Why the Michigan patient safety programme is so successful
4 July 2011
A team of social scientists and medical and nursing
researchers in the US and UK has pinpointed how a patient safety
programme dramatically reduced the rates of potentially deadly central
line bloodstream infections. The programme, which ran in more than 100
hospital intensive care units in Michigan, beame one of the world’s most
Funded in part by the Health Foundation in the UK, the
collaboration between researchers at the Johns Hopkins University,
the University of Leicester and the University of Pennsylvania, has
led to a deeper understanding of how patient safety initiatives like
the Michigan programme can succeed.
“We knew this programme worked. It not only helped to eliminate
infections, it also reduced patient deaths,” said programme leader
Peter Pronovost of the Johns Hopkins University School of Medicine,
who was named as one of Time Magazine’s 100 most influential people
in 2008 and was the recipient of a MacArthur Fellowship, or ‘genius
grant,’ from the John D. and Catherine T. MacArthur Foundation. “The
challenge was to figure out how it worked”.
The researchers found that one of the Michigan programme’s most
important features is that it explicitly outlined what hospitals had
to do to improve patient safety, while leaving specific requirements
up to the hospital personnel. A critical aspect of the programme was
convincing participants that there was a problem capable of being
“It was achieved by a combination of story-telling about
real-life tragedies of patients who came to unnecessary harm in
hospital, and using hard data about infection rates,” said co-author
Charles Bosk, a professor of sociology in Penn’s School of Arts and
Sciences and a senior fellow in the Center for Bioethics at Penn.
Infection rates were continuously monitored at hospitals
participating in the programme, making it easier for hospital
workers to track how well they were doing and where they needed to
The authors conclude that that there are important lessons for
others attempting patient safety improvements. Checklists were an
essential component, but not necessarily the most important element
of the Michigan programme.
“The programme was much more than a checklist,” said lead author
Mary Dixon-Woods, professor of medical sociology at the University
of Leicester, “It involved a community of people who over time
created supportive relationships that enabled doctors and nurses in
many hospitals to learn together, share good practice, and exert
positive pressure on each other to achieve the best outcomes for
“What we have learned is that it is the local teams that deliver
the results”, said Dr Bosk. “But they need to be well supported by a
core project team, who have to focus on enabling hospital workers to
get things right. That means providing them with scientific
expertise to justify the changes they are being asked to make, and
standardising measures so they are all collecting the same data.
"It also means trying to figure out why simple changes that make
life better are so difficult for healthcare delivery systems to do.
Getting the whole programme to work, rather than compliance with a
single one component, is the key to making healthcare safer for
“No one discipline has the answer to patient safety problems. We
have to bring together contributions from clinical medicine and the
social sciences to make real progress in this area” added Dr
Provonost. Last month, Dr. Pronovost was named director of Johns
Hopkins’ newly formed Armstrong Institute for Patient Safety and
Quality and senior vice president for patient safety and quality.
1. Mary Dixon-Woods, Charles Bosk, Emma-Louise Aveling, Christine
Goeschel, and Peter Pronovost. Explaining Michigan: developing an ex
post theory of a quality improvement programme. Milbank
Quarterly, June 2011.
2. The original paper: An Intervention to Decrease
Catheter-Related Bloodstream Infections in the ICU. Peter Pronovost,
M.D., Ph.D., Dale Needham, M.D., Ph.D., Sean Berenholtz, M.D., David
Sinopoli, M.P.H., M.B.A., Haitao Chu, M.D., Ph.D., Sara Cosgrove,
M.D., Bryan Sexton, Ph.D., Robert Hyzy, M.D., Robert Welsh, M.D.,
Gary Roth, M.D., Joseph Bander, M.D., John Kepros, M.D., and
Christine Goeschel, R.N., M.P.A. N Engl J
Med 2006; 355:2725-2732. December 28, 2006.
3. Checklists Alone Won't Change Health Care: The Full Story.
Peter Pronovost. Huffington Post. Feb 23, 2010.
4. Buy Peter Pronovost's book on the system: Safe Patients,
Smart Hospitals. How One Doctor's Checklist Can Help Us Change
Health Care from the Inside Out (can be delivered worldwide).