Dr. Peter Pronovost: “So much of this work that I’m doing now is relational. It’s about building trusting relationships, because change progresses at the speed of trust, and trust grows when we do things with rather than to people.” (Gus Chan, The Plain Dealer)The Plain Dealer
By Brian Albrecht, The Plain Dealer
CLEVELAND, Ohio — The ghosts of medical errors haunt Dr. Peter Pronovost.
Two deaths, both caused by mistakes. First, his father’s, who died as the result of a cancer misdiagnosis. Then a little girl, a burn victim who succumbed to infection and diagnostic missteps at the hospital where Pronovost worked early in his career.
Those deaths led Pronovost to pursue a medical career dedicated to patient safety, and to create the medical checklist he has become known for worldwide.
Now, he’s implementing his second act, at University Hospitals, as its chief transformation officer, a job he has held since late 2018. His goal: To transform a $4 billion health care system by reducing shortcomings in medical care and increasing the quality of treatment.
The challenge fits Pronovost, says one of his former Johns Hopkins University professors, Dr. Albert Wu. “He’s one of the few people for whom the title might be appropriate, because his work has led to significant changes and innovations in how we deliver health care in the United States.
“He’s a once-in-a-generation guy.”
“One of the lasting impacts of the work we did in infections [with the checklist] was to change the belief that harm was inevitable,” says Dr. Peter Pronovost, chief transformation officer for University Hospitals. (Gus Chan, The Plain Dealer )The Plain Dealer
Taking the harm out of health care
Pronovost appears younger than his 54 years; he’s a self-described wellness fanatic, who loves running, biking, hiking and lifting weights. He’s comfortable at the office in everything from a pink, French cuff, button-down to an open-collar, checkered shirt.
In conversation, he can link medicine with a seemingly disparate array of subjects: United Kingdom economics, the shared learning of birds, the autobiographical nature of a Picasso painting. And yet, somehow, it all makes sense.
People who know him use words like charismatic, passionate, gifted, caring and high-energy to describe a physician whose prescription for health care reform combines research, bottom-line statistics and an unabashedly fervent dose of love.
Pronovost earned the nickname Dr. Checklist for his pioneering work 19 years ago developing a simple set of mandatory steps to eliminate infections from catheter lines, which once killed from 30,000 to 60,000 patients in the U.S. every year.
He wasn’t the first to use a checklist in medicine. But he’s been recognized as being among the first to maximize its use to save lives.
The success of the checklist concept spread to other medical procedures and has since become an accepted standard of health care and patient safety.
“We’ve shown with the checklist that we can take one problem and reduce it by 90 percent across the country,” Pronovost says. “What I want to do is broaden that and say, ‘Could I now take one health care system and eliminate defects in value . . . so we make health care much less harmful, much more affordable and more patient-centered?’
“But just like we did in my prior role, I want to create a model at UH and share it with the world.”
And checklists are very much involved in his vision.
Genesis of the checklist
Preparation for Pronovost’s life’s mission began when he was growing up in Waterbury, Conn. He credits his parents, an elementary school teacher and a mathematics professor, with providing needed support and validation of his views.
Pronovost says his high school study of philosophers like Plato and Socrates inspired an interest in understanding systems.
“One of the things I enjoy is stepping back and saying, ‘OK, here’s all the levers, here’s how the system works. How do we begin to pull those levers to move the needle in a big way?’ ” he says.
Thinking bigger led to the creation of his first checklist, one that tackles infections resulting from central line catheterization.
The process worked, spectacularly, and hospitals in other states and abroad started using the checklist model, which was gradually applied to other hospital procedures.
One application of the checklist concept was developed for blood clot prevention by Dr. Elliott R. Haut, vice chair of quality, safety and service at Johns Hopkins’ department of surgery.
Haut describes Pronovost as “super energetic. He’s a big thinker . . . a broad, how-to-change-the-world kind of guy.”
Pronovost will quickly point out that checklists alone “aren’t Harry Potter’s wand.”
They have to be part of a broader program that includes setting goals, building an enabling infrastructure, engaging with frontline clinicians and creating accountability systems.
When the checklist team started in 2001, at Johns Hopkins in Baltimore, an emphasis on patient safety in medical training and treatment was just in its infancy, You couldn’t even mention “human error” in a medical setting, says Bryan Sexton, now an associate professor of psychiatry and behavioral science at Duke University, who worked with Pronovost.
“Then, here comes this guy who looks like a Ken doll, out of nowhere. He brought science to the table and made it easy to do the right thing,” Sexton says.
“Peter Pronovost provided almost like a list of to-dos to get where [patient safety] needed to go. He was the right person at right time for something that was sorely needed.”
Accolades and accountability
In the years after the checklist debut, Pronovost gathered an array of accolades as he continued working in patient safety.
Time Magazine named Pronovost one of the 100 Most Influential People in the World in 2008, and that same year he won a MacArthur Foundation “genius” grant.
In 2003 he established the Quality and Safety Research Group at Johns Hopkins, and later became head of its Armstrong Institute for Patient Safety and Quality.
“Peter was very effective in positioning his center [the Armstrong Institute] as being about innovation and research, but sufficiently connected to the [health care] delivery system to make the changes that are necessary. His center really got it right,” says Dr. Bob Wachter, a patient safety expert and professor and chairman of the Department of Medicine at the University of California, San Francisco.
“I consider him to be one of the most important forces of my generation in health care,” says Dr. Thomas Lee, chief medical officer for Press Ganey, a national health-care consulting service. “Getting people to use the checklist took a special mix of confidence and passion and resilience. He earned the reputation he has for being a real leader.”
Pronovost helped The Leapfrog Group, a national organization that monitors hospital performance and encourages patient safety, develop its Hospital Safety Grade and annual Leapfrog Hospital Survey programs, says Leah Binder, president and CEO.
“We track reductions in deaths, errors and accidents, and I can say that through Leapfrog, he has saved thousands of lives,” Binder says. “He holds health care accountable for its performance.”
Beyond the checklists
There’s another side to Pronovost, says his daughter Emma.
“A lot of people only see the professional side of him. I get to see the fun side. He teaches me lot about not taking life too seriously,” says Emma, 19, a sophomore at Tulane University.
Like during one of the family’s ski trips when her father, knowing her fondness for dance, started singing waltzes, skiing to the beat, as they sped downhill together, to make her laugh.
And no, he doesn’t make checklists at home. Emma says that falls to her mother, Dr. Marlene R. Miller, pediatrician-in-chief for University Hospitals and chair of the Department of Pediatrics at Rainbow Babies & Children’s Hospital.
Driven and dedicated are words Ethan Pronovost, 22, a software engineer in San Francisco, uses to describe his father.
The dedication extends beyond working hours. Ethan says his father is constantly “looking for opportunities to expand his horizons.”
At work, “he really enjoys the propagation effect. It’s not just him, directly doing it himself, but inspiring others, building this cohort of influence.”
Pronovost’s wife of nearly 24 years is also a quality and safety researcher and says her husband’s qualities as a researcher include being “methodical, persistent. He brings good ideas to the table and then helps, through good analytical approaches, to make sure we can actually know if that intervention makes a difference.”
When asked how he’ll meet his newest challenge at University Hospitals, she laughs and says, “He’s been pretty successful so far. I don’t see that changing.”
Transforming a system
Pronovost cited a quote by poet Emily Dickinson, “Hope inspires the good to reveal itself,” to open a recent meeting of the team of health care specialists who are helping him transform University Hospitals.
He used the quote to illustrate a story about a homeless woman who repeatedly came to a UH hospital emergency room to ask for food. Instead of turning her away, the hospital arranged to have social services bring food to her home and helped resolve her other problems.
“In so much of health care we live these extremes of humanity where we can see what could be despair and self-destruction, or you can see hope and beauty and love,” Pronovost said. “All of us have that choice every day . . . whether we go to the dark and see the despair, or whether we have the hope and see the dignity.”
That said, the meeting got down to the business of the job he was hired for.
Pronovost and UH CEO Thomas Zenty co-developed several goals for the hospital system after Zenty hired the doctor in late 2018.
Their objectives capitalized on trends and challenges in health care, including:
Treat more people on an outpatient basis.
Utilize new technology that enables an increasing number of patients to be cared for at home.
Enhance the value of treatment and services to be more cost-effective and quality conscious.
Pronovost brought several attributes to the job, Zenty says. “Peter is not just a theoretician, but he is also very practical in terms of finding better ways to care for the patients we treat.”
He also was impressed by Pronovost’s work as a practicing physician, which enhances his credibility among fellow doctors, Zenty says.
Pronovost says the first challenge to providing the highest-value health care was identifying defects and working with others to eliminate them.
“We want to develop a new attitude that defects aren’t inevitable, but preventable, and value is all our responsibility,” he says.
Instead of the past “whack-a-mole” approach of trying to resolve individual health care problems as they surface, Pronovost says they organized their goals into three general areas:
Addressing patients’ needs for regular doctor visits, getting needed immunizations and screenings, and developing healthy habits.
Helping people with chronic diseases get well by reducing the risk of misdiagnosis and needless hospitalization.
Improving acute-care management, such as coordinating hospital care with a patient’s primary physician, and reducing unnecessary procedures (as many as 30 percent aren’t needed, Pronovost says).
Weekly interdisciplinary team meetings were established to plan policies, programs and, yes, checklists.
“[Attendees] all have very specific goals on their checklists. [Such as] how are we implementing protocols to reduce the length of [patient] stay and complications? How do we put the right rules in place so people go home rather than to a [skilled nursing facility], and that they get personal care-physician follow-up?” he says.
Pronovost notes that as a result of new efforts “we had about 1,000 to 1,200 fewer people readmitted” to the University Hospitals system last year.
Pronovost also says: There was a 12% increase in patients returning home, vs. a skilled nursing facility, after hospitalization. Acute care costs decreased by 25%. And, personal care physician follow-ups for post-hospital treatment went from 2% to 69%.
In just over a year since he was hired, Pronovost says, “We’re maybe 15 to 20% deployed in building this web of eliminating all these defects.”
Pronovost is currently involved in an industry/government one-year Quality Summit to determine how to streamline programs administered by the U.S. Department of Health and Human Services to deliver a value-based care model. These programs include health care offered through Medicare, Medicaid and Veteran’s Affairs.
Part of that effort includes looking at the more than 2,000 measures the federal government uses to track health care quality. Pronovost says there needs to be a balance between unnecessary measures and those lacking in certain areas.
Additionally, Pronovost says, improving value in patient care and reducing preventable harm, the third leading cause of death, can trim health care costs, which run an estimated $3.5 trillion annually.
Pronovost’s program of value improvement and defect reduction at UH will probably take another four years to fully deploy, “and no doubt it will continue to get better and improve over time,” he says.
He hopes there will be a third act somewhere.
And would that involve checklists?
Of course it would.