Challenging Arrogance, Autonomy, and Fear

Janice Simmons, for HealthLeaders Media , July 15, 2010
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Last year, more than 31,000 people died from catheter-related blood-stream infections in the United States. However, an ongoing six-year initiative with Hopkins and member hospitals with the Michigan Hospital & Health Association found that many of those deaths could be prevented by using checklists—along with a strong medical culture supporting their use.

The project became the first cited in a Department of Health and Human Services series of healthcare "success stories." The spotlight was placed on how more than 100 Michigan hospital ICUs partnered and saved over 1,500 lives and $200 million through efforts to eradicate catheter-related bloodstream infections.

While the checklist was an important tool in accomplishing this, the culture change was a major factor as well, according to Sam Watson, senior vice president of MHA Patient Safety and Quality and director of the Keystone Center for Patient Safety and Quality.

"It started with a basic understanding that everything we do is tied to a system or process. Everything. And, while that seems to be obvious now, six years ago we weren't talking that way," Watson says. "We began to look where there was potential for errors."

This meant the ICU staff would talk to each other each day about how harm could occur—and then how they could prevent it from happening to patients. "We do this with every project we do now," Watson says.

Also, senior leadership—including CEOs and CNOs—were encouraged to participate in safety rounds and attend team meetings—talking, for instance, about infection prevention or ventilator-associated pneumonia. "The people on the unit realize that this is important to the leadership of the organization, and that reinforces their behaviors," Watson says.

Ellen Wahl-Lenkevich, RN, who is CNO and senior vice president of patient care at the 187-staffed-bed Mercy Memorial Hospital in Monroe, MI, has seen changes in attitudes toward the checklist—and infection control—up close while her hospital participated in the Michigan initiative.

Six years earlier, when she was an ICU manager, she remembered trying using the checklist because her "boss told her to use it." At the time, she ended up with stares from the other nurses and physicians while at the bedside. But when the culture had changed—when all the frontline staff was responsible for following the checklist—people changed.

"It wasn't until you engaged that staff and started changing that culture that your outcomes changed because you then held each other accountable for improving the care that you're providing the patient," Wahl-Lenkevich says.

The effort has moved beyond the ICU, she adds. "The rest of the hospital is engaged with us. We have kits available with the checklist—so it's not another piece of paper that the nurse gets. It's really just what we do here when we put in invasive lines."

Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at

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