Why the Michigan patient safety programme is so successful

4 July 2011

A team of social scientists and medical and nursing researchers in the US and UK has pinpointed how a patient safety programme dramatically reduced the rates of potentially deadly central line bloodstream infections. The programme, which ran in more than 100 hospital intensive care units in Michigan, beame one of the world’s most successful [1].

Funded in part by the Health Foundation in the UK, the collaboration between researchers at the Johns Hopkins University, the University of Leicester and the University of Pennsylvania, has led to a deeper understanding of how patient safety initiatives like the Michigan programme can succeed.

“We knew this programme worked. It not only helped to eliminate infections, it also reduced patient deaths,” said programme leader Peter Pronovost of the Johns Hopkins University School of Medicine, who was named as one of Time Magazine’s 100 most influential people in 2008 and was the recipient of a MacArthur Fellowship, or ‘genius grant,’ from the John D. and Catherine T. MacArthur Foundation. “The challenge was to figure out how it worked”.

The researchers found that one of the Michigan programme’s most important features is that it explicitly outlined what hospitals had to do to improve patient safety, while leaving specific requirements up to the hospital personnel. A critical aspect of the programme was convincing participants that there was a problem capable of being solved together.

“It was achieved by a combination of story-telling about real-life tragedies of patients who came to unnecessary harm in hospital, and using hard data about infection rates,” said co-author Charles Bosk, a professor of sociology in Penn’s School of Arts and Sciences and a senior fellow in the Center for Bioethics at Penn.

Infection rates were continuously monitored at hospitals participating in the programme, making it easier for hospital workers to track how well they were doing and where they needed to improve.

The authors conclude that that there are important lessons for others attempting patient safety improvements. Checklists were an essential component, but not necessarily the most important element of the Michigan programme.

“The programme was much more than a checklist,” said lead author Mary Dixon-Woods, professor of medical sociology at the University of Leicester, “It involved a community of people who over time created supportive relationships that enabled doctors and nurses in many hospitals to learn together, share good practice, and exert positive pressure on each other to achieve the best outcomes for patients.”

“What we have learned is that it is the local teams that deliver the results”, said Dr Bosk. “But they need to be well supported by a core project team, who have to focus on enabling hospital workers to get things right. That means providing them with scientific expertise to justify the changes they are being asked to make, and standardising measures so they are all collecting the same data.

"It also means trying to figure out why simple changes that make life better are so difficult for healthcare delivery systems to do. Getting the whole programme to work, rather than compliance with a single one component, is the key to making healthcare safer for patients.”

“No one discipline has the answer to patient safety problems. We have to bring together contributions from clinical medicine and the social sciences to make real progress in this area” added Dr Provonost. Last month, Dr. Pronovost was named director of Johns Hopkins’ newly formed Armstrong Institute for Patient Safety and Quality and senior vice president for patient safety and quality.

Further information

1. Mary Dixon-Woods, Charles Bosk, Emma-Louise Aveling, Christine Goeschel, and Peter Pronovost. Explaining Michigan: developing an ex post theory of a quality improvement programme. Milbank Quarterly, June 2011.

2. The original paper: An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. Peter Pronovost, M.D., Ph.D., Dale Needham, M.D., Ph.D., Sean Berenholtz, M.D., David Sinopoli, M.P.H., M.B.A., Haitao Chu, M.D., Ph.D., Sara Cosgrove, M.D., Bryan Sexton, Ph.D., Robert Hyzy, M.D., Robert Welsh, M.D., Gary Roth, M.D., Joseph Bander, M.D., John Kepros, M.D., and Christine Goeschel, R.N., M.P.A. N Engl J Med 2006; 355:2725-2732. December 28, 2006.

3. Checklists Alone Won't Change Health Care: The Full Story. Peter Pronovost. Huffington Post. Feb 23, 2010.

4. Buy Peter Pronovost's book on the system: Safe Patients, Smart Hospitals. How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out (can be delivered worldwide).


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