Improving Healthcare: Straight from the Heart | Sanjay Saint | TEDxUofM



I'd like to begin with a story and it happens to be true a young physician starts a job on a maternity ward in a famous European Hospital he watches young women who were previously healthy dying of overwhelming infection shortly after childbirth he's appalled at the high death rates which peak at fifteen percent in one year he investigates the problem comes up with a simple solution implements it on a small scale and sees a dramatic decrease in infection in mortality he tries to spread his simple solution elsewhere but for the most part he's ignored ridiculed and rejected he finds himself out of a job he goes to a different Hospital in a different European city confirms his findings tries to spread them and again is ignored and rejected he ends up dying at the age of 47 in an insane asylum thus ended the life of Ignacio Vice the famous Hungarian obstetrician who is known as the father of hand hygiene Semmelweis noted that when medical doctors who were coming from performing autopsies washed their hands with antiseptic solution before delivering babies the rates of infection and mothers in their death rate decreased by 9 percent credible consistently implementing evidence-based practices like hand-washing however remains a challenge even today this despite the fact that hand-washing is considered the most important way of preventing lethal hospital infections hospital infections affect about two million Americans every year a hundred thousand of whom die importantly 70 percent of these infections could be prevented if evidence-based recommendations were used so while on the one hand we have an explosion in biomedical research with novel diagnostic tests like functional MRI life-saving new drugs and robotic surgeries that are very high-tech what I'm going to talk about is decidedly low-tech something that we all learned the importance of in preschool and that's washing our hands we know that hand-washing prevents infection and we have known this for a century and a half my focus will be on what is preventing the widespread implementation of this and other practices that prevent Hospital infection studies have revealed that Americans and the receive recommended care about half the time even a hundred and fifty years after Semmelweis however another study reported that just 40 percent of health care workers comply with hand hygiene practices the rates are higher in nurses than they are in doctors and they are higher after touching the patient rather than before likely related to self-protection so despite knowing the importance of hand-washing for a long time why are doctors and nurses not washing their hands or put another way how can we change people's behavior so that the right thing is done each and every time a patient is admitted to the hospital our research has shown that there are several barriers to change one major hurdle is that health care workers often don't like to change behavior and in fact we call these individuals the active resistors they like doing things the way they've always been done why it's always been done that way and while there are some nurses in this category I have to say this is the purview of doctors at least the good news is is you know who these individuals are so you can engage them in a conversation because they'll raise their hand say I disagree I don't believe the data or that's not a problem in our Hospital the second group of individuals that serve as a barrier are people that are much more difficult to figure out who they are we call these individuals the organizational constipate urse they say the right things at meetings they nod their head in agreement you think they're on board with change but when it's time to act they're missing in action and the challenging thing about organizational constipate is that the people above them think they're doing a good job well the people below them can't believe they still have a job and while we know active resistors and organizational constipate ursa get exist in hospitals because we've seen them in action I suspect you see them in other areas as well higher education private industry as well as government more broadly however there's another barrier to change and that's a culture of mediocrity that exists in the hospital rather than a culture of excellence so what's a culture of mediocrity the hospital is happy to be average as long as their infection rates aren't too high they're okay organizational constipate are prevalent leadership is considered ineffective and over performers and over performers do exist in these hospitals are awarded their reward more work they have to do their job plus the job that the under performers are not doing because they're not being held accountable by ineffective leaders raise your hand if you currently or ever have worked in an organization that has a culture of mediocrity but 60% their sonar their with two hands up sometimes it can be difficult to detect underperformers but because a picture is worth a thousand words let me show you what a real-life underperformer looks like so this is my son Sean he will be graduating from the University of Michigan in 29 days but shown here he learned how to do something that he perfected while in medical middle school and that is and that is how to kick back and enjoy the ride so how do we overcome these problems there are many approaches but what I'd like to focus on is changing the culture through conformity and social learning conformity and social learning are universal I'm a member of many different groups many different cultures and each has elements of conformity and social learning first some definitions conformity just means that you behave in a way that the people around you are behaving and even though it has somewhat of a negative connotation I think conformity can be very powerful in changing behavior I'll show you how in a moment social learning occurs when the group's behavior becomes internalized by the individual and it becomes their own behavior and in fact this cultural transmission of behavior can be thought of is a second inheritance system behavior is transmitted from person to person but not through the genes or DNA but through culture let me share with you an example from the animal kingdom specifically related to monkeys in this study of a hundred and nine wild vervet monkeys the investigators did the following you should know that monkeys like corn so they call they took one color of corn which was pink and it was treated to taste bitter in two of the four groups the other color blue was left untreated and naturally tasty and the other two groups it was just reversed after six months the researchers returned and provided the two colors of corn to the various groups again this time all the corn was tasty the focus was on infant monkeys and immigrant monkeys and this is what they found the preference for the tasty color was retained even when both colors were untreated and tasted exactly the same infants never exposed to the bitter corn preferred the same color corn as their mothers and most interestingly males who migrated from a group where one color was preferred abandoned their previous preference and adopted the preference of the new group the monkeys acquired this new behavior through social learning another way to think about it monkey see monkey do the idea though social learning is something that happens every day and not just in experiments let me give you another example from the human Kingdom specifically my wife and her shopping habits so in Ann Arbor when we go grocery shopping we shop usually at one at one or two stores the first is Kroger and the second is Whole Foods so Kroger large discounted chain relatively inexpensive with no explicit focus on the environment Whole Foods on the other hand is an upscale chain euphemistic for expensive some people jokingly refer to his whole paycheck with an explicit focus on the environment and what I find really interesting is when veronika goes in to Kroger she thinks nothing of loading up the groceries into the environmentally unfriendly plastic bags but every single time she goes into Whole Foods it can be on the same day as the day we went to Kroger she brings her reusable bags same person same day acting differently so what's going on here I think has to do with culture not her culture but the culture of the stores which are very different when I'd asked her why she does this she said well if I don't bring my own bags into Whole Foods I get dirty looks and it makes me self-conscious from who cashiers the baggers the other customers so how can we use this idea of social learning to improve healthcare well I believe we need to create a culture so that we refuse to accept anything but the highest standard of care so that the only acceptable approach in a hospital or in a healthcare system is to treat a patient the way you would want your family member to be treated so that when a surgeon overlooks hand-washing before she examines a wound or a nurse forgets to wash his hands before inserting the IV catheter the people around them give them dirty looks and make them feel self-conscious that will change behavior so we've talked a lot about creating a culture of excellence but how is that reinforced and how is that maintained leadership is crucial since the culture of any organization is shaped by the worst behavior a leader tolerates if we let organizational constipated run rampant we shouldn't be surprised if the hospital gets even more backed up in leadership I realize is a top-down approach to behavioral change I'd like to now transition into a more bottom-up approach a more personal solution because grassroots changes usually happen when it becomes personal when we make decisions several times a day to behave differently more specifically I'd like to talk about mindfulness mindfulness has emerged as a popular concept but can it improve healthcare specifically can it help doctors and nurses remember to wash their hands before touching a patient perhaps mindfulness was introduced by Buddha 2,500 years ago when he said that all things are preceded by the mind the concept was popularized in the United States by John kabat-zinn in the 1990s who taught that mindfulness is the awareness that arises by paying attention on purpose in the present moment non-judgmentally and the thing about mindfulness fortunately is that it can be done all the time several times during a day like in the middle of a midterm examination on cognitive psychology or during a talk in front of 1300 of your new best friends or when washing one's hands before placing those very same hands onto a vulnerable patient importantly however when we talk about mindfulness and healthcare what we really are talking about is heartfulness which is a state of being in which kindness and compassion and connectedness to others helps guide one's life so how then do we kind of apply heartfulness to a busy hospital environment for guidance I turned to dr. Vitas non-abelian dr. Donna B daeun is known as the international leader in health care quality and he was a longtime faculty member here at the University of Michigan he in fact died in Ann Arbor of widespread cancer at the age of 81 and shortly before he died he was interviewed and he was asked how do you improve health care quality and dr. Don obedience said the secret to high quality care is love love for your patient love for your colleagues love for your hospital because if you have love you will work backwards to improve the system and if we had love we will wash our hands before touching our patient hands after all are meant to heal thank you very much you

10 Comments

  1. Great talk. In the 1940s, my father got an Academy Award for writing and directing a docudrama about Semmelweis. Medical history moves very slowly.

  2. HHS has confirmed that as of 2016 CAUTI rates have not decreased. This data was compiled 2009-2014, so the 25% that was targeted by HHS did not occur. Now HHS has set another target of 25% between the year 2015-2020, with 2015 being the data collection year to base the 25% target off. Dr. Saint I am sure is a wonderful well-intentioned individual who does champion better care. But when does he embrace "don't place catheters and get them out asap only goes so far" and there are times when one must look to other innovations??? I challenge anyone who knows the good Doctor to see if they can get him on the phone or email. It is a sad state when a man who is no doubt very smart will not embrace change that does not come from his facility or even worse from him. There is a saying doing the same thing and expecting a different outcome…. Nothing he suggest has changed over the 5 years…. Down here is Fl we are changing the CAUTI conversation, U of Michigan your double the CMS benchmark very sad 45 CAUTI events in 34,134 catheter days, benchmark would be 34 but why stop at benchmark right!!!! I wonder if the Doctor might want to explore a better solution to help patients. I will let all know I receive a call.

  3. It upsets me that in the year 2016 there was an entire lecture devoted to the importance of washing hands – and it wasn't directed towards children. The amount of infectious diseases spread simply by indiviudals not washing their hands is ridiculous! How can health care professionals not wash their hands as directed?! It's the FIRST health lesson taught in life, and then is taught countless times after that, with ANY health professions, not just doctors or nurses. Saint did a fantastic job of explaining the problem, and all of it's perpetrators. He also offered really solid solutions, which were simply enough for ALL health professional to follow and potentially make a difference. While I thought this lecture and Saint were great, I still just can't seem to understand why hand washing, or rather the lack of, is still this big of an issue.

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  8. Vintage Sanjay! Nice job. I would just challenge instead of mindfulness for hand hygiene that instead it become mindless, e.g. such an engrained habit you don't even have to think about it (like buckling your seat belt). This type of hardwired 'habit' is virtually impossible to 'undo' once it is stored deep in the brain. This also frees the brain up to complete more complex tasks. The problem is that for many healthcare workers hand hygiene is not one of their 'habits'.

  9. Great TEDx talk!

    "Kindness, compassion and connectedness to others help guide one's life"

    "The secret to high quality care is love. Love for your patient. Love for your colleague. Love for your hospital."

    "If we have love, we will wash our hands before touching our patient. Hands after all are meant to heal"

  10. "Hand are meant to heal"
    The great Sanjay Saint

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