdosed America: The Broken Promise of American Medicine" by John Abramson, "Selling Sickness: How the World's Biggest Pharmaceutical Companies Are Turning Us All Into Patients" by Ray Moynihan, "Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care" by Marty Makary, M.D., "Catastrophic Care: How American Health Care Killed My Father--and How We Can Fix It" by David Goldhill, "Sick: The Untold Story of America's Health Care Crisis---and the People Who Pay the Price" by Jonathan Cohn, "Complications: A Surgeon's Notes on an Imperfect Science" by Atul Gawande, and "Every Patient Tells A Story" by Lisa Sanders, M.D..
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