Sometime ago, I wrote a blog called, “One Thing…” which was about the one thing I would do — if I could do one thing — to improve the quality and reduce the cost of health care in the U.S. I talked about creating a National Institute for Health Care Delivery. But what do I know. I’m just the head of a regional non-profit health insurance plan. So imagine my surprise, and total delight, when I read a recent article in The New Yorker by world renowned surgeon and author Atul Gawande called, The Checklist.

Gawande’s article is a must-read for anyone who wants to know more about what can be done to improve health care, and it focuses on a simple question — why, when there is overwhelming evidence that it works — are health care professionals so reticent to use checklists? He traces the experiences of a critical care specialist at Johns Hopkins named Peter Pronovost, who figured out that when physicians and other clinicians working in the ICU at Johns Hopkins used a five-step checklist every time they inserted central line (like the ones used for IV fluids), they could reduce line infection rates to virtually zero. Line infection rates cost money and kill people. It’s a big deal. Reducing them saves lives, reduces costs, and dramatically improves health care quality.

Pronovost took his idea on the road — and eventually got the hospitals in the state of Michigan to try his checklist in their ICUs. In the first three months, they reduced ICU line infections by 66%, with many hospitals eliminating line infections completely. Before the checklist, Michigan hospitals overall had line infection rates above 75% of the nation’s hospitals. Afterward, they averaged rates that were below ninety percent of the nation’s hospitals — a remarkable turnaround.

In the first 18 months, hospitals saved over $175 MM in costs and 1,500 lives. Four years later, the early results have been sustained, as Gawande puts it — “all because of a stupid little checklist.”

So has the stampede to install checklists in every ICU in the country followed the experience at Johns Hopkins and in the state of Michigan? Sadly, no. I’ll use Gawande’s article to explain why. “I called Pronovost recently at Johns Hopkins, where he was on duty in an ICU. I asked him how long it would be before the average doctor or nurse is as apt to have a checklist in hand as a stethoscope (which unlike checklists, has never been proved to make a difference in patient care). ‘At the current rate, it will never happen,’ he said…’The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science. The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government and academia. It’s viewed as the art of medicine. That’s a mistake, a huge mistake. And from a taxpayer’s perspective, it’s outrageous. We have a thirty-billion-dollar-a-year National Institutes of Health, he pointed out, which has been a remarkable powerhouse of discovery. But we have no billion-dollar National Institute of Health Care Delivery studying how best to incorporate those discoveries into daily practice.”

Gawande says implementing Pronovost’s checklist for line insertions in ICUs across the country would cost a few million dollars — and would be far more successful than other attempts — mostly based on new, far more expensive toolkits — that have been tried previously. “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.”

If people in the health care and public policy community are serious about saving money, improving quality, and enhancing patient safety, ideas like the ones discussed in Gawande’s article should become commonplace quickly. So why aren’t we jumping at these opportunities?

And read the article. Please.

Posted by Charlie Baker in Care Management, Health Care Costs, Health Care Quality