Should Doctors Wash Their Hands?

Doctors know they must wash their hands, right?

They do now, but didn’t before a Hungarian doctor discovered that germs carry diseases.

Dr. Ignaz Semmelweis is known as an early pioneer of antiseptic procedures for medical practitioners. He is called the “savior of mothers”, having reduced the incidence of puerperal (childbed) fever by discovering the need for and mandating hand disinfection in maternity clinics.

So what does the story of Dr. Ignaz Semmelweis has to do with operational excellence and modern methods for problem solving? Plenty! As the germ-disease-antiseptic story reads a lot like a DMAIC or A3 project plan. Read on if you are curious and have a strong stomach!

Semmelweis used to practice medicine in the Vienna General Hospital obstetrical clinic in the mid-1840s. Obstetric services were open to all at no cost in exchange for permission to be treated by training doctors and midwives. In fact there were two maternity clinics at the hospital, the first one with a mortality rate over three times higher than the second. This fact was well known in the city, to the point that women begged on their knees to be admitted in the second clinic, seeking to avoid a terrible fate in the first clinic. It is reported that some women would prefer to give birth in the streets before having to go to the first clinic.

The death of a medical friend who succumbed with symptoms similar to those of women dying of puerperal fever prompted Semmelweis to study the problem of fatalities in the first clinic in detail, launching a journey of discovery that is uncannily similar to the work done by Lean and Six Sigma practitioners – when they follow the methods!

Semmelweis got to find the facts behind his friend’s death. The first important discovery was that the dead doctor got sick after been poked with a scalpel by a medical student practicing the autopsy of a dead mother. This meant that bodies sickened with puerperal fever carried something that could kill healthy people like his friend. Semmelweis called them “cadaver particles” and hypothesized that they should be stopped from propagating from patient to patient, somehow. Recall that Louis Pasteur had not yet formulated the germ theory and causes of death were not understood scientifically at the time.

So Semmelweis has a hypothesis based on early observation and some facts; not unlike what we know at the start of a project and could write in a project charter.

But then the doctor has to confirm the route followed by the cadaver particles and find a way to stop them before they can kill one more patient.

To find the route of death, Semmelweis does something commonsensical which still has to be stressed in every class and which is seldom practiced to today: he walks along the doctors’ daily routine to find the sequence of tasks and observe their actions in context. Here is where you need the strong stomach!

Semmelweis knows that doctors begin their day examining the corpses of the previous night fatalities. So he “walks the process” or “goes to the gemba” starting with the morgue. There, in the early morning, doctors pull women’s cadavers to be studied, classified and catalogued for the record. What they find in victims of puerperal fever upon opening their bellies is a pool of pus that covers the internal organs, making it impossible to conduct autopsies without touching the foul-smelling substance. Once finished, the doctors wipe their hands and walk to the clinic to attend the day’s births. Semmelweis observes that the doctor’s hands still carry a bad smell.

The smell is the key! Semmelweis hypothesizes that the smell is produced by “cadaver particles” that carry death from the morgue to the birthing wing in the first clinic. If he can stop the smell perhaps he can stop this cause of death.

What do we call this in modern terms? Process mapping or at least walking the process. Importantly, Semmelweis notices the smell because he was there. Do you think he would have thought of asking a morgue doctor “how does it smell in the morgue?” Even more, do you think a doctor would have reported “the hands of doctors leaving the morgue smelled foul today”? Of course not! What do you expect in a nineteenth-century public morgue?

Semmelweis genius was that he did not “outsource observation”, he did not feel he was superior to data gathering and walking the process. Taiichi Ohno also used to walk to the place where a problem was happening to observe it in person, in context. Do not rely on reports alone.

We have covered the Define, Measure and Analyze phases of DMAIC and the A3 sections on the left: background, current state, desired state and analysis. Before finding the end of the story, let’s consider that Semmelweis faced other explanations and obstacles to his theory. Is this not like what most improvement projects face?

The current, accepted, situation was that the second clinic where midwives attended to births had the smallest number of puerperal fever deaths, followed by higher rates among women who gave birth in the streets, and even higher rates at the doctors’ clinic.

Semmelweis was very distraught by this state of affairs. It is unclear whether any other doctors felt that the mortality problem in their clinic demanded to be solved. He looked at various “explanations” for the increased mortality in the doctors’ clinic, discarding some like the weather (it was the same citywide), and religious beliefs (women of all beliefs died similarly). A leading explanation was that women died because they were seen by male doctors in a delicate state, that of childbirth, with tragic consequences. Worse, some observers had suggested that the problem could not be solved because each patient is different (has a different combination of the four bodily “humours”) and thus each cause of death is different, not comparable with any other and thus could not be treated in a generalized way.

Against this background, Semmelweis’ thinking breakthrough came when he hypothesized that there could be one common cause to all deaths, based on the observation of smelly doctors’ hands. This was the “root cause.” We are in DMAIC Analysis.

To stop the smell and thus the infection, Semmelweis instituted that doctors should wash their hands with a solution of chlorinated lime after autopsies and before examining patients in the maternity clinic.

Puerperal Fever Monthly Mortality Rates

As a result, deaths in the doctors’ clinic plummeted by 90% within one month and stayed low for the next year (see chart at top). This is the mark of a real solution: right on the mark, not too complicated, not far-fetched, and with rapid results. The solution was instituted in the clinic’s practices, becoming “business as usual” with the support of timely training. We are in DMAIC Improve and Control, or the “right side” of the A3 method, though there is no evidence that any sustaining (PDCA) tasks were carried later on.

What would have been the course of action based on early theories and false explanations? Bar doctors and only have midwives attend to childbirths? Wait until women became doctors in the twentieth century? Throw our arms up in the air defeated because each case is different and “it is what it is”?

Luckily for many mothers Semmelweis persevered and saved many. Lean and Six Sigma practitioners may not get to have such dramatic effects with their projects, but are confronted regularly with similar denial, superstitious explanations and put-downs. Follow the method, be persistent and be successful.

Success is short-lived without a theory – Semmelweis had to endure ridicule from the medical establishment because he had no acceptable explanation for the success of his method (no germ theory, remember?). We are better equipped than the good doctor, with a theory for problem-solving that has its origins in Shewhart’s work from almost 100 years ago and Deming’s principles tested over 50 years. The methods are your allies, do not by-pass or short-circuit them for the sake of expedience.

Regards,

Francisco

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