What’s Your Improvement Mantra?

By Tom Best

Even if you’re not a football fan, you’ve probably heard phrases like these before:

  • Our team just needs to “get a win”, and we’ll turn this program around!
  • Let’s prepare for “one game at a time”, and in the long-run we’ll end up on top!

Successful coaches have used such phrases to make seemingly impossible goals feasible.  I’ve also found these two phrases helpful in guiding healthcare improvement efforts.

“Get a win”

While many projects require long-term effort to achieve sustained improvements, we sometimes undervalue the benefits of a short-term “win.”

I once worked with a hospital to increase the reliability of their med and lab specimen transportation system.  The bulk of items were transported via pneumatic tubes.  To the frustration of many, tubes were often unavailable.  Hoarding tubes at each care unit only seemed to make matters worse.  As a result, many had deemed this problem too difficult to fix. 

To start the project, our team decided that I set aside an afternoon to walk from unit to unit, releasing any stockpile of extra tubes back into the system (with help from unit management). 

As you might guess, I wasn’t too excited to build a reputation as the tube police.  But, you know what?  The effort served its purpose.  Although the improvements to tube availability were short-lived, a primary goal of our project became crystal clear to unit management after only one afternoon’s work. 

To sustain improvement, we implemented an annual education competency for all clinical staff on the proper usage of the tube system.  But the initial walkabout was just the “win” we needed to get improvement started.  It effectively communicated our long-term improvement goals, and demonstrated that we were going to address this problem directly.

“One game at a time”

Another project aimed to reduce the frequency of mislabeled lab specimens.  While the definition of a properly-labeled specimen was practically universal, each care unit had a different set of challenges impeding proper labeling.  It was next to impossible to recommend one solution for all units; previous efforts along these lines had not fixed the problems.

Our team decided that labeling procedures throughout the hospital should be addressed sequentially, group by group.  We first analyzed data to identify departments with a high percentage of mislabeled specimens.  We then started working with one department at a time.  We used a standard framework to guide our efforts (i.e. the SEIPS Model) but the details of the approach were dependent on the situational factors, such as the initial level of leadership engagement and the current state of the unit’s labeling process.  During these efforts, we shared our progress with the rest of the organization, highlighting the improvements that resulted in the areas we had visited.

There is a word of caution when applying the “one game at a time” mantra.  If misinterpreted, it can produce unsustainable improvements.  In our context, after moving to the next unit’s specimen labeling procedures, the team still needed to periodically circle-back with previously-visited units to ensure the problems were permanently fixed.  Revisiting an area can be done efficiently if standardized data collection and reporting mechanisms are in place.

In closing, “get a win” and “one game at a time” are just two mantras that apply across multiple industries. 

What other phrases guide your healthcare improvement work?

The power of a question

By Todd Schneider

Often in improvement work, we rely on Lean tools, Six Sigma methodologies, classic Industrial Engineering methods, etc.   However, perhaps we often overlook one of the most valuable skills of a change agent – Asking questions. 

Most often, improvement professionals are not the subject matter experts in the clinical or operational area in which they are improving.  This provides the perfect excuse to ask questions.  Sure, some questions are part of other tools or methodologies.  Obviously we ask questions when we apply the 5 Whys.  And it’s common to ask “what happens next?” when constructing a flowchart.  But do we ask the questions of “what if” or “why not” enough?  When done correctly, the questions asked are not so much for your learning, but instead to stimulate the group’s creativity and awareness.

 Several years ago, I was working with an organization that had been awarded a grant from the Robert Wood Johnson Foundation.  As part of the grant, the organization was provided technical assistance from the Institute for Healthcare Improvement (IHI).  One of the project teams was working to improve the care of the Acute Myocardial Infarction (AMI) patients, which typically present to the ER with chest pain.  At that time, there were two main goals the team was working to achieve: 1) Obtain an EKG within 5 minutes of arrival, and 2) Go to the Cath Lab and open the vessel within 90 minutes of arrival (commonly referred to as “Door to Balloon”).  We were reviewing this project with staff from IHI during a site visit.  During the discussion, Don Berwick, then President/CEO of IHI, asked a simple, yet important question.   “If I told you that a chest pain patient would arrive to the ER at 5:00 p.m. today, would you be able to meet the goals for Door to EKG and Door to Balloon?”  Almost immediately the team leader responded, “Yes, of course.”  Berwick responded, “Then go do it.  Get ready.  And if the patient doesn’t come at 5:00, keep waiting.  We know the patient will come.”

 The team did just that.  They figured out how to get the process right for that next patient.  That conversation was a pivotal turning point for this project team.  It helped them focus on how they could do it right once, and then figure out how to do that every time for every patient.  This organization went on to become an early leader in the care of the cardiac patient and several years later still referred to that moment as an important stimulus for their work.  It didn’t change their overall goal or even their general focus.  But it did re-frame the project, which allowed the team to look at the project from a different perspective.

By all means, we need to continue to use all the tools we have available, but we must not forget about the power of asking questions.  The questions may be simple; they don’t need to be complex or technical.  However, the questions should stimulate new ideas and help the team see the potential for new solutions. 

 Speaking of questions, have you asked a few today?

Patient safety: What if you can’t speak up?

Everyone in healthcare has stories of being silenced with a look or comment.  You need clarification, or think something might be wrong, and when you try to tell the physician, s/he snaps at you, or is sarcastic, or condescending.  In some cases, the physician may even be verbally abusive or threatening.  You quickly learn, at least with that physician, to keep quiet.   This can happen in any communication where there is a strong power differential:  between nurse or doctor and patient, between senior and junior healthcare professionals, between managers and their staff, etc. 

Still worse, many people have pointed out this situation to their manager or someone else in authority, only to be told to just deal with it, or to become labeled a complainer.  Or the manager may respond attentively and with concern, but then nothing changes. 

All of these situations work to stifle concerns healthcare professionals have about the quality and safety of patient care.  This is demoralizing:  your perspective is unimportant, you are not worth listening to.  You come to understand that the organization in which you work is not committed to quality and safety, but that the organization often chooses to protect the egos of powerful people (like physicians who are not employees but control a large revenue stream) over the safety of patients (and of other healthcare providers).    You are in a double-bind situation, and feel increasing stress and frustration. 

Yes, physicians are under tremendous pressure — but that’s when they are more likely to make mistakes, and more likely to need the situational awareness of the others on the care team to prevent these mistakes from harming the patient.  In a complex adaptive system such as healthcare delivery, where error-proofing is often not possible, we need to rely on the dynamic awareness of everyone involved in patient care to catch mistakes before they cause harm.  

Most physicians, and most managers and administrators, do not habitually intimidate people or dismiss their concerns.  But anyone can be under so much stress that s/he sometimes or occasionally responds this way. 

According to The Joint Commission, in Sentinel Event Alert Issue 40,

Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments.  Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team.

Intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. Intimidating and disruptive behaviors are often manifested by health care professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions. Overt and passive behaviors undermine team effectiveness and can compromise the safety of patients.  All intimidating and disruptive behaviors are unprofessional and should not be tolerated.
. . .
Several surveys have found that most care providers have experienced or witnessed intimidating or disruptive behaviors.
. . .
Organizations that fail to address unprofessional behavior through formal systems are indirectly promoting it.

Lucian Leape, in an article about problematic physician behavior, notes that:  “Performance failures of one type or another are not uncommon among physicians, posing substantial threats to patient welfare and safety. Few hospitals manage these situations promptly or well.” 

So what can we do?

At the organizational level, the Joint Commission has already required that hospitals set behavior standards and implement a process for managing disruptive and inappropriate behaviors.  It has also made a number of further recommendations, including training, contractual provisions, non-retaliation, and leaders modeling appropriate behavior.   

At the individual level, Maxwell et al. use positive deviance to identify what enables some people to successfully speak up in spite of an environment that is less than fully supportive.   These include:  work behind the scenes if the situation is not urgent;  avoid provoking a defensive reaction; keep your own frustration and anger in check; explain your intention to help the caregiver as well as the patient. 

As the organizational culture begins to change, scripted interventions may be very helpful.  In one hospital, “Doctor, I have a concern…” was used as an indicator that something might be going wrong, and requesting the physician’s attention.  If that didn’t work, the same person would follow up by saying, “Doctor, I have a patient safety concern.”  Regardless of whether the concern is founded or not, perspicuous or misguided, the physician or other caregiver who is being questioned should always thank the person who raised the concern, in order to encourage this behavior in the future.  (This can be very hard to do when the concern is unfounded, and the caregiver is irritated — but it is crucial to remember that this is how we prevent our mistakes from causing harm.) 

In your organization, do all staff members have the skills they need to speak up tactfully?  Will they be encouraged to speak up, and supported when they do so?  Are the behavioral standards applied equally to everyone in the organization?  “Respect for people” is a pillar of the Lean approach.  Are hospitals that have adopted Lean more likely to encourage and support speaking up? 

Reflections: Project ECHO, Quality and Leadership

By Alina Hsu

As I described in an earlier post, Project Echo is an innovative approach to delivering specialist care for complex chronic conditions to remote and/or underserved populations.  It has been shown to be as effective for treating hepatitis C as care in an academic medical center.

Primary care clinicians who have participated in this project with Dr. Arora are uniformly enthusiastic and personally grateful to Dr. Arora for enabling them to better care for their patients and for enriching their practice.  In a comment to a post on The Healthcare Blog, a community clinician remarked

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