Tuesday, July 21, 2009

What Gets Measured Gets Changed

Virginia felt powerless. She was one of the first women to ever be admitted to the surgical residency at Columbia University in 1933. Always a trail blazer, she didn't quit when told by the chairman at the end of her residency that, as a female, she had little chance of attracting patients and having a successful career. He persuaded her instead to join the college hospital staff as an anesthesiologist. She dedicated herself to the job and became only the second woman in the United States to become board certified in anesthesiology. She was often quoted as saying "Do what is right and do it now!" In spite of all this success, she felt helpless to change a situation that almost daily broke her heart.

As an anaesthesiologist, she was bedside for hundreds of births and was appalled by the the care that many newborns received. In the 1930s, delivering a child was the single most dangerous event in a woman's life: one in 150 pregnancies ended in the death of the mother. As shocking as these statistics are today, the odds were even worse for newborns: one in thirty died at childbirth, scarcely better than a century before. Virginia saw babies born blue and left unattended to die. Babies who were malformed, small, or not breathing were listed as stillborn and simply allowed to die with no attempts to revive them. She knew in her heart that many of them could be helped, but as an attending anesthesiologist she had no authority to help them or change medical practice. She wasn't an obstetrician, and she was a female in a male dominated world.

Then she had an idea, an incredibly simple idea that changed the course of medical history. She developed a measure for nurses to rate the condition of babies at birth on a scale of zero to ten. An infant got two points if it was pink all over, two for crying, two for taking good, vigorous breaths, two for moving all four limbs, and two it its heart rate was over a hundred. Published in 1953 the score turned an ambiguous and intangible concept (the condition of an infant at child birth) into data that could be collected and analyzed. Nurses and doctors had to pay more attention to the condition of an infant to rate its score, and during this time many babies improved quickly with simple care. The measurement started being applied virtually world-wide one minute after birth and again five minutes after birth. If for no other reason than the competitive nature of attending physicians, scores began to improve and thousands of lives saved. Neo-natal units and hundreds of other transformational changes to infant care such as ultrasounds, fetal heart monitors, and spinal and epidural anaesthesia were developed over the years to improve scores.

And the results? Today a full term baby dies in just one childbirth out of five hundred, and a mother dies in less than one in ten thousand. To put this into perspective, relative to the statistics of the 1930s over 27,000 mothers and 160,000 infants lives have been saved. And it all started with a frustrated and heart broken doctor who decided to measure what had never been measured before. Virginia Apgar changed the course of medical history and saved thousands of lives with her simple but ingenious measurement, which became know world-wide as the "Apgar Score."

One cannot improve what one cannot (or chooses not) to measure. Often organizations put measures in place to gauge the effect of their improvement efforts. But many overlook the power of the measurement itself. Simply giving timely and accurate feedback to those who can affect change can transform organizations. Perhaps the health care crisis in which we find ourselves today could have been averted if similar measurements had been put in place for all surgical procedures and hospital administrators. Who knows, what we choose to measure today may change the world tomorrow...