The Sledgehammer

The List That Saves Lives

December 14, 2021

Think about the countless tasks you undertake every workday:

  • Getting dressed (in sweatpants, obviously)
  • Brewing coffee
  • Making breakfast
  • Working out (err, maybe)
  • Responding to all those emails
  • Designing that slide…

It’s a list of dozens, if not hundreds, of actions.

A study found that the average ICU patient is the recipient of about 187 different actions every day — HCPs administer their medication, adjust their oxygen, suction their lungs, even brush their teeth to prevent bacteria-causing pneumonia. And while the actions that we take in our daily lives feel important, in an ICU, they are truly a matter of life or death. The consequences of a missed step or slight oversight could be catastrophic. The same study found that an error was made in only 1% of those actions, but that means nearly two mistakes every day with each patient — two chances for catastrophe, on top of an already precarious situation. So how do you reduce error in a practice that is so very complex?

There are a lot of things that can go wrong in the ICU, but a critical care specialist named Peter Pronovost decided to tackle one of the most prevalent: Infections in IV lines. His solution? Not a complex device, not a novel cleaning solution. It was a checklist. One piece of paper. Five tasks aligned to five checkboxes.

To test the checklist’s effectiveness, first he studied patient care without the checklist. In a third of cases, doctors skipped at least one critical step in setting up patient lines. Then they implemented the checklist and empowered nurses to stop a doctor if a step was skipped. The results after a year were incontrovertible: The 10-day line infection rate dropped from 11% to zero. It was calculated that the checklist spared 8 lives, prevented 43 infections, and saved $2 million. Pronovost roped in a few other ICU colleagues to create their own checklists, and the results were similarly dramatic: In all, the average length of stay in the ICU dropped by half. All this progress is thanks to a few rudimentary tools that Pronovost estimates would cost only about $2 million dollars to implement in every hospital in the United States.

In thinking about our own desire to deliver helpful tools to HCPs, here are some simple yet powerful takeaways from this amazing effort:

  • Medicine is wildly complex. It’s a constant stream of decisions and actions, which is hard even for the most highly trained, specialized professional. Imagine having to make life and death decisions every hour of every day. So, any useful tools we can give to HCPs to help them make decisions — checklists (of course), diagnostic criteria, cheat sheets — can have a profound impact.
  • HCPs have egos. This is not a criticism — we all have egos. But remember that when introducing new behaviors to HCPs, you’re not only up against medical precedent, you’re also up against the way these individuals see themselves as practitioners. One of the ways that Pronovost overcame this was by enlisting insurance companies to offer bonuses to institutions that agreed to implement the checklists. And it worked. Another strategy you could consider is to find trusted HCPs to become early adopters and advocates for the desired behavior change.
  • Nurses matter. Remember, in the case of the line infections checklist, it was nurses who were the enforcers. Their influence on patient care can’t be discounted. All too often, nurses are treated as a secondary audience and are the first to go when a brand loses budget. But without them and the accountability they provided for the checklists, these life-saving results in the ICU wouldn’t have been possible.
  • This isn’t an HCP solution, it’s a health system solution. Without buy-in at all levels — the docs, the nurses, the administrators, the insurance companies — the checklists simply doesn’t work. Thus when you’re designing solutions for professionals, consider the entire ecosystem: Is there a pharmacist that has to buy in? Is there an office manager that must be on board? Are managed markets standing in the way?

So the next time you’re gravitating toward a shiny new marketing tactic (marketing in the metaverse, anyone?!), stop and make sure that there isn’t a “clear line” to a simple solution, much like the one Pronovost identified.

At any given time, there are hundreds of actual sledgehammers present in the Heartbeat office. To celebrate their first year on the team, each HB’er receives their very own sledge—a nod to our daily pursuit of tearing down tiresome healthcare marketing. To determine what is built in its place, we often turn to outside industries, cultural forces, and personal experiences. We eagerly share them with one another, and now we’re sharing them with you. Clear the way—here comes The Sledgehammer.