Almost as frightening as the cost of the U.S. health care system is how poorly it performs. More money per person is spent on health care in the United States than in any other nation in the world, yet US life expectancy lags 42nd in the world. That’s well behind most rich nations, and after Chile (35th) and Cuba (37th). Yes, Cuba!
One can debate how far the health care system itself is responsible for these shocking statistics, since access to care has been far from universal. But it is hard to argue with the death rates from medical errors.
Going into hospital is a dangerous occupation
In July 2000, the Journal of the American Medical Association published a landmark study by Dr Barbara Starfield, MD, MPH, of the Johns Hopkins School of Hygiene and Public Health, showing that medical errors are the third leading cause of death in the United States. The report showed there were:
- 2,000 deaths/year from unnecessary surgery;
- 7,000 deaths/year from medication errors in hospitals;
- 20,000 deaths/year from other errors in hospitals;
- 80,000 deaths/year from infections in hospitals;
If you include the 106,000 deaths/year from non-error, adverse effects of medications, these add up to 225,000 deaths per year in the US as a direct result of treatments by a physician. Subsequent studies have argued about the details of the study, but the broad conclusions still stand: going into a hospital is one of the most dangerous things you can do in life.
Part of the problem is the complexity of medical treatment in intensive care. Atul Gawande writes in The New Yorker:
“A decade ago, Israeli scientists published a study in which engineers observed patient care in I.C.U.s for twenty-four-hour stretches. They found that the average patient required a hundred and seventy-eight individual actions per day, ranging from administering a drug to suctioning the lungs, and every one of them posed risks. Remarkably, the nurses and doctors were observed to make an error in just one per cent of these actions—but that still amounted to an average of two errors a day with every patient. Intensive care succeeds only when we hold the odds of doing harm low enough for the odds of doing good to prevail. This is hard.
If the problem is complexity, the eventual solution is obvious: perfect performance every time. How to accomplish this?
Radical management grew from the need for perfect performance
Radical management has several antecedents. It grew from the need to do better than traditional management, which was unable to achieve perfect performance in sectors where that was essential.
One field is auto manufacture. Making a car is a complex undertaking. Each car has around 20,000 parts. Each part must be made perfectly and fit perfectly with every other part. When you are making many cars on a production line, a single error in making any one part, if not corrected, can cause massive costs in fixing the error.
After fifty years of global experience, we now know that the hierarchical bureaucracy of traditional management doesn’t work nearly as well as self-organizing teams focused on eliminating the root causes of errors and steadily improving performance. The findings are documented in the classic 1990 study, The Machine That Changed the World and have been confirmed many times over.
Another field was software development, which is particularly unforgiving to human error. One tiny error in a vast program of millions of lines of code can cause the whole program to crash. In the 1980s and 1990s, performance in large software development projects using the traditional management of hierarchical bureaucracy was so disastrous that most large projects not only didn’t finish on time. Most of them didn’t finish at all: Applied Software Measurement: Global Analysis of Productivity and Quality by Capers Jones
Again the solution was self-organizing teams focused on eliminating the root causes of errors and steadily improving performance. (This is known in software development as Agile software development.) Critical to achieving perfection in performance is spelling out in advance the criteria for correct performance, continuous verification of whether the criteria were being met and collaborative work environments where the effort to eliminate errors is a mutually shared undertaking.
The Checklist Manifesto
What should be done to deal with medical errors? Atul Gawande, who is one of my very favorite authors, suggests that the solution is: tah-dah! A simple checklist. His New Yorker article, The Checklist, has now become his best-selling book, The Checklist Manifesto
Gawande draws his conclusions in part from studying the use of checklists by pilots. Flying a plane is another field were perfect performance every time is crucial to safety. The use of checklists by pilots during takeoff and landing led to massive gains in airline safety and is now mandatory everywhere.
So, Gawande argues, if checklists work for pilots, why not for medical care?
Gawande writes about the use of checklists in intensive care as practiced by Peter Provonost, a critical care specialist at Johns Hopkins Hopsital. The results of his initial work in 2001 were so dramatic that they didn’t know whether to believe them. The ten-day line infection rate went from 11 per cent to zero.
Since then, Provonost has been evangelizing the use of checklists across the country. In general, he has met with a skeptical audience in the medical community, who question whether such a simple idea could possibly have the massively beneficial results he claims for them. He has had some requests to help, for example, in Michigan, in Rhode Island and in Spain.
According to Gawande, the still limited response to Provonost’s use of checklists is “easy to explain but hard to justify. If someone found a new drug that could wipe out infections with anything remotely like the effectiveness of Pronovost’s lists, there would be television ads with Robert Jarvik extolling its virtues, detail men offering free lunches to get doctors to make it part of their practice, government programs to research it, and competitors jumping in to make a newer, better version.”
One can attribute the lack of response to Provonost’s work to the conservatism of the medical profession or to its preoccupation with high-tech solutions.
But is there also something else at play?
Checklists by themselves are not enough
When we set aside the magnificent sweep of Gawande’s storytelling and take a moment to reflect, it is obvious checklists by themselves aren't responsible for the gains being made. When checklists are inserted in a traditional management setting, with the processes and structures of hierarchical bureaucracy, they become another piece of paperwork, an encumbrance on the real work of helping patients, another report to fill out.
Why do checklists appear to make a difference? The reality is the checklists represent criteria of performance. In environments like car manufacture, software development and aircraft cockpits, where criteria of performance have been made explicit and you have teams of people working collaboratively to achieve those criteria of performance every time, then, yes, checklists make a huge difference.
But what’s making the checklist work is as much the collaborative work environment tightly focused on the goal, as it is the checklist itself.
If you read carefully Gawande’s accounts of how the checklists improved performance in intensive care units, you will see that what makes the difference in performance are things like the low-status nurse knowing what is needed for perfect performance and being able and willing to point out to the high-status surgeon that a critical step has been missed, and the surgeon paying attention to what he or she has been told.
It’s the shift in work environment from traditional management to radical management—collaborative teams tightly focused on the real goals of the work, rather than the internal bureaucracy—that is making the difference, not the introduction of a piece of paper.
So let’s not get carried away with checklists. There are no silver bullets. A simple checklist cannot transform intensive care. Let’s focus on what really makes the difference: radically different management.
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