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Op-Ed Contributor

The Health Factory

CAMBRIDGE, Mass. - TODAY, going to an American hospital seems about as safe as parachuting off a bridge. An estimated 98,000 Americans die each year as a result of medical error, and a nearly equal number succumb to infections they acquire in hospitals. Those rates are unacceptable in the world's most medically advanced country.

This month, President Bush signed a bill intended to reduce the rate of medical errors. The legislation authorizes the creation of "patient safety organizations" to which health care providers can report errors and near misses. On the basis of these reports, the organizations will recommend ways to avoid such mistakes. And to reduce disincentives to reporting, the bill prevents information disclosed to these organizations from being used in malpractice lawsuits.

The new legislation is a step in the right direction. It will allow hospitals to study their errors without fear that acknowledging mistakes will lead to reprisals. But within the hospitals themselves lies a far bigger opportunity to reduce the rate of catastrophic medical error, if the hospitals would just follow the example of the world's most successful industrial organizations.

Companies like Toyota, Alcoa and Vanguard differ from one another in the products they produce and the technologies they employ, but they share a management approach that has resulted in a combination of safety, quality, efficiency and responsiveness unmatched by their competitors.

It may seem a stretch to compare a carmaker's, aluminum refiner's, or mutual fund company's operations with a hospital's. But all these companies manage complex processes that require a great deal of problem solving -- and they have something important to teach health care.

Typically, health care workers, like employees in many other industries, tend to work around problems when they encounter them, meeting patients' immediate needs but not resolving the problems' root causes. Therefore, people confront "the same problem, every day, for years," as one nurse phrased it to me. These persistent difficulties manifest themselves as regular inefficiencies within the system, and they occasionally lead to catastrophic mistakes.

What sets the non-health care leaders apart is that as they do their work, they are constantly learning how to do it better. Work is designed to reveal even little problems as they occur-- well before they cause errors or near misses worthy of being reported. Managers respond to these problems immediately, with rapid experiments aimed at generating sustainable fixes, rather than with workarounds that are constantly repeated. The knowledge that results from this process is then shared through collaborative experimentation in which all employees take part.

A number of American hospitals have tried this approach, with promising results. For example, hospitals in the Pittsburgh Regional Healthcare Initiative addressed a recurring predicament in intensive care. Catheters placed directly into veins or arteries, called central lines, are used to deliver medication swiftly to critically ill patients. But a quarter-million patients nationwide who receive this treatment each year suffer bloodstream infections as a result, and of those, 15 percent die. At one Pittsburgh area hospital, mortality was a staggering 40 percent of those infected, and the cost for each infected patient was $25,000 to $80,000. To eliminate these infections, the hospitals taught themselves to find problems and institute small process enhancements at a rate far faster than a national reporting program will most likely allow. Together, these small fixes added up to a significant improvement.

For periods of days or weeks, the Pittsburgh hospitals observed the placement and maintenance of every central line, looking for minor breaks in routine that could create opportunities for infection. Along the way, they found dozens of factors that were potentially suspect. One hospital realized that in its line-maintenance kits, gloves were stored on the bottom, causing nurses to fish through sterile material with bare hands. Other kits had drapes -- sheets that isolate the area on which a nurse or doctor is working -- that were either too small to be effective or so large that patients knocked them out of the way.

Other hospitals discovered that only on certain shifts were there doctors expert in placing the more difficult but least infection-prone type of line. And the shifts that lacked such expertise also lacked simple, reliable ways to signal the experts on other shifts to move lines from high-risk to low-risk locations or to remove them entirely when they returned to work.

By quickly identifying and resolving these small procedural problems, the Pittsburgh hospitals as a group cut their central line infection rates in half, and some hospitals were able to cut their individual infection rates nearly to zero. These hospitals and others used a similar approach to solve other problems, like patient falls and faulty medication administration.

To go from working around problems to identifying and solving them required hospital workers to change the way they worked, from the front lines to the senior levels. But the effects were profound. If the rest of the country's hospitals follow that example, the national savings would be measured in tens of thousands of lives and billions of dollars every year.

Op-Ed Contributor Steven J. Spear is a senior fellow at the Institute for Healthcare Improvement.

A version of this article appears in print on  , Section A, Page 15 of the National edition with the headline: The Health Factory. Order Reprints | Today’s Paper | Subscribe

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