Monday, December 12, 2011

Raising expectations in healthcare: Scotland NHS central line infections bottom out

All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.

     - Arthur Schopenhauer

My son and I were browsing through the electronics store yesterday.

He picked up an Amazon Kindle e-reader and tried to make the text scroll by touching the screen.  He was puzzled when it didn't work.  We discovered that this model had button controls.  That is so 5 minutes ago!

He's used to touch-screens through playing with his brother's iPod Touch and Grandma's iPad, so he's come to expect that every electronic device works that way.  It's like the classic scene in Star Trek IV, when the crew goes back in time and Scotty tries to use an early-model computer:

As Schopenhauer predicted, Scotty is ridiculed for having expectations (his "truth") beyond what was thought possible in that era.

Last week, at the IHI National Forum, I had my expectations raised by someone else's truth.

Jason Leitch, NHS Scotland's National Clinical Lead for Quality, gave an energetic presentation about Scotland's healthcare quality strategy and results.  One slide stood out.  It showed the drop in central line infection rates since 2008.  The March 2011 data point was annotated "zero central line infections in whole country".

Entire country of Scotland.  Central line infections. None.

It's like getting rid of polio or smallpox.

I was imagining what it must be like to be a physician inserting a central line, or a nurse caring for one, in Scotland.  The motivation to follow standardized protocol meticulously must be tremendous.  The country's reputation is on the line!  Expectations are sky-high.

What if patients and families in other countries found out that central line infections can be avoided?  If they got hold of Scotland's data and the care bundle they use, expectations everywhere would be sky-high.  Then, after the ridicule and opposition (from healthcare professionals), it would become self-evident that these infections are a defect in care, and not inevitable.

Central line infections - how quaint!


  1. Hi Kishore. You are right. A central line infection is preventable, manageable, and a true defect in our care. I'm pleased to be able to report that in Saskatoon's Intensie care units we have gone 15 months with Zero central line infections. Only three units (about 33 beds) but still evident that when you have a culture of safety an a commitment to standard work (both for insertion and maintenance) great things are possible. Now if we could only get ventilator associated pneumonia to zero..... But that's another story. We are working on it!

  2. Thanks, Susan. That's a fantastic achievement on behalf of your patients. Culture of safety + standard work = exceptional results. That's a powerful answer to those who deride "cookbook medicine".

    Any other organizations out there want to help raise expectations by sharing your results?

  3. Inspiring story and great local work Susan. What's unique about Scotland is not the achievement; it's the scale (country-wide). Scaling up is the great Canadian hurdle over which we seem always to trip and fall. At some point the protocol morphs from being optional to being mandatory, and somehow the resistance to standardization dissolves. How do they do it? Is it that Scottish accents are more persuasive than our dialect? Is it incentives, positive or negative? Is it competition in the best sense? Is the primary motivation excellence or the avoidance of shame? Or does it all come down to a culture that prizes achievement over autonomy?

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  5. infectious diseases are no longer in vogue - until the next big epidemic comes and then we see how ready they are