Published in the April 2015 issue of Today’s Hospitalist
HERE’S A THOUGHT EXPERIMENT. Your group has 17 hospitalists. How many approaches to managing heart failure are there?
“Seventeen!” you reply with a chuckle. But the true answer is probably much higher. It very well could be infinity because each hospitalist probably does things a little differently each time. And maybe that’s a good thing, customizing therapy to individual differences.
But a lot of times it’s not. Practice variation is literally killing our patients.
Here’s your next thought experiment. You’re working on the floor of a Toyota factory in Kentucky that makes cars. Your job is to install front passenger seats into the car’s chassis. As Steven Spear, PhD, and H. Kent Bowen, PhD, explain, there’s not much to it: “[You] take four bolts from a cardboard box, carry them and a torque wrench to the car, tighten the four bolts, and enter a code into a computer to indicate that the work has been done without problems.”
Piece of cake, right? Wrong! As Drs. Spear and Bowen explain in their classic article from the September 1999 issue of the Harvard Business Review:
“[T]hose specifications actually allow “and even assume “considerable variation in the way employees do their work. Without anyone realizing it, there is plenty of scope for a new operator to put the seat into the vehicle differently than an experienced employee would. Some operators might put the front bolts in after the rear bolts; some might do it the other way around. Some operators might put each bolt in and then tighten them all; others might tighten as they go along. All this variation translates into poorer quality, lower productivity, and higher costs.”
And, of course, compromised safety. My wife drives our three kids around town in a Toyota Siena. Their welfare quite literally depends on those four bolts and whether that seemingly simple task was done right.
That’s why Toyota has created insanely detailed instructions “standardized work “for installing that seat. As Drs. Spear and Bowen explain, this exemplifies the company’s overarching principle: “All work shall be highly specified as to content, sequence, timing, and outcome.”
Back to the hospital
Here’s your final thought experiment. Your patient needs a central line. You’ve placed many of these before and call for the necessary supplies. What’s the best way to minimize your patient’s risk of infection?
Duh! Maintain sterile technique. No, I mean the actual sequence of steps for the procedure, from beginning to end “your equivalent of Toyota’s four bolts.
Chances are, you don’t have a sequence of steps. You have steps, no doubt, but the order might change from patient to patient. Or you might drop a step. Or add a step. Or forget a step, which is different than deliberately omitting a step.
This was the basis for some now-famous work by Peter Pronovost, MD, PhD, of Johns Hopkins University in Baltimore. He came up with a simple checklist for central-line insertion that spells everything out. (See “Central-line insertion checklist,” below.) And the results were astonishing. As his team reported in the Dec. 28, 2006, issue of the New England Journal of Medicine, “the median rate of catheter-related bloodstream infection per 1000 catheter-days decreased from 2.7 infections at baseline to 0 at 3 months after implementation of the study intervention.”
Did you catch that? Zero.
This prompted Atul Gawande, MD, to observe in the Dec. 10th, 2007, issue of The New Yorker: “If a new drug were as effective at saving lives as Peter Pronovost’s checklist, there would be a nationwide marketing campaign urging doctors to use it.”
Problems with translation
But I doubt that your pockets are brimming with checklists. This is medicine’s age-old problem: We know what’s effective but don’t consistently do it. Why?
Doctors are notoriously independent and recoil from anything that smacks of “cookbook medicine.” Patients aren’t Toyotas and we won’t be reduced to automatons. There’s just way too much texture and subtlety “which is why medicine is an art and profession.
And people who advocate for translating Toyota’s methods into health care agree. Mark Graban, author of “Lean Hospitals,” points out that our reluctance stems from a linguistic confusion: “Standard can sound like an absolute, a method with zero variation or zero flexibility. It starts sounding like the word identical, which makes employees concerned that they are being turned into robots.”
But as he further explains, “Standardized work is the plan that frees us from having to make hundreds of small decisions throughout our day, thus freeing brain capacity and reserving energy to deal with the smaller number of more important decisions that arise.”
Which, when you think about it, is exactly what Dr. Pronovost’s checklist achieves. It routinizes things you shouldn’t waste time thinking about so you can devote your mental bandwidth to what really matters.
Back in my February column (“Discharging Mr. Wood“), I challenged you to improve quality by eradicating waste. Here’s my next challenge: In what ways can you “individually or as a team “deliver better outcomes by standardizing your work?
I’d like to hear your ideas. Better yet, I’d love to see your outcomes. And if you come up with a really effective checklist, we’ll post it to the magazine’s Web site.
David A. Frenz, MD, is a hospitalist for HealthEast Care System in St. Paul, Minn., and is board certified in both family and addiction medicine. You can learn more about him and his work via LinkedIn or at www.davidfrenz.com.