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Minimal: Many elements in clinical care are routine and should be standardised. (AFP)

Comment: Simple logic saves patients' lives

Paul Levy
Doctors and nurses don't need a miracle drug to prevent the massive number of premature deaths.

With the progress in the delivery of healthcare over the past several decades, one wonders where the next advances will arise. Will it be a new series of drugs developed by scientists and pharmaceutical companies? Will it be new generations of medical devices? Will it be a better understanding of the genetic determinants of disease? 

Certainly all of the above are likely to occur, but each comes with a high cost: years of research and employment of hi-tech approaches will necessarily require that corporations invest in, and protect, their intellectual property rights.  

A recently developed drug for hepatitis C, for example, has a purchase price of thousands of dollars a dose. The pharmaceutical company explains that it has invested hundreds of millions of dollars in the drug’s development and therefore needs to recover this money.  It also rationalises the high costs of the drug by pointing out that the cost of the current therapeutic approach to the disease – which can include liver transplants – exceeds the cost of the medication. Therefore, the company implies, we should be content with the high cost of the drug.

Cost-effective interventions
All of this is subject to debate, but the underlying premise is correct: firms invest in medical advances for humanitarian reasons and to make a profit.  Although some technological approaches to disease diagnosis and management will reduce a country’s healthcare budget, most will not.  

As a society, we accept this because the ultimate result is that we get to live longer and participate as productive members of society.  Thus, we have a personal (selfish) reason to encourage this trend, and we also have a societal imperative to do so. 

But there is a hidden gem of intervention in the healthcare system that requires little or no investment, and little or no technological advancement, but has the potential to save more lives than most of the drugs and medical devices that will come to the market over the coming ?decade. That this intervention remains largely untapped results in the premature death of hundreds of thousands of people around ?the world. 

What can this "miracle drug" be? Well, it is no miracle. Rather, it’s reorganising the way in which hospitals provide quality care, but many medical professionals have not been equipped with the skills to implement effective procedures. 

Here’s the story. In hospitals throughout the world, doctors and nurses devote their lives to alleviating human suffering caused by disease. Intelligent and highly trained, these clinicians are engaged in the many tasks required to take care of patients with a broad range of diseases. Yet these very same doctors and nurses participate in a form of healthcare delivery that is quite dangerous. 

Many people are harmed in hospitals or die from preventable medical errors. I do not refer to the occasional explicit error made by a surgeon during a complicated operation. I refer instead to the insidious presence of infections, missed test results and other similar events that occur in hospitals.  These do not happen out of negligence: rather they result from the manner in which work is organised in hospitals. 

Inadequate training
The problems remain because doctors and nurses are not trained in the methods and approaches needed, first, to notice that the problems exist and, second, to fix them. 

One of the great medical educators, Harvard University’s Lucian Leape, has noted: "Medical schools are not doing an adequate job of facilitating student understanding of basic knowledge and the development of skills required for the provision of safe patient care." 

What are these skills? Here we can learn lessons from several other industries that have spawned high- performance systems of production or service delivery. There are two common characteristics of such companies. 

First, they take steps to adopt proven protocols and reduce variation in their production or service delivery processes. Second, they encourage their front-line staff to point out problems in the production process, and they act on those call-outs to engage in continual process improvement.  

I can already hear some people objecting: "But medicine is different. Each patient is a unique human being, requiring expert attention and the judgment and creativity of a thoughtful doctor’s care. Don’t tell me that we have anything to learn from automobile or computer chip production."

Need to standardise 
True and not true. We never, ever want to remove the element of professional judgment from the provision of care. But we do need to recognise that many elements in clinical care are routine and should be standardised. In fact, there are many hospital-related procedures for which the last thing we want is creativity. The beneficial effects of such standardisation have been proven worldwide over the past several years. 

One example relates to a common clinical practice, the insertion of central lines, catheters that deliver high doses of medication through a vein in the chest or neck of a patient. These central lines have saved many lives, but if they become infected, serious problems result because the infection can travel quickly through the body. 

For years, it was accepted and expected that a certain number of central line infections would occur in hospital patients, a rate equal to four or five cases per thousand patient days. When a patient had such an infection, the response was: "These things happen."  

But then physician Peter Pronovost at Johns Hopkins University worked with a number of hospitals in Michigan, in the United States. They developed and encouraged the widespread use of a single protocol for the insertion and maintenance of central lines. Within months, the rate of central line infections dropped to zero, and that result was sustained for several years. 

Lives saved
In 2012, the British Medical Journal reported that a safety checklist programme developed by a Johns Hopkins doctor had reduced patient deaths in Michigan hospitals by 10%, in addition to nearly eliminating bloodstream infections in healthcare facilities that embraced the prevention effort. The effort required investment but also saved substantial sums of money.  

As noted by the American Journal of Medical Quality, the average cost of the intervention is $3?375 per infection averted, measured in 2007 dollars. The cost of the intervention is substantially less than estimates of the additional healthcare costs associated with these infections, which range from $12?208 to $56?167 per infection episode. 

In summary, Pronovost and his colleagues adopted the following process: 
(1)?Determine and document the most efficacious protocol with regard to this procedure;
(2)?Train all clinicians to follow it precisely; 
(3)?Track the results and report them to people within the hospitals and across all the participating institutions; and
(4)?Modify the protocol over time based on the experience of those involved, responding to suggestions from those on the front lines. 

"simple logic"
Although these suggestions carry a simple logic and have been proven to work in saving lives, they are often not followed in hospitals around the world.  The training received by doctors and nurses usually does not cover these elements of process improvement. 

Doctor are taught to use their judgment, their creativity and their initiative in taking care of patients. The problem with that is that there are a great number of routine clinical procedures for which creativity should be minimised in exchange for strict adherence to evidence-based approaches. 

Many doctors bridle at the thought that they might lose their independence and prerogatives if they follow such protocols. Accordingly, doctors have to be brought into the design of quality and safety efforts.  Where this kind of respectful engagement has occurred, doctors have become true champions for efforts to reduce harm. 

Then, working with the nurses to create high-performance clinical teams, lives have been saved.  The "medical miracle" is not so miraculous. It is right on our doorstep, waiting for leaders in the ?profession to make it a priority, every day and for every patient. 

Paul Levy is a senior adviser at Lax Sebenius, LLC, a firm that provides negotiation support and training to companies worldwide. He is the former president and chief executive of Beth Israel Deaconess Medical Centre in Boston, Massachusetts.

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