Tuesday, August 28, 2007

Tuesday column: The secret to saving lives is repetition, not keeping open small hospitals.

"There probably isn’t a single worker in an Australian or Japanese car production line who knows how to make an entire car, but each becomes particularly good at his or own specialised repetitive task."

So Kevin Rudd wants to take control of Australia’s 750 public hospitals.

It’s only a start.

Each year some 18,000 of us die in hospitals most of whom should not.

By comparison fewer than 2,000 of us die on the roads...

The 18,000 deaths, six out of ten of which were avoidable, were identified along with 50,000 cases of permanent disability in a landmark 1995 study that has not since been updated.

Ten years later in 2005 an editorial in the Medical Journal of Australia asked whether a decade on we could “confidently state that healthcare is safer for patients.”

It concluded: “Unfortunately, the answer is no. It is regrettable that we have not measured the frequency of adverse events in Australia in a way that allows us to assess how we have fared since 1995; how we compare with other countries; and whether any initiatives have been effective in reducing patient harm.”

The Foundation Director of the Monash Centre for Health Economics Professor Jeff Richardson describes the reported rate of preventable deaths in Australian hospitals as “equivalent to a Bali bombing every three days”.

Indeed he says we are probably justified in thinking about those deaths in the same way as we would casualties in a war. Some 50 Australians die in hospitals every day. Another 140 are permanently injured.

But in a war we would be galvanized into action. We would immediately identify the likely clauses and the likely solutions, not sit around and wait for the “confirmed, demonstrated cause” and a “solution based on professional consensus”.

More of Professor Richardson later.

In the United States a young surgeon named Atul Gawande has made a specialty of examining the sort of things that go wrong in hospitals. His books Complications (2002), and Better (2007) also examine what’s needed to put things right.

He says, contrary to what we in Australia might imagine from the “Dr Death” scandal in Queensland and the ACT’s own problems at the Canberra Hospital detailed in this morning’s paper, most of the unnecessary deaths in hospitals have nothing to do with “bad doctors”.

Only a tiny proportion of doctors have very high death rates, and only a tiny proportion have very low rates. The vast mass are about average. A statistician would say that the distribution of deaths is bell-shaped. Gawande says that the question isn’t “how to keep bad physicians from harming patients; it is how to keep good physicians from harming patients.”

He says to find out you need to examine what is different about the very small number of doctors and hospitals that have extraordinarily low death rates.

The answers would not surprise any one who has done an industrial economics course and would have come as no surprise to the father of the automobile production line –Henry Ford.

I’d sum them up this way: routinisation, repetition and extreme specialization.

Gawande says: “Consider a relatively simple surgical procedure, a hernia repair. A hernia is a weakening of the abdominal wall, usually in the groin, that allows the abdomen’s contents to bulge through. In most hospitals fixing it – pushing the bulge back in and repairing the wall – takes about 90 minutes and might cost upwards of $US4,000. In anywhere from 10 to 15 per cent of the cases the operation eventually fails and the hernia returns.”

“There is however a small medical centre outside Toronto, known as the Shouldice Hospital, where none of these statistics apply. At Shouldice, hernia operations take from 30 to 45 minutes. Their recurrence rate is an astonishing 1 per cent, and the cost of the operation is about half of what it is elsewhere. There is probably no better place in the world to get a hernia repaired.”

“What’s the secret of that clinic’s success? The short answer is that the dozen surgeons at Shouldice do hernia operations and nothing else. Each surgeon repairs between 600 and 800 a year – more than most general surgeons do in a lifetime.”

Gawande says the repetition changes the way they think. “The doctors at Shouldice deliver hernia repairs the way that Intel makes chips: they like to call themselves a focused-factory. Even the hospital building is specially designed for hernia patients. Their rooms have no phones or televisions, and their meals are served in a downstairs dining hall; as a result the patients have no choice but to get up and walk around, preventing problems associated with inactivity such as pneumonia or leg clots.”

As strange as it seems this kind or ultra-specialisation raises the question of whether better education - the Kevin Rudd catch-all for improving productivity in Australia - is even needed to preventing hospital deaths. Gawande says “none of the three surgeons I watched operate at the Shouldice hospital would even have been in a position to conduct their own procedures in a typical American hospital, for none had completed general surgery training. Yet after apprenticing for a year or so they were the best hernia operators in the world.”

He asks: “If you do nothing but fix hernia’s or perform colonoscopies, do you really need the complete specialists’ training in order to excel?”

The key to saving thousands of Australian (and US) lives each year may well be the same as the key to making defect-free cars. There probably isn’t a single worker in an Australian or Japanese car production line who knows how to make an entire car, but each becomes particularly good at his or own specialised repetitive task.

Applied to Australia Gawande’s insights would require us to travel longer distances to specialised hospitals, often interstate, not only us in the ACT but also for residents of the Northern Territory and Tasmania.

It most certainly would not mean championing the survival of small general community hospitals such as Tasmania's Mersey, which the Prime Minister has promised to keep open.

A few years back Jeff Richardson took time out from his duties at Monash to work for the Tasmanian government conducting the review that recommended that the Mersey be closed and its patients be directed to more specialised units.

His thinking would have been informed by what he knew about hospital deaths.

When John Howard announced the Mersey takeover at the beginning of this month Richardson described the move as vandalism.

He said, “I suspect that unless there is something we are not being told, Tasmanians will pay for that decision with their lives.”

The work of Atul Gwande provides a pointer as to why.