Assorted links

1) A high-tech substitute for the medical checklist.

Hat tip: Jason Bade.

2) Two manhole covers specifically for tourists. We could use these here in Chicago.

Hat tip: Danny Vincent.

3) More on the benefits of a nudge for long-term care insurance. The existing incentives aren’t strong enough to encourage long-term care purchases.

A decade ago, a handful of states—notably California, Connecticut, Indiana and New York—partnered with private insurers in an attempt to encourage people to purchase long-term care policies. As an incentive, these states allowed people to shield assets they might otherwise have to spend down in order to qualify for Medicaid. Since 2005, more than 30 states have taken similar steps.

Yet most observers have been disappointed by the results. “It’s not a model,” Feder says. “Even the most optimistic projections for the numbers of people it might cover over time don’t come remotely close to the coverage we have on health care—and we consider 16 percent uninsured a national disaster.” A 2005 study by the Congressional Research Service found that a majority of people who purchased these policies in California and Connecticut had more than $350,000 in assets—far more than the $55,000 held by the typical 55-year-old whom the program was hoping to reach.

4) The U.K. Natural History Museum has tacked on a voluntary tax-free donation of £1.50 to its £8 ticket price for online orders.

Hat tip: Jill Rutter.

5) Tweetwhatyoueat. Someone is really going to have to do a study on the effectiveness of all these twitter commitment strategies.

6) Don’t try to tackle all your new year’s resolutions at once. Spread them out over the course of the year.

Human routines are stubborn things, which helps explain why 88% of all resolutions end in failure, according to a 2007 survey of over 3,000 people conducted by the British psychologist Richard Wiseman.

Hat tip: Christopher Daggett.

Alternatives to the medical checklist?

In Maryland, state leaders recently kicked off a program that will send 45 teams of observers to 47 hospitals to record the hand-washing habits of doctors and nurses. Governing Magazine calls the teams, spies. They have to be anonymous in order to alleviate the potential Hawthorne effect.

So far, the medical checklist is the most successful and best known nudge for improving hand-washing habits in hospitals, but the program’s FAQ makes clear it is open to other strategies that include “campaign branding, addition of new members to the multidisciplinary HH (hand hygiene) team, hand hygiene education, signage, environmental enhancements, improved reporting process, new tool development, enhanced communications concerning HH, and others.”

A reader’s proposal for more consistent handwashing in hospitals

Reader Calvin Freeman wants to combine technology and a cliff notes version of the medical checklist to reduce infections in hospitals.

Use an infra-red beam across the doorway to activate a large silent Red Message that says “Please wash your hands” every time someone enters the room. The sign should be placed so that the person entering cannot miss it and that it is visible to patients but not intrusive enough to wake a sleeping person. The sign would nudge not only busy hospital staff, but also visitors.

What choice architects can learn from a new medical checklist

A new study on another medical checklist is out, this one conducted on noncardiac surgery in eight hospitals in eight cities around the world to ensure a diverse range of clients. As with the now-famous previous checklist – call it Checklist I – this one produced decreases in death and infection rates. What is most interesting about this checklist – call it Checklist II – is that is undercuts one of the supposed insights of Checklist I, namely that shorter was better.

Checklist II is long. Very long. Totaling 19 items. (Recall that Checklist I uses only six.) Does this mean checklist designers need not worry about keeping the number of items to remember to a minimum? Though it would tempting to draw this conclusion, it would be as foolhardy as pronouncing the absolute virtues of brevity based solely on the findings from Checklist I. What is more likely is that checklist length matters less than the overall environment in which each step is taken; the mechanisms in place for enforcing each step are what matter most. This enforcement is all the more necessary since human memory is not reliable enough to count on recalling every step. Indeed, the authors of the Checklist II study point out that, in spite of the medical improvements, “omission of individual steps was still frequent.”

Designers of Checklist II broke the 19 steps into three subcategories, administering the steps at different points in the surgical process. The number of steps and points of administration make the identification of key steps difficult. But the authors explain the overall choice architecture this way:

Use of the checklist involved both changes in systems and changes in the behavior of individual surgical teams. To implement the checklist, all sites had to introduce a formal pause in care during surgery for preoperative team introductions and briefings and postoperative debriefings, team practices that have previously been shown to be associated with improved safety processes and attitudes and with a rate of complications and death reduced by as much as 80%. The philosophy of ensuring the correct identity of the patient and site through preoperative site marking, oral confirmation in the operating room, and other measures proved to be new to most of the study hospitals.

After devising the steps, determining the appropriate points in the surgical process to implement them was the key challenge. For example, the designers encouraged administering antibiotics in operating rooms instead of preoperative wards, “where delays are frequent.”

The paper’s authors are unsettled about the potential of a Hawthorne effect – in which an improvement in performance is the result of doctors’ knowledge of being observed – in the overall results. At the risk of carelessness, for now, this concern is perhaps best left to the academics. Building in an observant whose presence leads to changes in behavior is a perfectly acceptable option for someone who is not so worried about the exact contribution of each casual mechanism. As social scientists know, even trying to isolate the effect of observation can be futile, for in some cases observation is one way to enforce particular social norms, making the combination of the two what influences behavioral change. So while the Hawthorne effect has confounded social scientists for years, everyday choice architects may need not worry so much. After all, the Hawthorne effect itself is just another nudge.

The secret to the medical checklist nudge

In the field of medicine, there is perhaps no better nudge than Peter Provonost’s medical checklist. Adapted from pre-flight preparations by airline crews, the medical checklist is a six-step set of routine actions for preventing Intensive Care Unit line infections that doctors may otherwise forget to do because of time constraints, stress, or distractions. The success of this checklist in Michigan hospitals has been well documented. After two years the checklist had prevented 43 infections and eight deaths, saving $2m dollars in costs. (The graph below comes from a lecture by former Congressional Budget Office Director Peter Orszag.)

Changemakers, an initiative by the non-profit social entrepreneurship group Ashoka, is preparing to launch a competition to generate medical nudges (more on that in a later post), and the contest organizers have selected the checklist as one of their case study examples. They remind us why the checklist is such a brilliant idea. It’s not the six simple steps. It’s the observing nurses who provide instant feedback ensuring that the medical checklist is followed.

Pronovost’s masterstroke came next: asking ICU nurses to observe doctors’ behaviors after the lists were posted. If they didn’t follow the list, nurses should intervene. Nurses were also to ask doctors daily whether lines ought to be removed, so as not to leave them in longer than necessary.

“When we first said it, the nurses said, ‘Hey, I’m gonna get my head bit off’,” recalls Pronovost. “And docs said, ‘You can’t have nurses second-guessing me in public’. So I pulled all the teams together and said, ‘Is it acceptable that we can harm patients here in this country?’ And everyone said, ‘No’.”…

(Provonost) made the nudge public – involving nurses and reframing the issue as one about harming patients, not authority, Provonost created a cultural shift, empowering everyone in ICU to nudge each other toward right choices to preventing infections.

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.