I recently saw a TED talk by Dr Atul Gawande titled “How do we heal medicine?”. The talk was informative and thought provoking and caused me to reflect on the role of information technology and information management in the work of busy healthcare providers. Sadly it also reminded me just how much opportunity to put in place simple solutions is missed in our search of sophisticated, complex solutions.
Dr Gawande maintains that “Our medical systems are broken.” A key contention is that as medicine has become more complex, for many serious conditions it has become impossible for a single clinician, acting alone, to deal with the diagnosis and treatment effectively. It is becoming clear that medicine is a team activity with professionals supporting each other to deliver truly effective care.
As an example Dr Gawande says that in 1937 a doctor could know all there was to know about healthcare, “medicine was cheap and generally ineffective”. However we have now treatments (not necessarily cures) for nearly all of the tens of thousands of conditions that a person can possibly get, we have more than 4,000 medical and surgical procedures and, as a surgeon in the US, Dr Gawande can prescribe more than 6,000 drugs. Even primary care clinicians are today, specialists.
Clearly, doctors can no longer know it all or do it all.
More startling in 1970 it took just over two clinicians to take care of a person in a typical hospital visit. By end of 20th century number was more than fifteen clinicians per patient. How can we ensure that with this increased complexity, that the quality of care and the quality of the patient experience continue to improve commensurately?
Initially Dr Gawande suggests that we need more pit-crews and less cowboys in medicine and, although he eventually acknowledges that the cowboy analogy is false (even cowboys use best-practice to do their jobs these days), the pit-crew analogy is strong. For the doctor’s contention is that; as a pit-crew uses strong, well-rehearsed processes and procedures to work together to minimize risk and deliver consistent results; so should clinicians.
We have known for some time that the incidence of inappropriate or incomplete care in even the best healthcare systems in the world is too high. This is well documented in World Health Organization (WHO) reports and in the famous Institute of Medicine publications To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm.
Atul Gawande explores how doctors can dramatically improve their practice using something as simple as a checklist. This approach to quality control and has long-been understood by the airline industry in whom many of us place our faith regularly and; it is my understanding that proven and well-accepted quality assurance mechanisms like the ISO standards are based on this premise. Organizations effectively use checklists to be able to demonstrate that they can consistently meet target levels of excellence.
Checklists can be used in many areas of clinical practice to ensure that safety of patients and to ensure that known best-practice is followed and that outcomes are consistent.
Formal continuous improvement regimes will ensure that systems do not stagnate, that they are improved and enhanced to provide the best possible outcome given current knowledge. And a key to learning from our systems is to ensure that a feedback loop is built in so that we know the system is being adhered to and that the outcomes are as-expected.
Here is a checklist for venous canulation in a UK hospital, nurses are expected to complete the checklist and, when they do so, incidents of human error resulting in outcomes such as hospital acquired infections are greatly reduced:
I have also seen simple checklists introduced to track the administration of patient medication in hospitals. These work by recording the time when medications are administered and, in the process helping to ensure that work processes can be managed, and that there is an evidence base upon which to understand the impact of the medication on the patient’s healthcare outcome.
Checklists like the above have been introduced to support surgical teams. The evidence points irrefutably to their effectiveness. Dr Gawande quotes that, following the introduction of checklists in surgery in hospitals around the world – complications fell 35% and death rates fell 47%.
However healthcare is often slow to adopt such systems and to use technology to ensure that processes that help people handle complexity and improve their performance and output.
Where else might checklists and processes be used to improve the performance of helathcare providers?
What are the possibilities for primary care?
As always I am interested in your thoughts and will be happy to publish relevant comments.