The Checklist Manifesto_ How to Get Things Right - Atul Gawande [17]
Pronovost had been canny when he started. In his first conversations with hospital administrators, he hadn’t ordered them to use the central line checklist. Instead, he asked them simply to gather data on their own line infection rates. In early 2004, they found, the infection rates for ICU patients in Michigan hospitals were higher than the national average, and in some hospitals dramatically so. Sinai-Grace experienced more central line infections than 75 percent of American hospitals. Meanwhile, Blue Cross Blue Shield of Michigan agreed to give hospitals small bonus payments for participating in Pronovost’s program. A checklist suddenly seemed an easy and logical thing to try.
In what became known as the Keystone Initiative, each hospital assigned a project manager to roll out the checklist and participate in twice-monthly conference calls with Pronovost for troubleshooting. Pronovost also insisted that the participating hospitals assign to each unit a senior hospital executive who would visit at least once a month, hear the staff ’s complaints, and help them solve problems.
The executives were reluctant. They normally lived in meetings, worrying about strategy and bud gets. They weren’t used to venturing into patient territory and didn’t feel they belonged there. In some places, they encountered hostility, but their involvement proved crucial. In the first month, the executives discovered that chlorhexidine soap, shown to reduce line infections, was available in less than a third of the ICUs. This was a problem only an executive could solve. Within weeks, every ICU in Michigan had a supply of the soap. Teams also complained to the hospital officials that, although the checklist required patients be fully covered with a sterile drape when lines were being put in, full-size drapes were often unavailable. So the officials made sure that drapes were stocked. Then they persuaded Arrow International, one of the largest manufacturers of central lines, to produce a new kit that had both the drape and chlorhexidine in it.
In December 2006, the Keystone Initiative published its findings in a landmark article in the New England Journal of Medicine. Within the first three months of the project, the central line infection rate in Michigan’s ICUs decreased by 66 percent. Most ICUs—including the ones at Sinai-Grace Hospital—cut their quarterly infection rate to zero. Michigan’s infection rates fell so low that its average ICU outperformed 90 percent of ICUs nationwide. In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated $175 million in costs and more than fifteen hundred lives. The successes have been sustained for several years now—all because of a stupid little checklist.
It is tempting to think this might be an isolated success. Perhaps there is something unusual about the strategy required to prevent central line infections. After all, the central line checklist did not prevent any of the other kinds of complications that can result from sticking these foot-long plastic catheters into people’s chests—such as a collapsed lung if the needle goes in too deep or bleeding if a blood vessel gets torn. It just prevented infections. In this particular instance, yes, doctors had some trouble getting the basics right—making sure to wash their hands, put on their sterile gloves and gown, and so on—and a checklist proved dramatically valuable. But among the myriad tasks clinicians carry out for patients, maybe this is the peculiar case.
I started to wonder, though.
Around the time I learned of Pronovost’s results, I spoke to Markus Thalmann,