Want change? What Self-Image Are You Offering?

After decades of training, and years of making daily life-saving decisions, doctors may have developed a self-image which does not include checklists. Like the rest of us, doctors may not want to be reminded of their limitations. In the world of process improvement where I come from—and that’s what we are talking about here—the hard part is seldom designing a better procedure (aka: checklist), but how you will get people to use it. As evidenced by Dr. Pronovost’s resignation that checklists may never be accepted in US Medicine, he is recognizing the greater challenge: changing doctor’s behavior.

As practical and apparently effective as Dr. Pronovost’s checklists are, his strategy for adoption is, apparently, ineffective. Process improvement consultants today include a “buy-in plan” as part of any initiative. Many companies today have “change management” managers responsible for stewarding new ways of doing things. Like we ask our change-initiative clients to consider, what self-image are you asking people to accept when you ask them to change? Are you asking people to accept a story that they have failed, that they are incompetent, forgetful? Given that medicine has—as Robin Moroney of the Wall Street Journal aptly points out—gone the route of specialization over process, it was predictable that Medicine would chafe at a procedural cure.

Furthermore, the protestations of some doctor’s groups that one can’t possibly make a procedure for everything, grotesquely distorts the truth that codification of a few important and simple procedures can make a big difference. Dr. Pronovost has proven that, as have many others in scientific, technical and business disciplines.

But what successful change-agents do that apparently Dr. Pronovost has not done is offer an alternative self-image for doctors as attractive as the one that he seeks to replace. If you are going to challenge doctor’s self-image of expertise, then you must replace it, for example, with one of selfless service to patients, and leadership by example.

Can we find an effective counter-story, a countervailing machismo for the hyper-competent, cool and collected doctor? A culturally-shared story that occurs to me is that scene in the movie Apollo 13 where the engineers at Houston Control have to design a procedure—a checklist—for the astronauts to use to assemble improvised filters to remove toxic levels of CO2 gas from the cabin air. Later mission control boss played by Ed Harris commands “failure is not an option.” And with that, the men of Mission Control get busy making their lists and savings astronauts. Ed Harris’ character Gene Kranz challenged one self-image and offered another: He challenged mission engineers’ by-the-book thinking with throw-the-book-out and-improvise-a-new-book thinking. Kranz offered an equally appealing self-image for his engineers. What is Dr. Pronovost offering doctors?

Dr. Pronovost writes about Medicine lacking a discipline of medicine-delivery. He may be right. But that will take years—probably decades—to change. But immediately with each proposal he can borrow from the business-improvement playbook: Every change needs a change-management plan. Every self-image that you will challenge needs an appealing replacement. Every storyline that you want to re-write needs a new story. Dr. Pronovost, what is your story for doctors?

How can something be so simple yet so impossible?

If a drug saved 1,500 lives and millions of dollars, we would see commercials for it on TV. Doctors across the country would be demanding it from their hospitals. In fact, Dr. Peter Pronovost, intensive care specialist, Johns Hopkins University Hospital, saved the state of Michigan more than $100 million and 1,500 lives over an 18-month period by teaching doctors to use something more prosaic than a new drug. He taught them to use checklists.

Now, when I say ‘checklist,’ business people typically think of job aids commonly deemed by a work group as the minimum tasks required to ensure a job-well-done. It is not that workers don’t know what to do without a checklist. Rather, it is that in the real world with interruptions and distractions it is easy for anyone no matter how skilled to miss something, or simply forget if a task has been completed. In my marketing and business-improvement work, I often help teams come up with their own checklists. Teams usually see lists as helpful because they ensure consistency and engender trust among co-workers. Everybody ends up looking good. Here is the kind of list that Pronovost was using:

• Doctors should wash their hands with soap, and wear a sterile mask, hat, gown, and gloves


• Clean the patient’s skin with Chlorhexidine, a chemical antiseptic common in hospitals


• Avoid insertion of the catheter in the femoral (groin) area which has a higher infection rate


• Take the catheter out when it is not needed


• Use sterile drapes over the entire patient, a common practice in hospital intensive-care units.

Nothing high-tech here. Within three months of implementing the checklist, the likelihood of following all these steps went from 30% to nearly 100%, and infection rates dropped to near zero.

Stories this week in The New Yorker magazine and National Public Radio recount the dramatic results Dr. Pronovost showed in trial usage of such lists in the intensive care unit of the resource-starved Sinai-Grace Hospital in inner-city Detroit. Results were jarring enough so that the state of Michigan requested that Dr. Pronovost test checklists state-wide in reducing infection due to catheter use. State-wide results were equally as jarring.

Would you rather look like a test pilot or a nerd?

So why haven’t doctors jumped all over this? Why aren’t checklists —as posited by New Yorker journalist and surgeon Atul Gawande—as ubiquitous as stethoscopes? After all, checklists have been proven to save lives, and stethoscopes have not.

Dr. Pronovost holds out little hope that checklists will ever be widely adopted in US medicine. “At the current rate, it will never happen,” Pronovost said. “The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science.”

To explain but not excuse this disconnect, Gawande adeptly selected the analogy of the test pilot cowboy culture. As planes became ever more complex, pilots missed mundane flap-releases and pressure checks. They crashed. They died. The engineers survived. A culture of safety and procedure ascended. Like aircraft, hospitals have become exponentially more complex. It’s not a matter of expertise, but a matter of human capacities.

Maybe what we need is to ‘sex up’ the idea of checklists. Can we find an effective counter-story, a countervailing machismo for the cowboy test pilot image? The closest culturally-shared story that I can come up with is that scene in the Apollo 13 where the engineers at Houston Control have to design a procedure—a checklist—for the astronauts to use to assemble improvised filters to remove toxic levels of CO2 gas from the cabin air. Later mission control boss played by Ed Harris commands “failure is not an option.” And with that, the boys of Mission Control (all males) get busy making their lists and savings astronauts. What kind of impending disaster will it take to get doctors busy making checklists?

Dr. Pronovost, maybe you need to hand out DVD’s of Apollo 13 with every proposal. Or maybe you can find some doctor-movie where the nerdy checklist doctor-guy saves the patient, or maybe even an entire city? Maybe, instead of that clunky clip board, you can hand out PDA’s or iPhones, anything brightly lit and rechargeable that looks cool when you pull it out of a lab coat pocket.

OK, so maybe I am being glib. But we in business as in medicine must recognize the conceit that we are asking our people to make when we ask them to use job aids like lists, or to accept improvement initiatives more broadly. Nobody enjoys admitting that they are fallible (e.g.: human). Not customer service personnel, not mechanics. Not doctors. What self-image are we are asking our people to adopt?

I have no background or expertise to evaluate Dr. Pronovosts’ assertion that a new discipline of medicine-delivery is needed to address error rates that in other settings would never be tolerated. Yes, 1% error as measured in hospitals in Pronovosts’ studies is at least an order of magnitude worse than quality levels measured in hundreds of thousands of adequately run product and service companies across this nation.

But I guess that setting up a new branch of medicine will take awhile. For now, Dr. Pronovost, where is your Houston Control story? So I ask you Dr. Pronovost, and my business manager-readers, what self-image are you offering? What is your story?