The book starts with the case of a 18 month old child with severe burns that is brought to John Hopkins medical centre. During her stay there she develops several infections, partly due to an infection of her central line, that leads to her death. This case had a huge impact on the hospital since to all people involved it was clear that her death was unnecessary with a better organization in the hospital. This led to a project where a simple checklist decreased central line infections from 11 in 1000 catheter days to zero. Peter Pronovost created this checklist from all evidence available on the prevention of central line infections. He called this process TRIP (Translating Evidence Into Practice). The checklist was:
- Wash your hands with soap.
- Clean the patient’s skin with chlorhexidine antiseptic.
- Put sterile drapes over the entire patient.
- Wear a sterile mask, hat, gown and gloves.
- Put a sterile dressing over the catheter site.
Hardly rocket science. Of course a checklist alone is never the solution. Changing the culture so people are willing to use this checklist, have nurses correct doctors that do not use it, get the right equipment in the right place is the difficult part.
In his book he describes several issues that are paramount to a good implementation of such improvement measures:
- The checklist must be based on sound data. All over the world research is published about how to prevent infections. In the case of these central lines there was a 180 page directive from the CDC. Translating these directives in useable processes (training, checklist, measurements) is important
- Peter Pronovost was successful in his ICU because he new the culture and was part of it but he found out that attention to culture should be first. He calls this CUSP (Comprehensive Unit-based Safety Program). A focus here is on the unit since the cultures in different part of the hospital can be very different.
- Compliance to agreed working practices processes is important. Even in the research on the SURPASS checklist it was mentioned that compliance was only in the range of 80% (1).
- Without indisputable data it is hard to convince many people about the usefulness of a new approach. Clear measurement and reporting on the effects of safety programs lead nowhere.
- An last but not least the importance of storytelling. From the start in 2001 to now the story of the little girl that needlessly died (Josie King) is told numerous times. We have to keep reminding ourselves about the danger of preventable adverse events. Since they do not happen daily in every ward it is important to keep repeating the clear cases where preventable harm is done to a patient what must be done to prevent this for the next patient.
The CUSP process for increasing safety culture in the hospital is as follows:
Prior to implementation a baseline needs to be determined on safety culture, measurements on the relevant adverse events and the inclusion of all stakeholder.
- Train the staff in the science of safety: looking at processes from a safety view is different than people working on the front line are used to (importance of system and process, standards, learning cycle, technical and not technical, diversity);
- Engage staff to identify defects: how is the next patient going to be harmed, how to prevent this from happening;
- Senior executive partnership/safety rounds: bridge the gap between front line and leadership
- Continue to learn from defects
- Implement tools for continuous improvement.
The AHRQ (Agency for Healthcare Research) has on the basis of the work of Peter Pronovost and his team an extensive toolkit developed that can ben found here.
The book can be found here
(1) De Vries, E. N., Prins, H. A., Crolla, R. M. P. H., den Outer, A. J., van Andel, G., van Helden, S. H., … Boermeester, M. A. (2010). Effect of a comprehensive surgical safety system on patient outcomes. The New England journal of medicine, 363, 1928–1937. doi:10.1056/NEJMsa0911535