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Highly suggest we discuss this as a community. Gawande highlights innovation from BRAC in discussion why some innovations spread quickly and others take time to reach full scale adoptions. Gawande's writing echoes your voices.

Sarah Kessler
Replied at 8:19 AM, 23 Jul 2013

I would be so interested to hear members' thoughts and experiences with this topic. It's certainly something Lifebox Foundation (which Atul Gawande chairs) is working through, in looking to implement the WHO Surgical Safety Checklist in low-resource settings.

The below video is from our project in Rwanda.

Attached resource:

Bistra Zheleva
Replied at 4:04 PM, 23 Jul 2013

Just chiming in to say that I can't wait to sit down and read it and will join the discussion in the next few days :).

Marie Connelly
Replied at 4:50 PM, 23 Jul 2013

Thanks for sharing this piece, Rebecca - it is (unsurprisingly) quite thought provoking.

While many of the more recent examples of innovation (and their paths to adoption) in the article came from low resource settings, I was struck by Gawande's analysis that:

"This has been the pattern of many important but stalled ideas. They attack problems that are big but, to most people, invisible; and making them work can be tedious, if not outright painful...Meanwhile, the carbolic-acid remedies to them, all requiring individual sacrifice of one kind or another, struggle to get anywhere."

Clearly, many of the issues we face in the health care system here in the US are plagued by similar challenges - the problems are not always well understood, and many stakeholders are highly motivated to maintain the status quo. Nobody wants to get their hands burned.

I was struck by the discussion of scalability in the piece as well. I think sometimes we have such a fascination with finding technology solutions to these problems that we can be blinded to the potential for solutions of a much different nature and scope - such as the development of a whole new professional class, like anesthesiologists, or Gawande's proposed "childbirth-improvement workers".

I was reminded of a similarly "high touch" program here in the United States that was featured in the Washington Post a few months back (article below). Health Quality Parters employs nurses to visit patients at home. These patients, typically older, chronically ill adults, receive a regular visit (weekly or monthly), whether they're sick or not. HQP has seen some success in reducing both hospitalizations and Medicare costs for their patients. Much like the example Gawande shares from the BetterBirth Project at the end of his piece, these successes seem to be a result of capacity building through "high touch" relationships and, ultimately, trust.

I hope everyone in the community will continue to share thoughts on why some innovations are adopted more quickly than others. If there are particularly innovative approaches that you're familiar with in the US, please help us highlight those in this discussion as well!

Attached resource:

Busi Mombaur
Replied at 6:23 AM, 24 Jul 2013

Atul Gawande's vivid description of the skilled birth attendant/nurse illustrates the importance of using what we already know to find solutions to re-align health delivery with care:

"As with most difficulties in global health care, lack of adequate technology is not the biggest problem. We already have a great warming technology: a mother’s skin. But even in high-income countries we do not consistently use it. In the United States, according to Ringer, more than half of newborns needing intensive care arrive hypothermic. Preventing hypothermia is a perfect example of an unsexy task: it demands painstaking effort without immediate reward. Getting hospitals and birth attendants to carry out even a few of the tasks required for safer childbirth would save hundreds of thousands of lives."

While the nurse was highly skilled and continued to do her heroic work under difficult conditions, it is quite possible that the baby succumbed to complications of hypothermia, something that may have been prevented by using a checklist, and perhaps insisting on kangaroo care. This is true for some hypothermic newborns arriving in ICUs in the US. We need to create a generation of specialists, primary care physicians, medical students, nurses, skilled birth attendants and community health workers who are "global health practitioners", practicing the principles that have proven to work in their daily lives as health care providers, whether it is using anesthesia or a checklist. It is these small steps, taken by millions of workers in the front line that will ensure that we achieve equity in health for all people worldwide. In addition to traveling across the world to work in a resource poor setting, or participating in a global health class in Boston, global health needs to start at home.

Bistra Zheleva
Replied at 1:50 AM, 25 Jul 2013

As usual, a great read.
I would add to the list of the "unsexy" tasks infection prevention. As he points out, hand washing is still an issue around the US. In the words of an infection control nurse I talked to recently, "most people don't want to talk to us and feel we only pester them". Sadly not much change in attitudes from the times of Joseph Lister.

A lot of what he discussed in the article is related to quality improvement. Yet, as far I am aware, QI methods are not consistently taught in medical or nursing schools. People can become QI experts by doing simple PDSAs but many don't even know what that is. We run into this in my work where we want our volunteers to mentor (another great suggestion by Atul Gawande!) health professionals from low resource countries in improving their practice and some volunteers can't suggest a process to do that. Lectures, reading and access to educational materials are not sufficient, people also need guidance, encouragement and periodic check ins.

The examples he gave confirmed my personal belief that relationships, or what he called the human touch, are what make or break outcomes. What that human touch ultimately creates are desire to improve, passion for one's work, desire to help, and confidence you can make a difference with a small change in your practice. It's like having a great teacher or professor who empowers you to pursue great things, or a supportive supervisor at work who allows you to learn and pushes you to create good ideas.

For better or worse, all this relationship and trust building takes time, so these kinds of changes are bound to happen slowly and we need to be better at managing expectations and at explaining it to all stakeholders, especially donors.

Richard Waters
Replied at 6:13 PM, 27 Jul 2013

Hi all,

Definitely a very thoughtful article. Similar to using "high touch" techniques to change the behavior/beliefs/norms of health care providers, the same strategy could be made for looking at the way the health system interacts with patients. We have all likely seen examples where there are a set of recommendations (typically with excellent intentions) made to a patient - maybe at discharge from an inpatient stay, or after a visit to a primary care clinic - but these recommendations don't get followed, or maybe only in part. Often not for lack of patient self-interest or self-care, but for a system that (similar to getting health care providers to change) hasn't used the right strategies to convey a message or promote change.

I can imagine a "high touch" system in primary care where, for example, after a patient & provider agree to start insulin, and after self-teaching in the clinic, a health care worker meets up with the patient for lunch the next day. Together, they check the glucose, work-through how much correction insulin to give in addition to the regular amount, practice administering it. Then again a week later. Then again. Only one example of many possible.

thanks for sending out!

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