Grassroots efforts can boost hospital excellence
By Karen Jorge
I’ve been reading Atul Gawande’s The Checklist Manifesto: How to Get Things Right, which, as the book’s title suggests, discusses the surprisingly significant positive effects of implementing such a low-tech system (a checklist) in various fields.
Along the way, Gawande discusses how in complex situations that demand expertise from many areas (e.g., medicine), it is often most effective to farm the responsibility for decisions to the most distal areas – to the people who are actually on the ground doing the work, instead of locating it in some central decision-making body. In one anecdote, he explains that one reason for governmental failures in the response to Hurricane Katrina was that nobody could decide who should be making the decisions. The only thing various levels of government could agree on was that some centralized body should be calling the shots, even though the central body was far removed from what was actually happening. The governments chose that approach instead of letting people on the ground figure out how to best respond and adapt to the constantly changing situation.
Interestingly, Wal-Mart Stores(!) staged one of the most effective responses. The CEO decided that each and every Wal-Mart employee be empowered to make decisions that they deemed necessary, and the employees certainly stepped up. Store managers distributed food, water, and supplies to first responders, created rudimentary but effective methods to systematically hand out goods to displaced citizens, and responded to the needs they saw. In essence, they identified problems and solved them, something that couldn’t be accomplished with higher levels of centralization.
This example came to mind when I was listening to the impressive presentation given earlier this week by Kathy McCoy, Dr. John Kaiser, and their ICU team at Sentara Williamsburg Regional Medical Center. They haven’t had a case of ventilator-acquired pneumonia (VAP) in six years, which is particularly notable because VAP is the most common hospital-acquired condition in the ICU, and occurs in almost one-quarter of patients on mechanical ventilation. Six years without a single case!
As they explained how they accomplished this feat, I was struck by how many of the elements of on-the-ground responsibility that Gawande espouses in his book were also integral to the success at Sentara Williamsburg. Notably, the impetus for this project didn’t come from some higher-level quality or performance improvement (PI) department, but from patient care providers themselves. A small group of nurses, respiratory therapists, physicians, dietary staff members, and pharmacists decided to form a council, listed a number of possible projects, and chose to tackle VAP. They created a plan, implemented it, and consistently evaluated it to make sure that it was: A) followed; and B) effective. By owning it at the “grassroots” level and educating other staff members to ensure they owned it, too, they were able to achieve significant results and solve obstacles they encountered.
Of course, you still need quality and PI departments. These departments often have the requisite clout, resources, and experience, as well as a mandate to make important changes in hospitals, and we’ve seen them be highly effective. However, if all of the innovation- and change-related responsibility is centralized in these departments – if they are the only ones empowered to take on problems and solve them – then care providers on the floor might abdicate responsibility. It can cause the classic “someone else will take care of it” mentality. In reality, these on-the-ground people often have the best view of what areas need change and how to get it accomplished. The flip side is that uncoordinated, independent players can create chaos. So developing a balance between grassroots and higher-level change is crucial, and can be accomplished through quality and PI departments actively supporting and encouraging grassroots-level innovation.
Karen Jorge is an analyst at HMC.
