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In the mid-1800s, giving birth could be dangerous. Ignaz Semmelweis worked as a house officer in an obstetrical ward in Vienna, Austria, where nearly one-in-six woman died following childbirth. In the other obstetrical clinic he worked in, the maternal mortality rate was less than half that, at 7%. He began to wonder why there was such a discrepancy in the outcomes between these two clinics. Ignaz noticed that doctors and medical students at the first clinic were often coming directly to the delivery room after performing autopsies, even frequently with a “disagreeable odor” on their hands. He began to hypothesize that there may be “cadaverous particles” that could be transmitted by the hands of these physicians resulting in harm for birthing mothers. He recommended hands be scrubbed in a chlorinated lime solution before every patient contact. Of course, we all know what happened. Hand-washing resulted in the mortality rate in the obstetrical ward to plummet to less than 3%.1

The experience of Ignaz Semmelweis and others across the globe around that time showed convincingly that hand-washing could dramatically save lives. So, naturally every clinician immediately began washing his or her hands prior to every patient contact, right? Well, incredibly this is not what happened. Over the next 150 years there was slow incremental progress in achieving universal hand-washing practices. It turns out that changing behaviors, especially in the traditions of medicine, is very challenging. Even when there is a mortality benefit, the availability of convincing evidence is generally not enough to ensure widespread changes.

Only recently have hand-washing practices improved substantially in most medical centers. This has been achieved through multidimensional strategies that connect available evidence with accountability, such as flagging nosocomial infections and providing 360-degree feedback, as well as with systems that address barriers to hand-washing, such as removing the need for a sink by strategically placing alcohol-based handrubs in clinical areas.

As we have stated previously, “When it comes to reducing healthcare waste, we may still be in the equivalent of the mid-1800s; we have convincingly identified the problem and some are now shouting from the mountaintops for change. But much like hand-washing, we may need to do a better job thinking about how to make it easier to do the right thing.”2

Drawing on the lessons of hand-washing, our Costs of Care group has created a “COST” framework for designing multidimensional strategies to prevent harms from overuse: culture, oversight accountability, system support, and training. We introduced this framework in Chapter 11 in the context of educational efforts to teach value, but just as that discussion focused mostly on experiential learning and culture change, this structure also applies directly to implementation efforts. We believe that effective efforts need to target all four of these “COST” areas (Table 16-1includes a worksheet that can be used for designing interventions).

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