40% to 60% of patients fail to receive appropriate care. What does Dr. Atul Gawande advocate hospitals and healthcare providers do differently?

Jamie Dimon, Warren Buffett and Jeff Bezos’ choice for their new healthcare venture firm‘s CEO is Dr. Atul Gawande.

This surgeon-CEO advocates the notion of “Pit Crews for Patients” (Medicine has become a team sport, TED Radio Hour, 2017), adoption of systems akin to Industrial Engineering Principles such as Standardization and Lean Six Sigma’s Mistake-Proofing, combined with Using Data, Execution Discipline, Culture Change, fostering Humility, Teamwork and Stakeholder Buy-In – to transform healthcare delivery effectiveness and reduce cost.

Revolutionizing healthcare systems requires adopting the notion of “Pit Crews for Patients,” according to Dr. Atul Gawande. The newly minted CEO urges a culture of cohesive and coordinated systems combined with utilization of checklists, discipline, humility and teamwork.

Forty percent of coronary artery disease patients receive incomplete or inappropriate care (How do we heal medicine, TED Talk, 2012). Sixty percent of asthma patients suffer the same fate. Two million patients pick up infections they didn’t have when they were admitted into the hospital. What can hospitals and healthcare providers do differently to improve the effectiveness and outcomes of patient care? Deploy the best technology? Perhaps hire the best nurses and physicians?

Nope. In fact, the principles and techniques Dr. Atul Gawande urges providers to consider adopting are quite simple in nature and have been tested. Dr. Gawande explains that our healthcare system culture has “hired, trained, and incentivized for (medical professionals) to be cowboys” (Medicine has become a team sport, TED Radio Hour, 2017). Clinical specialists (physicians, nurses, radiologists, physical therapists, etc.) have been trained and groomed to cultivate “daring, independence, and self-sufficiency” traits that they apply on-the-job while treating patients, he elaborates. This has consequences, Dr. Gawande tells us. Rather than the cowboy “trademark,” it is the notion of, “Pit crews for Patients” instead that our healthcare system needs, he explains. We also need an attitude change about cost, he said. Cost of patient care is rising at an unmanageable pace. Warren Buffett calls it the “tapeworm of American economics.” If left unmanaged in a purposeful manner and collectively, there will come a time in the not so distant future when cost of care will become inaccessible to even middle-income Americans, let alone lower-income wage earners. As cost of care rises, insurers and government agencies will require patients to pay more in deductibles and premiums. As medical out-of-pocket expenses put pressure on American families, more Americans will delay or refuse treatment and prescription drugs. Beyond increased numbers of uninsured and percentage of patients who delay or do not get treatment when needed, the National Bureau of Economic Research suggests rises in healthcare costs also adversely impacts wages and unemployment because every 10 percent increase in healthcare costs decreases wages by 2.3% and reduces probability of employment by 1.6%. (Effects of Rising Health Insurance Premiums, 2018).

Dr. Gawande, a surgeon himself, offers that a contributing factor to increases in healthcare costs is that healthcare professionals are not trained to be cost conscious. Their attitude towards costs can be characterized as nonchalant. The sentiment appears to be one of, “it is what it is,” “that’s just the way it is” and patient “care is complicated and, therefore, expensive.” This attitude is detrimental to our system and needs to change. Dr. Gawande believes between applying the notion of “Pit Crew for Patients” and changes in attitude towards healthcare costs as well as other techniques discussed briefly in this article, we can begin to move the dial on reducing healthcare costs as well as increasing the effectiveness and outcomes of care. This is the ethos Dr, Gawande espouses:

#1 – Recognize success and recognize failure
As a specialist, such as a surgeon, you can’t tell how successful the surgery outcome for your patient has been just by knowing that the patient survived your surgery. You must be interested in data for the whole value-chain process to understand the impact and outcome of your procedure. In one example he cited, a physician was stunned to learn that 50,000 MRI tests were run a year in a town of 300,000 residents. In another example, we learn a physician performed a procedure faster than the average but required a lot more resources than the average to perform it. Data is necessary to inform us of the effectiveness of the entire process and an accurate picture of the patient’s holistic experience, and the procedure performed by the surgeon alone is insufficient for us to make the right decisions to adequately impact the patient’s outcome, experience, and cost. You will also need a coach, he tells us (You want to get great…, 2017). As experts in our fields, we think we couldn’t possibly improve any more. This couldn’t be further from the truth. A good coach who observes your work live could point out things and habits you never knew you had that may require small tweaks for your performance to be elevated. Dr. Gawande uses himself as an example. At the peak of his surgical career, he asked himself, “Is this it? Is this the best I can be?” Then, he got a coach who pointed out actions that were barriers to his improvement. Hard as it was at first, he made the changes recommended by the coach and saw marked improvements in his performance. In business speak, we call this continuous improvement. In HR speak, we call it performance management. In process speak, we call it the “Gemba Walk,” as in walking the actual process to identify what works, what doesn’t, and what is waste that can be removed, and identify opportunities for process improvement. Whatever we call it, it is clear Dr. Gawande believes there isn’t enough being done to actively and purposefully identify and improve performance in the healthcare setting.

#2 – Devise Solutions
The second principle he advocates is to devise solutions comprising of a cohesive and coordinated system that utilizes tools like checklists for the entire process involved in delivering patient care. The system, Dr. Gawande explains, is a system of parts that come together and must work well by design and intent. He believes providers need to develop systems where “diverse people actually work together to direct their specialized capabilities toward common goals for patients. They are coordinated by design.” Think of a Pit Crew in NASCAR races. Races are won not only by having talented drivers. Race car owners and sponsors realize having top crew teams is a key to success. Heavy investments are made in a team’s training and equipping the crew. Excellent communication, teamwork and coordination are paramount to the best race team’s success. A good pit stop, run by a top-notch crew team, can make a difference as to whether their driver remains in the lead, according to Fox Sports (Pit Crews now key element to success, 2013). The best car and driver alone will not deliver coveted championships.

Incidentally, Dr. Gawande emphasizes all the same things – that a talented surgeon is insufficient to provide complete care. “Communication, teamwork and humility” are essential. America is obsessed with having the best technology. Having all the best healthcare technology, bells and whistles or the most expensive care are unfortunately not the ingredients for great care. In fact, having the most expensive treatment does not correlate to having the best care, according to Dr. Gawande. Herein lies part of the contributing factor to increasing healthcare costs. In our current system, we are quick to refer the most expensive treatment when in fact a simple and cheaper alternative may suffice. We equate expensive treatment with better treatment and this is not necessarily the truth.

The other part of devising solutions and effective systems is having tools like a checklist. Dr. Gawande drew inspiration from other industries with zero/low tolerance for safety defects, such as building skyscrapers and aviation for this next approach he advocates. Tools like checklists, he stated, help make experts and specialists better. In process engineering or Lean Six Sigma speak, we call this tool Mistake-Proofing. Designing checklists to deal with complex situations like administering care and treatment is more difficult than one thinks (How do we heal medicine, TED Talk, 2012). You have to think about Pause Points. What are they? They are moments in the process that you have to catch a problem before it becomes a danger and do something about it. In aviation, it’s called the “Before Takeoff,” Next, you have to think about the “Killer Items,” he says. This killer item checklist is not to guide you on how to perform a medical procedure but to remind you of the key things that get forgotten or missed if they are not checked.

By applying this principle, and creating a 19-item, 2-minute checklist that included pause points involving checkpoints “immediately before the knife hits the skin, before the patient leaves the room, and making sure antibiotics are given within the right time frame” (How do we heal medicine, TED Talk, 2017) and rolling out this checklist to several hospitals, from rural Tanzania to urban and city center locations, Dr. Gawande claims to have reduced complication rates (in surgical procedures) by 35% in every hospital. More remarkable was how surgical-related death rates fell 47% in every one of the hospitals, be it rural, suburban or city locations around the world. Even the simple things that we take for granted are on the checklist. The example he cited was one where everyone in the surgery room must take a moment to introduce themselves by name when they first get together, “to plan for the unexpected”, as he explains. Frequently individuals are assembled from various specialties and locations who have not worked together to perform a surgical procedure. In a high-intensity process where milliseconds during a procedure could mean a life or death situation, knowing who to call out for something that is needed in a split second is important. This, too, was on the checklist.

#3 – Implement the System
The ability to implement the system devised is equally important to the ability to develop the system. Why? Without implementation, there is no outcome. Implementation, however, is no easy task. That is why it needs emphasis. Why expect implementation to be difficult?

Implementing a system requires hospital administrators, physicians, non-clinicians and clinical specialists to embrace values that are different than those with which they were trained and told were important. Humility, discipline, teamwork are key to success (How do we heal medicine, TED Talk, 2012). In contrast, healthcare specialists, from surgeons to executives, nurses to physical therapists have been trained to develop and reward self-sufficiency, independence and autonomy, traits that are counterproductive to implementing an effective system. Implementing the system effectively requires good change management and “buy-in” skills. You need to get everyone that touches the entire value chain to be onboard, and you need to drive cultural change because shifts in attitudes are necessary to transform the system.

In a nutshell, healthcare providers must take simple but difficult steps to transform their delivery care system, lest a high number of patients continue to receive inappropriate or incomplete care, and healthcare costs continue to rise uncontrolled and our children and grandchildren and subsequent descendants fail to receive any kind of care because the price of healthcare has become something only the privileged can afford. To successfully transform your hospital or provider system, to increase effectiveness and efficiency while also reduce cost, Dr. Atul Gawande deeply advocates that you drive cultural change, foster a pact with the physicians, manage stakeholders and get “buy-in”, develop a standardized system and apply it with discipline. And make sure that system includes checklists.

1. How do we heal medicine? Atul Gawande, 2012, From https://www.ted.com/speakers/atul_gawande_1
2. Medicine has become a team sport – So how do we treat it like one? TED Radio Hour interview with Dr. Atul Gawande, December 2017
3. Pit crews now key element to success, Fox Sport, July 2013
4. Want to get great at something? Get a coach., Atul Gawande, 2017, From TED Talk https://www.ted.com/talks/atul_gawande_want_to_get_great_at_something_get_a_coach

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About the Author
Lilian is co-founder and Managing Director of aVM Health, a joint venture management and technology consultancy founded and managed by physicians, former hospital executives, health informaticists, advanced data analysts, technologists and former Tier-1 executive management consultants. Lilian has 20 years of executive and leadership experience advising Fortune 500 companies, SMBs and agencies in consulting and industry capacities. Her specialty includes process, operational and service excellence, transformation change, risk management, governance, technology and advanced analytics implementation and program management.


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