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Challenging Arrogance, Autonomy, and Fear

Janice Simmons, for HealthLeaders Media, July 15, 2010
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Perhaps no one knows more about using checklists in hospitals to improve quality and prevent errors than Peter Pronovost, MD, PhD, who brought the checklist's potential to light nearly a decade ago, initially to help lower bloodstream infections in a surgical intensive care unit.

But Pronovost, a professor and medical director for Johns Hopkins' Center for Innovation in Quality Patient Care in Baltimore, is first to admit that checklists will not change anything until the current medical culture—which he says can contain a certain degree of arrogance, autonomy, and even fear—evolves to a point where everyone on a medical staff can speak up and look out for the patient.

The challenge was there from the beginning when the first checklist was compiled using five simple evidence-based recommendations, such as telling physicians to wash their hands before inserting central venous catheters into patients. "What was so striking about that was nobody debated the evidence for the checklist," Pronovost says. "Nobody questioned: 'Should I wash my hands?' It was the culture that was the barrier."

Pronovost, who relates his experiences with checklists and patient safety in his new book, Safe Patients, Smart Hospitals, recalls how the medical staff he was working with at Hopkins initially refused to use the simple checklist to help reduce catheter-related bloodstream infections.

When nurses were asked to assist physicians in inserting catheters—or to suggest to physicians that something was wrong during the process—"that caused World War III," says Pronovost, a practicing anesthesiologist and critical care physician. "The nurses revolted. The nurses said it's not their place to police the doctors. And, if they did [correct a physician], they said they might get their heads bit off."

Similarly, the physicians expressed skepticism. "The doctors ironically said, 'There's no way you could have a nurse question me in public. It makes me look like I don't know something,'" Pronovost says.

To break the impasse, Pronovost brought the groups together and asked them if they should complete the tasks on the checklist. The response was yes. Then he asked if it was "tenable that we harm patients?" The response, not surprisingly, was no. The solution?

Pronovost told the nurses that if they spoke up, he would back them up and support them "any time of the day or night" if they received flack from a physician using the checklist process.

Over the years, this scenario of medical staff buy-in or acceptance has been played out time and again at hospitals and medical facilities across the country. The idea of having checklists available for everything from surgical-site infections to ventilator-associated pneumonia has caught on. However, nationwide, infections and errors still occur at a rate similar to a decade ago.

The problem is "that nobody is accountable for the outcome"—for the results, Pronovost says. "From the national level down to the local hospital, what I see is a bunch of people being accountable for the process"—such as using checklists. However, he still sees cultures where nurses are afraid to speak up or where physicians or surgeons dominate the way medicine is practiced.

Now may be the time for hospitals to consider "relational competency" when hiring to improve the medical culture of their facilities. Hospitals, for instance, may hire a hotshot physician or surgeon to bring in more money and patients. "From day one, you can see that they will be a relational nightmare," he says. "They don't want to hear from anybody else."

Instead, hospital executives should be focusing on bringing in senior physicians who could be considered role models in working together with medical teams. There should be no room for tantrums or "bad behavior in the sandbox," Pronovost says. Instead, more emphasis needs to be placed on learning better self-care and how to grow socially and emotionally.

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