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Sunday, December 09, 2007

Better Decision Making? CHECK

The December 10, 2007 issue of The New Yorker has an excellent article written by a physician, Atul Guwande, who summarizes an approach for dramatically improving care and cutting healthcare costs -- with one simple change in daily hospital practices. The full article can be read here:


The article starts by recounting the successful treatment (resurrection, really) of a drowning victim and uses that to depict the THOUSANDS of tiny individual steps that all must be performed nearly flawlessly in order to save a life in an ICU environment. Thousands of individual steps which, when analyzed independently, may not be terribly difficult to perform correctly but can snowball into bigger problems if overlooked or performed incorrectly.

Guwande then goes off on a seemingly unrelated tangent by describing the final test flight of a new plane delivered to the United States military by Boeing. The plane, the model 229, surpassed all the Army's criteria and was a shoe-in for a major purchase. The military's top test pilot climbed in, fired up the engines, took off smoothly, climbed to 300 feet, then stalled and crashed. Subsequent investigations found the pilot forgot to release a lock on key controls at take-off. The article continues:

The Boeing model was deemed, as a newspaper put it, “too much airplane for one man to fly.” The Army Air Corps declared Douglas’s smaller design the winner. Boeing nearly went bankrupt.
Still, the Army purchased a few aircraft from Boeing as test planes, and some insiders remained convinced that the aircraft was flyable. So a group of test pilots got together and considered what to do.
They could have required Model 299 pilots to undergo more training. But it was hard to imagine having more experience and expertise than Major Hill, who had been the U.S. Army Air Corps’ chief of flight testing. Instead, they came up with an ingeniously simple approach: they created a pilot’s checklist, with step-by-step checks for takeoff, flight, landing, and taxiing. Its mere existence indicated how far aeronautics had advanced. In the early years of flight, getting an aircraft into the air might have been nerve-racking, but it was hardly complex. Using a checklist for takeoff would no more have occurred to a pilot than to a driver backing a car out of the garage. But this new plane was too complicated to be left to the memory of any pilot, however expert.


The plane was better known as the "flying fortress" and obviously became a key part of our arsenal. Guwande then returns to the problems of modern, high-dollar health care and explains how one doctor devised a simple checklist for nurses and doctors to follow to ensure the proper placement of lines in patents. Like the checklists for pilots involving 1) tanks full, 2) chocks out, 3) instruments lit, 4) radio working, 5) controls unlocked, the items on the checklist for placing lines were all common knowledge items:

On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting a line in. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in. Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years. So it seemed silly to make a checklist just for them. Still, Pronovost asked the nurses in his I.C.U. to observe the doctors for a month as they put lines into patients, and record how often they completed each step. In more than a third of patients, they skipped at least one.

Of course, if you miss one of these simple steps, the risk of infection goes way up along with patient costs and patient mortality rates. Hospitals which implemented the checklists, altered personnel policies to ensure nurses had adequate backing when calling doctors on missed steps and ensured the proper supplies were on hand any times lines were placed saw infection rates and complications plummet.

Obviously, one barrier to adopting such a simple fix was overcoming the arrogance on the part of highly trained doctors, interns and nurses who didn't think they needed a reminder of such obvious requirements. As the author points out, the ego of those doing the work isn't the key concern. The goal is to create a process and a mindset in which simple details aren't left to chance.

The point of the story seems not only apropos to problems in healthcare but to problems throughout our society in general. How many financial firms failed to compile and use a checklist for monitoring their involvement in the sub-prime fiasco?

1) who is the borrower?
2) where's the paperwork the borrower completed?
3) do the cash flows really add up here?
4) can someone explain the calculations behind the ratings of these CDOs?
5) if no one can explain the ratings math, how were ratings compiled for millions of loans?
6) are the incentives of the loan originator aligned with the re-sellers?

More generally, how many American citizens watch the news or vote without following a rudimentary checklist to separate all the fact from fiction? Maybe a checklist like the following?

1) can the proponent clearly describe the DIRECT tie of this solution to the problem being solved?
2) does this solution produce multiple benefits that all contribute to solving the problem?
3) does this solution counteract another policy or program that is also needed?
4) can the advocate of this solution even compute the cost of the first five years of this solution?
5) who drafted the legislation?
6) if solution A is so vital, can the proponent explain the tax plan that will pay for it?
7) if solution A is so vital but a tax isn't needed, can the proponent name the program to cut to pay for it?
8) does the proponent actually KNOW what they're talking about?

Our economy and society have become so complex and inter-related that it's easy to lose track of basic criteria that can lead to better solutions if consistently followed. A better checklist of sorts certainly seems in order. We seem to be making far too many easy mistakes on financial, military and political matters to continue free-lancing the country into the ground.