Medical checklist

Joseph Simmons of Yale’s School of Management points to a nudge from Atul Gawande’s New Yorker piece that reduces doctor error in treating hospital patients. Because a single patient’s medical care can require hundreds of decisions each day, some doctors and hospital administrators have experimented with using checklists for certain treatments. The checklists contain simple, routine actions, all of which doctors learned in medical school but may simply forget to follow because of time constraints, stress, or distractions. For instance, the checklist designed by a critical care specialist at Johns Hopkins Hospital for treating line infections includes the following items:

(1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in.

Johns Hopkins’ doctors were stunned by the results from the line infection checklist.

The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from eleven per cent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs.

The checklists provided two main benefits…First, they helped with memory recall, especially with mundane matters that are easily overlooked in patients undergoing more drastic events. (When you’re worrying about what treatment to give a woman who won’t stop seizing, it’s hard to remember to make sure that the head of her bed is in the right position.) A second effect was to make explicit the minimum, expected steps in complex processes. (The critical care specialist was) surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions. In a survey of I.C.U. staff taken before introducing the ventilator checklists, he found that half hadn’t realized that there was evidence strongly supporting giving ventilated patients antacid medication. Checklists established a higher standard of baseline performance.

NFL Draft 2008

We recently received an email suggesting that the number of offensive and defensive lineman taken in this year’s first round of the NFL draft was higher than in recent years. Taking a quick and crude look back at first round selections from 2000-2008, teams did select more linemen this year, 15, than in recent history. However, that number is within two standard deviations of the mean for those eight years – 11.12 with a standard deviation of 2.3 – so it would be hard to say that this year’s draft was a substantial outlier.

The graph of first round draft picks is posted below. Picks were divided into four categories: 1) Quarterbacks; 2) Linemen (offensive and defensive); 3) Skill positions (running back and wide receiver); 4) Defensive backs, linebackers, and tight ends. Kickers were excluded. There don’t appear to be any major surprises or conclusions to be drawn from these trends. All of the picks trade within relatively narrow ranges, and there are no extreme values for any of the four categories.

A reader reacts to the slippery slope problem

Reader Phil Armour, a 23-year-old economics major who says he has been “interested in Behavioral Economics and Asymmetric/Libertarian Paternalism” for a quarter of his life offers some intelligent commentary on the slippery slope problem. Bans and mandates should be absolutely prohibited, he says.

Continue reading the post here.

Default rules for social networking sites

Over at Freakonomics, Daniel Solove, author of The Future of Reputation, muses about default settings and social nudges to help protect online privacy. An excerpt:

Q: You say the design choices of websites and their default settings have an enormous impact on privacy. Can you suggest a way a current website might be changed to improve privacy along these lines?

A: Many social network websites are set up with a default setting that makes information fully available to the public. This is the easiest setting, and many people just go with the default.

Social network websites are also not very nuanced about how they categorize relationships — the world can’t easily be divided into friends and not-friends.

Off-line, we have a myriad of different types of relationships — each with very different norms of information sharing. But social network websites have a simpler, more reductive typology of relationships, and as a result, people wind up sharing information with others that they might normally not share information with.

If sites were structured to set the defaults toward making disclosure more restricted, it would help matters quite a bit — and make people think before exposing information to the entire world.

Thaler on Tavis Smiley’s PBS show

Richard Thaler appeared last week on Tavis Smiley’s PBS show. You can listen to the interview here. Tavis brings up a nudge at McDonald’s.

Tavis: I think of a friend now who may be watching who is a McDonald’s franchisee. He owns a number of stores. I remember being in a conversation not too long ago. He, of course, is no behavioral scientist. He’s an entrepreneur, but he was expressing to me one day his surprise at how, when inside the store they put up the special, you’d be amazed, he said to me, at the number of people who, when they get to the counter, came to get one thing, but we nudge them to buy this because they see that today, Wednesday, is the two cheeseburger special. You put it in front of them and you nudge them toward it and they go for it.

Thaler: Well, you know, one of the things that makes nudges work is just getting peoples’ attention.

How many mortgage problems could have been helped with RECAP?

Barbara Kiviat, at The Curious Capitalist, suggests using Nudge’s RECAP (Record, Evaluate, and Compare Alternative Prices) idea as a way to help customers understand complex mortgage agreements. RECAP would not allow the government to set the price for service charges; it would only require their disclosure. It’s goal is to increase information availability and awareness among consumers.

For mortgages, lenders would be required to provide a spreadsheet, too. It would break down the cost of a mortgage into two categories—fees and interest—and it would also, importantly, provide a digital interface for third party vendors to come along and sell comparison services. Similar to what Morningstar does for mutual funds. With downloadable data, third parties could create systems to flex the assumptions behind a mortgage (how much interest rates will go up; the year you go to sell your house), and then help you make a better decision about which sort of loan to pick. There could also be some sort of worst-case scenario feature. That would have been handy.

A parking meter that warns you when time is about to expire

Duncan Solutions offers a parking meter than sends a text message to your cell phone 10 minutes before your meter time expires, and gives you the option of purchasing more time by making a cell phone call.

The company also sells meters that allow users to pay by credit card. This option, it says, actually increases the amount of revenue a city generates through parking fees. “We’ve found that people paying the meter with coins tend to pay the minimum or with whatever coins they have readily available. But, with credit cards, people tend to put in a lot more, generally the maximum. Our current average credit card transaction is $2.22. But, our average coin transaction is only 74 cents,” reads a company brochure. So far, these meters are up and working in Las Vegas.

Default deliberation and charity on your laptop

Cass Sunstein, in places like Republic.com (and Republic 2.0), has argued that healthy democracy requires healthy deliberation. The fractionalization of media outlets has made it easier (and cheaper) to acquire information from a wide array of viewpoints, and increased the amount of information potentially available to anyone with a computer and an internet connection. But media fractionalization has a downside. It can encourage echo chambers and group polarization that ultimately harm a deliberative process.

How to foster deliberation is a huge question with many answers, but one place to start is by thinking narrowly about fostering deliberation electronically. How would online media consumption patterns change if desktops and laptops came pre-loaded with a range of blogs and traditional media sites? Currently, if you buy a computer from, say Dell with Windows Vista, Dell sets its web site as the homepage and provides a special favorites folder with links to all of Dell and Window’s technical sites. In another favorites folder, it would be easy enough to pre-load a set of links to liberal and conservative news sites and blogs (Daily Kos, Townhall.com, National Review, the Nation) as well as traditional mainstream media publications (Washington Post, New York Times, Wall Street Journal), as a kind of deliberative public forum. Certainly all of these sites are easy to find online, but would a new set of bookmarks organized coherent in a separately labeled folder tempt people take a peek? Or since they could be deleted with a single click, would they be discarded or simply ignored?

Beyond deliberation, a computer manufacturer could partner with a few charitable non-profits and set the home page each new computer built that month to the charity’s site. Over a year, there could be one charity for each month, perhaps. The computer company could set the computers to reset to their homepage at the end of 30 days.

Deliberation failures

Cass Sunstein and Reid Hastie of the University of Chicago Graduate School of Business have a new working paper titled “Four Failures of Deliberating Groups.” Here is the abstract:

Many groups make their decisions through some process of deliberation, usually with the belief that deliberation will improve judgments and predictions. But deliberating groups often fail, in the sense that they make judgments that are false or that fail to take advantage of the information that their members have. There are four such failures.

(1) Sometimes the predeliberation errors of group members are amplified, not merely propagated, as a result of deliberation.

(2) Groups may fall victim to cascade effects, as the judgments of initial speakers or actors are followed by their successors, who do not disclose what they know. Nondisclosure, on the part of those successors, may be a product of either informational or reputational cascades.

(3) As a result of group polarization, groups often end up in a more extreme position in line with their predeliberation tendencies. Sometimes group polarization leads in desirable directions, but there is no assurance to this effect.

(4) In deliberating groups, shared information often dominates or crowds out unshared information, ensuring that groups do not learn what their members know.

All four errors can be explained by reference to informational signals, reputational pressure, or both. A disturbing result is that many deliberating groups do not improve on, and sometimes do worse than, the predeliberation judgments of their average or median member.