Dreaming the dream

Susan BoyleThe video of Susan Boyle’s debut on Britain’s Got Talent is well worth watching. She walked on stage, wearing a frumpy dress, overweight and awkward. Members of the audience snickered and rolled their eyes as this 47-year-old told the judges that she wanted to be a singing star. I suspect she had her own doubts. Yet she had the courage to try. She believed in herself and stunned the audience with her voice.

Susan’s story is typical of so many personal journeys. We face skepticism from others, and we are filled with self-doubt. Sometimes we listen to those little voices whispering: You cannot do this. Yet when we overcome the doubts, we are often successful. If we give into those voices, we will surely fail.

This same self-doubt exists in patient safety. I know because I had plenty of uncertainty about my ability to reduce patient harm. More than a decade ago, we decided to reduce central line-associated bloodstream infections on one intensive care unit. We doubted it was possible and whether we could have a role in reducing harm. Most of the physicians thought it couldn’t be done. Sick people get infected, they said. These infections just happen. In our own way, we felt frumpy and awkward.

Initially, we did not debate whether we could stop these infections. We focused on consistently following those practices shown by evidence to reduce them. We had been complying with those practices just 30 percent of the time. Our clinicians agreed that we would follow a checklist to help ensure 100 percent compliance and then see what happened to our infections. As compliance rose, the rates went to nearly zero, and the doubts disappeared.

As we spread this program around the United States and other countries, working with thousands of clinicians, we routinely see the same initial doubt in others. The ICU nurse manager in a small hospital wonders if she can implement a safety program there. The physician working in an academic medical center wonders if he can engage other physicians and hospital administration in the work. In all of these interactions, there is a crucial moment, a moment in which the light gets turned on or stays off, a moment in which they either believe that they can eliminate infections, or that they do not believe—and therefore will not reduce infections.

Much has been written about the power of checklists to improve safety, and many think that these tools are like an all-powerful magic wand. Yet for a checklist to be effective, it must be supported by social norms and embraced by a community that believes it can make a difference.

We learned about the power of social norms from a collaboration with Mary Dixon-Woods and Charles Bosk, sociologists from the University of Leicester (United Kingdom) and University of Pennsylvania, respectively. We conducted a study to evaluate why the bloodstream infection effort was so effective while most other large-scale quality improvement efforts produced disappointing results.

One of the main reasons for our success was that bloodstream infections came to be viewed as a social problem capable of being solved. We did not argue about which infections were preventable versus inevitable; to do so would distract from efforts to improve. (For most types of outcomes, we do not really know how often they are preventable, because most of the benchmarks are from less than optimal systems.) Only by assuming that all harm is preventable and working to make it so, will we really know how low harm can go.

Clinicians also felt empowered to make change, which often is not the case. Even though clinicians have the knowledge to improve safety, they are often frustrated because they are too often dismissed or not given the authority to improve. They don’t feel empowered to change the system. Patient safety will not be significantly improved by regulation or by insurers’ efforts alone, although they are both needed to ensure a baseline of safety for all. Success will also depend on efforts by clinicians who believe that they can stop harm from occurring and then act to make it happen

Susan Boyle elegantly sang “I Dreamed a Dream” from Les Miserables. Health care needs a revolution, and your patients are asking clinicians to dream the dream and reduce preventable harm. I hope more clinicians believe they can.

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