Tuesday, December 11, 2007

Pronovost, Checklists, and Putting Evidence into Practice

In this week's New Yorker:
Atul Gawande, a popular physician writer who may be familiar to readers from his columns in the NEJM and the NYT, chronicles the hurculean efforts by Peter Pronovost, MD, PhD at Johns Hopkins Hospital to make sure that the mundane but effective does not always take back seat to the heroic but largely symbolic efforts of critical care doctors.

One of my chronic laments is that evidence is not utilized and that physician efforts do not appear to be rationally apportioned to what counts most. There appears to be too much emphasis on developing evidence and too little emphasis on making sure it is expeditiously adopted and employed; to much emphasis on diagnosis, too little emphasis on evidence-based treatment; too much focus on the "rule of rescue" too little focus on the "power of prevention". Pronovost has demonstrated that simple checklists can have bountiful yields in terms of teamwork, prevention, and delivery of effective care - then why aren't we all familiar with his work? Why doesn't every ICU use his checklists?

My own experience at the Ohio State University Medical Center is emblematic of the challenges of getting an unglamorous thing like a checklist accepted as a routine part of clinical practice in the ICU. In spite of evidence supporting it, its obvious rational basis, widespread recognition that we often miss things if we aren't rigorous and systematic, adopting an adapted version of Pronovost's checklist at OSUMC has proven challenging (albeit possible). As local champion of a checklist that I largely plagarized from Pronovost's original, I have been told by colleagues that it is "cumbersome", but RNs that it is "superfluous", by fellows that it is a "pain", by people of all disciplines that they "don't seen the point" and have been frustrated that when I do not personally assure that it is being done daily (by woaking through the ICU and checking), that it is abandoned as yet another "chore", another piece of bureaucratic red tape that hampers the delivery of more important "patient-centered" care - such as procudures and ordering of tests.

All of these criticisms are delivered despite my admonition that the checklist, like a fishing expedition, is not expected to yield a "catch" on every cast, but that if it is cast enough, things will be caught that would otherwise be missed; desipte my reminder that it is an opportunity to improve our communication with our multi-disciplinary ICU team (and to learn the names of its constituents); despite producing evidence of its benefit and evidence of underutilization of evidence-based therapies which the checklist reminds practitioners to consider. If I were not personally committed to making sure that the checklist is photocopied/available and consistently filled out (by our fellows, who deserve great credit for filling it out), it would quicly fall by the wayside, another relic of a well-meaning effort to encourage concsientiousness through bureaucracy and busy-work (think HIPPA here -the intent is noble, but the practical result an abject failure).

So what is the solution? How are we to increase acceptance of Pronovost's checklist and recognition of its utility and its necessity? It could be through fiat, through education, through a variety of means. But it appears that it has survived at Hopkins because of Pronovost's ongoing efforts to promote it and extol its benefits and its virtues and to get "buy-in" from other stake-holders: RNs, patients, adminitrators, the public, and other physicians. This is not an easy task - but then again, rarely is anything that is worth it. Hopefully other champions of this and other unglamorous innovations will continue to advocate for mundane but effective interventions to improve communication among members of multidisciplinary healthcare teams, the utilzation of evidence-based therapies, and outcomes for patients.

1 comment:

  1. The reason people do not change their behaviors or adopt different practices is because humans are averse to change. However, like everything in life, it is about cost and benefit. In other words, the cost of the aversion to change has to be outweighed by the benefits reaped by that individual resulting from the change. That's just change management 101. The challenge we face with this particular problem is that there is not, as you suggest, a fish at the end of each line that is cast. But I would submit to you that somehow it is possible for these types of standardized processes to become integrated into the fabric of the organization--the aviation industry, as pointed out by Gawande and many others, is a prime example of that.


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