

 The Checklist: If something so simple can transform intensive care, what else can it do? - nickb
http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande

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iamelgringo
I moonlight as an ER nurse while I'm finishing my software engineering degree.
I've worked ICU for a number of years as well.

It sounds simple to institute a checklist, but the key issue isn't the
checklist, it's about allowing nurses to hold doctors accountable and the
hospital backing the nurses up in those disputes.

Say you're a night shift ICU nurse. Your patient craps out at 3am, and your
intensivist crawls out of bed to come and "line up" your patient and put them
on life support. Do you think that Dr. Intensivist with 15 years of school
wants to hear at 3am is a nurse with an associates degree tell him to stop
what he's doing and start over because he didn't wash his hands properly
before starting. I've had charts thrown at me for stuff like that.

This issue is accountability and incentives. This plan places accountability
on the doctors, but it puts a lot of strain on the doctor/nurse relationship
when that nurse is the one blowing the whistle on the doctor.

What we need is an incentive system for doctors. You need both a carrot and a
stick. Doctors only get paid when the patient is sick. And, if the patient
gets sicker, that doctor spends more time with the patient and bills more.
There is no incentive to keeping the patient healthy, only payment for taking
care of as many sick patients as possible. Doctors don't like it they
generally want to take good care of patients. They just have to pay of
$200,000 of student loans, and the only way to do that is to rush and see as
many patients as possible.

If the doctors received a large bonus every year if their lines did not get
infected, or if their patients did not get a pneumonia when the patient was on
life support, you better believe that complication rates would go down.

If nurses got a small bonus every year based on our infection control
practices, we'd all wash our hands a lot more often. But we don't. We're all
paid by the hour on a patient assembly line.

The doctors or nurses haven't set up this system, the insurance system has.
It's just the unintended consequences of our third party payer system.

Although, there are winds of change. Medicare is starting to threaten
hospitals by not paying them if a patient gets an infection from the hospital.

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DocSavage
I think you're overly cynical. Docs don't need monetary incentives for
"keeping the patient healthy." They need proof that something is wrong and a
simple remedy will fix it and help patients. Not every doc, particularly those
with relatively fixed salaries, are rushing to see patients to maximize their
personal wealth. I'd think it was financial pressures to reduce costs at the
institutional level that create an imbalance between # of caregivers and the #
of patients. I've seen some new medical practices (e.g., here in Palo Alto)
where you can pay a lot more and get seen by docs with a relatively very low
patient load.

~~~
iamelgringo
One of the few things that has reduced health care costs the past few decades
has been the advent of HMOs. Why is that? Because HMOs give a doctor a
financial incentive to keep the patient healthy.

No, I don't think I'm cynical. I'm speaking from over 15 years experience in
the Critical Care business. I've worked at over 35 hospitals and medical
facilities in 6 different states.

And, it's a plain fact of nature. People do what you pay them to do. Just
because someone is in health care doesn't change the fact that they want to
get paid. And, we should give people financial incentives to give good care.
Pay them to do a good job.

A founder gets paid if their company has a successful exit. So, we bust our
buts to make a successful exit for our company. Stock options reward employees
for increasing the stock price. So, employees will work to increase that stock
price. If you pay people per hour, they work a lot of hours. If you salary
people without regards to performance, performance drops. If you pay a person
per widget made, they make a lot of widgets.

I'm speaking from experience. The best ER's that I've worked in were ER's
where the doctors are paid a base rate and then a bonus for performance based
standards. That ensures excellent, efficient practice of medicine. Those are
the ER's where the doctors push the nurses to line up more patients to be
seen. The ER that I work in now is one of those. I'm working with some of the
best doctors I've ever worked with.

I've worked in ER's like that where the group of doctors got paid a flat rate
to staff the ER per year. So, if they understaffed the ER, they got paid more.
Needless to say the patient wait times in that ER were often over 16 hours. I
saw patients waiting a full 24 hours just to see a doctor for a broken arm or
a gallbladder attack.

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Tichy
Oh man, that story interests me, but why can't they just get to the bloody
point??? I stopped reading after page two, and there still was no mentioning
of a checklist...

~~~
rms
The Boeing B-17 was an early four engine plane and was extraordinarily
complicated. Previous planes were simple enough that checklists were
unnecessary but the B-17 only became practical with the introduction of a pre-
flight checklist. The current state of Hospital Intensive Care is compared to
flying a B-17 before the checklist was used.

Empirical evidence is given about IV line infections, a major problem in ICUs.
A 5 step checklist lowers the 10-day line infection rate from 11% to 0% at
Johns Hopkins, an almost unbelievable result. It is confirmed over 15 months.

These results are again confirmed at an understaffed inner city hospital in
Michigan with similarly dramatic results. The study from the Michigan hospital
is published in the December 2006 publication of _The New England Journal of
Medicine_. Despite these dramatic results, there is resistance against the
increased use of checklists.

The checklist study author says he can introduce ICU checklists across America
for 3 million dollars at the most. Because of the resistance in the USA, the
country of Spain will be the first country to use checklists nationwide. The
study author hopes that the USA will not be the last country to start using
ICU checklists.

If anyone here has money to burn, lobbying for the increased use of checklists
in intensive care units would get more net local social returns (in lives
saved) than building Stanford a new emergency room and it would cost less
money.

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ph0rque
Reading this, it seems that maybe the first market for Trevor Blackwell's
Anybots might be robo-nurses. Being computers, they'll be able to follow
algorithms perfectly.

~~~
nickb
Liability's way, way too high for that. Industrial uses where there's no
chance (or a small chance) of injury to humans is a lot better application.

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edw519
An incredibly powerful argument for the effectiveness of "low tech"
approaches. Whether it's health care, business, or technology, it's almost
always counter-intuitive. That's why it's often such a hard sell.

(Case in point at a client of mine: When the parking lot was scheduled for
paving, email was sent to everyone. For whatever reason, about half didn't
read it or know about it. The next time, paper notices were posted on both
sides of every door. Not one person parked in the lot. Who knew?)

