Lay of the Land

As I mentioned last time, when we decided to rejuvenate our office improvement work, we wanted to address issues more broad than access to urology consultation.  Urology Associates QI 1.0 – focused on access - had many successes including pooled referrals, improved communication with referring physicians, and reducing unwarranted practice variation.  But, we didn’t sustain the process. 

While we’ve continued to pick away at smaller QI initiatives in our practice, we needed to get back to a formal QI process lead by a core team.  We did not want to fall off the wagon again.  Helping us on that path was the task we set for our new QI coach, Katherine Stevenson, principal of The Groundwork Strategy.  (Disclaimer: Katherine and I co-teach the Canadian Medical Association’s Physician Management Institute course “Prescribing Quality Improvement”.  Like I said in the last post, “Right under our noses…”)

While many of the broad strokes of the process Katherine has lead us through are similar to our initial Advanced Access work (e.g. form a core QI team with staff and physician members, regular meetings, document our work, communicate with the other stakeholders), I see many contrasts.  The Advanced Access project came with a preset goal: Improve access to urology care.  With our QI reboot, Katherine suggested that we look at our entire office system before deciding what was the most pressing need. 

This involved surveys and in-person interviews of every urologist and staff member.  We were asked about our impressions of how our system was working, what frustrated us and what we’d like to see improved.  This step had to be performed by someone from outside our office.  Aside from the time and expertise needed to conduct these interviews, it was apparent that uneven power dynamics between physicians (employers) and staff (employees) would make free discussion of at-work frustration difficult, if we tried to carry out the interviews on our own. 

Among the several common themes that Katherine extracted from the interviews, virtually everyone mentioned problems with office communication.  There was frustration and uncertainty around communication between staff and physicians, between staff and patients, and between physicians and patients.  Physicians weren’t sure which staff member was responsible for specific tasks (e.g. booking tests, arranging appointments, billing for procedures), and this lead to a lot of variation in how each of us would assign those tasks.  Staff felt that a lot of time was taken up by answering phone calls that could be dealt with by other means (e.g. office address or fax number, or appointment confirmations).  Physicians felt that staff could deal with many requests that were currently addressed by asking the physician to return the patient’s phone call (e.g. normal test results).

My observations about these discoveries:

-       Leaders shouldn’t presume that everyone in their organization shares their view of the most pressing issues in the workplace. 

-       Medical office staff and physicians don’t necessarily understand the challenges of each others’ work

-       Small, repetitive annoyances can weigh heavier on us than “big ticket items” like improved access to care

-       We had found common ground between staff and physicians.  Perhaps this was a topic that would get our QI work going with a quick win that would improve work life for everyone.

Before we could start with improvements in office communication though, we needed a robust process for our core improvement team. 

What makes a good QI coach?

Give a man a fish and he eats for a day.

Teach a man to fish and he eats for a lifetime.

Show a man how to use a phone and he can order pizza.  Who wants fish everyday?

How do you go about selecting a quality improvement coach? 

A coach could be a mentor, guide, cheerleader, or teacher (and probably all these at different times).  The origin of the word gives insight into its true meaning.  “Coach”, in its original use, refers to a carriage or means of transportation.  Later, it referred to someone who helped students (or, carried them) through exams.  In both usages, a coach helps someone reach their goal. 

I distinguish a coach from a consultant.  I see a consultant as someone who assesses the problem and prescribes a solution.  We were interested in working with someone who could help us develop (or rekindle…) an independent capacity to identify and solve the problems in our practice.  Also, we wanted to develop a sustainable quality improvement process.

While we wanted someone to help us eventually develop our own capacity, we recognized that this coach would likely need to do some of the initial diagnostic work to jumpstart the process.

In retrospect, after having been in the coaching process for almost 9 months now, I judge the 2 key qualities of a QI coach to be patience and breadth of experience.

Novices make mistakes; it’s a powerful way to learn.  The coach may be tempted to curtail exploration and experimentation, intending to speed the journey along.  Feeding the student the “correct” answer may shorten the process, but deprives him of the experience of understanding what doesn’t work.  This is particularly important in QI work where the solution(s) may not be known and experimentation (PDSA cycles, action research, etc.) is the only way forward.  An experienced coach may have seen certain initiatives fail in other settings, but must be patient in allowing students to conduct learning trials and develop their own understanding about what works in their system.

The coach’s patience was particularly important as we started to rank the importance of problems areas to be improved.  I suspect our coach had preferences as to which improvements would have the greatest impact on patient, staff and physician satisfaction, but kept quiet about it.  Instead, we were shown methods to reach a consensus around which projects were our priorities.  This has been an important factor in maintaining enthusiasm around the work: The projects we’re working on are meaningful for us, not ones foisted on us from outside.

This relates to the “give a man a fish” aphorism that I tweaked at the start of this post.  The kernel of wisdom in the original saying is very much the philosophy of coach over consultant.  A consultant may give you the fish/answer, whereas a coach will show you how to get the fish/answer for yourself.  I think the next step in QI independence and sustainability is to give the team the tools to decide what they want to have for dinner.  And that means the coach has to give up control of the direction of the work.  Therefore, we wanted a coach who was not personally invested in “fish for dinner”, i.e. a predetermined direction that our QI work would take. 

A coach’s breadth of experience is important when the QI team wants to develop an independent, sustainable capacity.  This relates most closely to the common use of “coach” in athletic training.  Athletes who specialize in a particular event seek out coaches with expertise in that area.  A specialized coach may help elite athletes reach their potential in individual events, but these athletes may not have well-rounded fitness, may be prone to certain injuries, or find that they cannot sustain that level of training in the long-term.  A particular training technique may work for some athletes, but a coach who is familiar with a variety of techniques will be able to help many athletes achieve their goals. 

In Saskatchewan, our health system has adopted Lean as our quality improvement system and is investing heavily in training providers and administrators.  I’m excited that we have a consistent method to guide our QI work.  At the same time, I’m conscious that “when all you have is a hammer, everything looks like a nail.”  Lean may not be the right hammer for all our nails.  Rather than signing up our QI team for Lean training, we decided to take a non-denominational approach that would let us pick and choose from various QI models.  That required a coach with broad exposure and experience with different QI systems.  Also, we wanted to start our QI work immediately rather than spend weeks in formal training.  This approach demanded a coach who was confident and expert enough to give us just-in-time training as we proceeded.

Whew! That is a tall order for a QI coach.  Where would you find such a person?

Right under our noses…

A new beginning

It’s difficult to tell this story.  It’s a story of failure and disappointment.  It’s about letting people down.  I only have the courage to tell it now because it is also a story of learning and inspiration.  I think it will have a happy ending.

The tenacious few who have followed this blog from the beginning know that it started as a record of Saskatoon Urology Associates’ work to improve patient access to specialist consultation.  Starting in 2007, with support from the Health Quality Council, we learned about, and applied the Model for Improvement.  We implemented pooled referrals (centralized referral intake), reduced our missed appointment rate, and requested standardized referral information from family physicians.  We discovered the ubiquity of practice variation in our group, began to discuss the reasons behind variation, and then agreed on best practices. 

At its nadir, our average consultation wait time was one month – down from 4 months or longer.  Even though we never reached our original target of 2 weeks, we were very pleased with the process and results.  Then, circumstances changed.  Wait times ballooned.  The frustration that sparked our work in the first place was back.

Our urologist manpower has changed significantly. Early in our improvement work, we had 8 full-time urologists.  Due to retirement and semi-retirement, we now have 6.5 full-time urologists.

How we distribute work has changed over the last 3 years.  The Saskatchewan Surgical Initiative has focused attention on surgical wait times, that is, the time patients wait from being booked to having the procedure performed.  The initiative has been hugely successful in reducing the surgical backlog.  And how do you reduce a backlog?  Hard work, i.e. more surgeons in the operating room more often.  This has taken us away from seeing patients for office consultation.  Predictably, our patients’ wait time for surgery has dropped, but wait time for consultation has burgeoned.

We’ve seen this happening over the last 2 years.  It meant that we started to see (again!) all the phenomenon that go along with long wait times: more calls from patients and referring physicians, referring physicians sending repeat consult requests detailing worsening of patient symptoms, and more urologist effort into triaging consultation requests.  Long wait lists make more work for everyone.  Most disheartening are the comments from family physician colleagues: What happened to you guys?  I used to tell my patients that you had done such a good job of reducing your wait times.  Now I don’t know what to tell them about how long they’ll wait to see you!

We were frustrated by the poor service we were providing to patients and referring physicians.  We regularly griped to each other about it.  The situation was very similar to the one we found ourselves in back in 2007 when we started our improvement work.  The difference now was this: We knew that positive change was possible.  We had experienced the Model for Improvement and had success with it.  We knew we weren’t powerless.  And so, last October, our docs got together to document our concerns.

Rather than jump back into the game with the sole goal of reducing our consultation wait times, however, we decided to look at all the areas of our practice that we were dissatisfied with.  Each urologist recorded 2 or 3 problems on sticky notes that we grouped into themes.  We did a second round of this after major themes had been identified.

It was a long list with some of the main themes being:

• workload/workflow processes
• human resources (lack thereof)
• quality improvement
• partner communication
• office practice management

But, the biggest thing to come out of that meeting was an agreement that we wanted to revitalize our quality improvement commitment and that we needed help to do it.  We needed someone to show us how to get back on track and how to create a sustainable system of improvement.  We needed a quality improvement coach.

We hired one!  And that starts a new chapter in this story.

P.S. Thanks to Greg, Kunal and Katherine for encouraging me to start telling our story again – warts and all.

I get it! I'm a fish! - Communication as a prerequisite to improvement

I had an interesting conversation last week with someone who shares my enthusiasm/impatience to move ahead with health system improvement.  He offered me a new perspective on a point that has been frustrating me for years, that is, we seem to be able to make fairly rapid improvements within our Urology group, but change at the provincial level is often slow.

Even though Saskatchewan is seeing amazing improvements through some focussed initiatives (see Sask Surgical Initiative and wait time trends chart), I want the changes to be faster and deeper.  "Faster" speaks for itself, but "deeper" is a little elusive.

Many of the changes we've made in Saskatchewan are "first-order", that is they're incremental and happen within the existing structure.  For example, we're doing more surgery to reduce the backlog and waiting list.  But, if the underlying mechanisms and culture that created the backlog in the first place aren't themselves changed, we're in danger of backsliding.  As the Surgical Initiative enters its last of 4 years, we're going to invest in processes designed to maintain surgical wait times at the desired levels.  That is, we're going to spend money pushing back against a resistant system.

A second-order change involves new ways of working and thinking about a process.  In the context of reducing surgical wait times, we might reward (not necessarily financial!) providers for their ability to deliver timely care.  Or, we might look closely at whether or not a particular operation is actually appropriate for a given patient.  If someone is unlikely to benefit from surgery, or, after being fully informed of risks, benefits and alternatives, decides against having surgery, wait times may be maintained by reducing demand.  Ultimately, we might change the system deeply enough that the disease currently treated with surgery no longer exists (quit smoking!).

Of course, second-order change requires a profound commitment to improvement, and investment in building communication and cooperation.  That's where my friend offered me insight into why I'm frustrated by the generally slow pace of change in the provincial healthcare system.

He follows some of the work described in this blog, and in particular our recent work on rapid improvement through 5-minute huddles.   He knows that I've challenged the need for week-long RPIWs (Rapid Process Improvement Workshops) that occupy huge amounts of staff and administrator time, sometimes to accomplish seemingly trivial results.  If our Urology service can move forward an improvement project over 1-2 weeks in 5 minute daily aliquots, why can't other services/departments do  the same?  His answer to me: Much RPIW time is spent establishing the team and setting context, whereas our urology team is already highly functional and knowledgeable about our own practice.

A-ha!  Our Urology group is already used to working cooperatively and collegially, discussing issues frankly, and developing consensus.   We've have regular times to meet and expectations that process improvement is part of our daily work.  In the same way that fish don't see the water they're swimming in, we're so used to being immersed in a supportive environment that we don't notice it anymore!

So, how do we make more fish? Or, maybe it's the water we need...

Training all healthcare staff and administrators in process improvement techniques is a toe in the water; it's first order change.  To get everyone to jump into the pool will take a more profound intervention.  I think that formal communication training is the key.  I flattered myself a couple of paragraphs back when I congratulated us for our collegial urology environment.  But, it's easy to get along when you all live essentially the same professional life: hospital rounds, take out a kidney, clinic, repeat.  Urologists have similar training, goals and professional culture.  It's much more difficult trying to communicate with someone from a different tribe.

A proposal: Rather than investing in training lots of people deeply in a specific process improvement methodology that they may use only occasionally, let's train everyone in healthcare in a common communication methodology.  That training would be used every day.  Healthcare would be safer, and better communication would obviate some of the process messes we're trying to fix.  Smaller numbers of process improvement experts could then be deployed to coach others in project teams, which would hit the water swimming because communication and teamwork would already be second nature to them.

Execution is a killer

Our urology ward's standard work for morning rounds has evolved and is now stable.  These are the steps:

• Good morning!
• Report
• Discharge planning (prescriptions, Home Care)
• Discharge date
• M&M book
• Followup (testing/imaging) assigned to ...
• Off-service patients
• Improvement work
• Thank you!

The reminders I find most useful are about discharge planning and followup of testing.  Prior to having the checklist, the docs didn't consistently let nursing staff know when to expect a patient to be discharged, so advance planning (patient education, transportation, Home Care referral) wasn't done.  The "followup" reminder requires the docs to be explicit about which of us is responsible to check Mrs. Smith's chest x-ray.  This important work is less likely to slip through the cracks when one person is accountable.

"Improvement work" refers to our 5-minute huddles, both for new initiatives and followup of ongoing work.


The next step is to make this checklist part of our routine.  This is the stage where we need to move from the "champion" leading the checklist to anyone on the team being able to do it, and having the expectation that we will use it at every morning round.  Many worthwhile improvement ideas falter at this "execution" step.

We started with the idea of assigning a specific person to lead the checklist.  One of the docs suggested that our "ward doc" should do it.  Each week, a urologist is assigned to be the ward doc, with responsibility for new patients admitted to hospital who don't have a previously assigned urologist.  We tried this 2 weeks ago.

I thought this would be an easy one, because there is always an assigned ward doc.  As it turned out, the reality was slightly different.  Because of the vagaries of our holiday schedule, the assigned ward doc was away on Monday.  On Tuesday, the ward doc didn't attend rounds because he was at a meeting.  On Wednesday, we recognized that assigning leadership of the checklist to the ward doc may not be reliable, so we asked the nurse who was leading patient rounds (by reading the ward census) to lead the checklist.  It was this nurse's first time seeing the checklist and she wasn't familiar with what each of the items meant.  We had not recognized that there is enough turnover in nursing staff attending morning rounds that some are not aware of the ongoing 5-minute improvement work.  On Thursday, we were back to one of the doctors leading the checklist. (Friday was a holiday.)

Looks like we'll carry on with the docs taking turns to lead the checklist.  I'm away from the practice a fair bit this month, so it will be interesting to see whether we've already reached a tipping point with this work and whether it will continue while the "champion" is not around.

Low tech rules!

Still no communication whiteboard!  Oh, well - we decided to get the ball rolling with pen and paper instead.

Every weekday morning, our urologists make inpatient rounds and then do a group report with the ward nurses.  (This is also the setting for our 5-minutes quality huddle.)   One of the morning tasks is to record any complications or adverse events in a log book.  While we usually discuss management of any complications immediately at rounds, one doc is assigned to review the book from time to time and report any trends or gaps in management.

Last week, while recording in the book, one of my partners pointed out that there had been nothing recorded for 2 weeks.

"Were there no complications, or did we forget to record them?"

We weren't sure.  Hmmm - how to get surgeons to remember to do important stuff?  Checklist, anyone?

I thought our new whiteboard would be a great place to develop a morning rounds checklist (AKA standard work).  But, this is how our whiteboard's (future) spot on the wall looked this morning:

So we tried this:

Paper and felt pen.  We quickly sketched out a list of morning tasks and posted them for review tomorrow.

We'll try out the list and see if anything needs to be added.  Once we've tried it on a few occasions and with different mixes of staff present, we can turn it into something prettier and have it laminated.

That went so well (and quickly) that we took a stab at improving and standardizing the format for logging adverse events.

Take that, whiteboard!

5-minute improvement huddles - part III. Sustainability

(Note: links to Part I and Part II)

The changes to our voiding trial process have taken root.  Here are some data from the week after post "Part II".

Time catheter removal ordered	Time catheter removed	Saline instilled?	Time of first void
0730	0800	Yes	Immediate (pt incontinent)
0730	0815	Yes	1100
0910	0910 (removed by doc)	Yes	0925
0940	0940 (removed by doc)	Yes	0950

The key changes here are that catheters are being removed promptly and voiding trials are successful earlier due to the new process of filling bladders with saline just before catheter removal.  We'll measure again after 2 months, both to see what time catheters are being removed and how staff and docs feel about the new process.

Now, back to my hidden agenda!

I want to see if we can improve our urology ward processes without establishing formal teams.  More complex changes may require formation of teams, but I wonder if we can get more people involved using the 5-minute improvement huddles at our morning reports.  Shared involvement means shared shared responsibility and ownership of an initiative.  Unfortunately, I have been a barrier to that in the past.

Throughout much of our practice's improvement work, I've been the "champion".  The champion's role is to provide enthusiasm and momentum.  However, if the champion is the only person driving the work forward, it's difficult to sustain the effort when his attention is directed elsewhere.  I don't mean this to be derogatory to my partners and staff - they are certainly committed to improvement.  Rather, it is a comment about the fact that we haven't been deliberate about developing an improvement infrastructure.  To be sustainable, improvement work needs a process that drives it forward independently of individual effort.  I've been guilty of taking sole responsibility for projects, taking on too much, and then dropping the ball.  

On the urology ward, I'm not always present for morning rounds.  If I'm the only one keeping track of a process improvement, things will falter.

Also, we need to build capacity for this work.  Everyone should have a chance to participate and lead these improvement huddles.  I can't be greedy about the "champion" role!

We discussed how to sustain our improvement efforts and we're going to start with a communication board in our meeting room.  We can document current initiatives along with next steps, data to be collected, etc.  I think this will give day-to-day continuity for our work without needing to rely on one person's presence. We'll post reminders about followup on previous efforts, such as the voiding trial process.  I'm also interested to create standard work for our morning report, including time for the 5-minute huddles.

It's a multi-use room that patients and visitors use as a lounge, so we can't post any confidential information.  There were some questions about whether or not it was appropriate to display our improvement efforts publicly.  One of the nurses pointed out that staff already publicly display many quality measures on the ward, and that patients and visitors seem quite pleased to see that we are making efforts at improvement.  (Also, this blog has been sort of public...)

5-minute improvement huddles – Part II. Trying out new voiding trials.

Our story so far… (See last week’s post.)

This week: What we learned, and some insightful comments on the last post.

Last week’s suggestions for process improvement (PI) were well-received by nursing and medical staff.  Our quality improvement nurse lead reported that nursing staff were keen to expedite voiding trials once they appreciated the implications for patient flow.  I think this initiative was accepted because it was only a minor departure from current practice (i.e. night staff removing catheters before leaving their shift, filling bladders before removing catheters).  Both of these ideas have previously been successful, either on our ward, or in other local settings.  If we had started with the idea of shifting the decision for catheter removal from physicians to nurses, it would have been a much bigger change in practice.

We have data!

Order Time	Foley Removal Time	Time of first void
Am rounds	0720	0800
Am rounds	0845	1300
Order to d/c in am	0600	0730
Am rounds	0825	1030
Am rounds	0705	0915
Am rounds	0740	1245
Am rounds	0800	Unable to void

This is not a “control” group.  We had already discussed making process changes while making these measurements.  Measurement wonks will have spotted something missing from this table: Dates!  We’re interested to see change over time, so we’ll need to start recording the date of each voiding trial. 

The absence of this important information illustrates a peril of the informal, 5-minute PI.  We didn’t spend time refining what information we wanted to collect.  On the other hand, it was a small trial of measurement using minimal resources and we learned something for next time.  Also, we’ll need to record whether or not the man had his bladder filled before catheter removal.

Thanks to Susan Shaw and Katherine Stevenson for their insights.

Ever looking for ways to improve the client’s experience, Susan wondered if we had asked our patients for any suggestions on how to improve our processes.  No, we haven’t. 

Ironically, on the same day that I read Susan’s comment, I was being reminded – in another setting - of the value of soliciting client feedback.  We welcomed our first patients at the new Urology Centre of Health at St. Paul’s Hospital, and were finding that, even with extensive planning, there were still rough spots to be smoothed.  The nurse and I asked one of the first clients about her impressions and suggestions.  She had striking insights about things we hadn’t considered, such as the distance between our examining rooms and the washroom, given that many of our patients often have urgency to void. 

So, Susan, thanks for the reminder that we may be missing out on a valuable source of PI ideas.

On further thought, why is it that I had to be reminded about the importance of asking clients about their experience?  Perhaps we haven’t explicitly valued client feedback.   Our hospitals conduct client satisfaction surveys, but they produce aggregate data and we wouldn’t be able to dissect the results to determine whether our PI changes had helped or hindered.  Also, the feedback comes many months after those patients had been in the hospital.  On the other hand, managers, physicians and staff are made aware regularly of the pressure to maintain patient flow.  We have daily feedback about bed occupancy, surgical cancellations and patients waiting in the ER. 

Katherine pointed out that, while our 5-minute huddles may have been informal, they weren’t completely unstructured.  She’s right that I was trying to apply the principles of teamwork, measurement and learning cycles (PDSA) to the process without clubbing anyone over the head with these PI tools.  I agree that there should be at least one person who has formal training and experience in quality improvement methodology involved in the process.  Otherwise, there’s a high risk of failure.

Perhaps it’s a little like playing jazz.  Jazz musicians must have deep technical knowledge so they can improvise (and fail!) with the confidence that they can find their way back when things get dissonant.

5 minute Process Improvement huddles on our urology ward

Here’s a fresh process improvement (PI) project.  And a hidden agenda or two.

Last week, a staff member on our urology ward approached me with a concern about how we were managing voiding trials for men after prostate surgery.  TURP (transurethral prostatectomy) is a commonly-performed operation for men who are having difficulty passing urine because their prostate gland is enlarged.  After the surgery, men stay overnight in the hospital with a catheter (rubber drainage tube) in their bladder.  Most men have the catheter removed the next morning.  After the catheter is removed, we want to be sure that the man can pass his urine – a “voiding trial”.  After a successful voiding trail, the man can go home later that day.

Because the bladder is kept empty by the catheter, it may take several hours for it to fill enough for the man to pass urine.  Also, some men may have difficulty urinating initially and it may take several attempts before we’re confident that they are voiding well.

The problem:  It’s unpredictable how long a voiding trial will last.  It may take several hours.  This means that it’s difficult to be sure what time the man should arrange to be picked up at the hospital - a significant issue in Saskatchewan when family members may be traveling several hours to reach Saskatoon.  Also, it’s difficult to know when the man’s hospital room will be vacated and be ready for use by another postoperative patient. 

As the staff member informed me, in order to expedite room turnover, some postop men had been asked to wait in our ward’s common room while conducting their voiding trial.  This meant that they would use a public washroom to void and then bring the urinal to the nurse for measurement.  If there was any question about how well they were emptying their bladder, the nurse may perform a bladder ultrasound scan.  If the bladder isn’t emptying well, the nurse may reinsert a catheter to drain the residual urine.  All these steps can be performed comfortably and privately when men are in their own hospital room.  (Our ward is extremely fortunate to be able to provide private rooms for all patients.) The process may not be so comfortable and private when men are waiting in the common room.  This was the staff member’s concern.

I agreed with that concern, and at the same time I appreciate the pressure that managers feel to serve the next patient who needs to be admitted to an open bed later in the day.  We want to make sure that patients being admitted through the operating room or emergency department can have a bed promptly, both for their own comfort and also to reduce congestion in other areas of the hospital.  We agreed that we weren’t satisfied with the solution being tried currently, but there was still a problem to be addressed. We need a new process.

Hidden agenda: Process improvement can move at a glacial pace.  Sometimes the formal structure around quality improvement (project charters, team assignments) can be so daunting that people are too intimidated to try to make a change.  I accept that large-scale projects are more successful with a formal structure, but smaller process improvements may never see the light of day.  This has been a concern for me as I watch our health region’s managers and leaders participate in Lean training.  Rapid Process Improvement Workshops (RPIWs) take up 100% of the team’s time for the week of the workshop.  In addition, the team leaders spend significant time in preparation before the RPIW week.  I like structure and discipline in my work (just ask anyone who has to work with me in the OR…), but I wonder if this degree of investment pays off adequate returns in process improvement.  Time will tell.

While time is telling, however, we need to continue improving our services at the microsystem level.  If our ward, or particular clinical problem, isn’t chosen for one of the initial RPIWs, we still need to make changes.  So, I want to explore a less formal approach to PI.

Every weekday morning, our urologists make rounds to visit inpatients on our ward.  Immediately following that, the urologists and nurses meet to discuss patient management plans.  (No, we haven’t quite graduated to multidisciplinary bedside rounds.  Yet.)  The urologists need to get to the office or the OR, and the nurses are ready to go off shift, so we don’t have time to have a formal (read: lengthy) PI meeting.  On Tuesday, I asked for 5 minutes at the end of rounds to present the problem (see above).  There was agreement that we could improve this process.  The initial idea was that urologists should “pre-program” catheter removal by leaving orders the night before about what conditions needed to be met in order for the nurse to remove the catheter the next morning.  We’re interested in things such as whether or not a man has a fever (an objective measure) and how much blood is mixed with his urine (a more subjective measure).  If the criteria are satisfied, the nurse will remove the man’s catheter early in the morning (perhaps 0500) to start the voiding trial.   The downside of this plan is that the man would be wakened early in the morning, and it would also require introducing a new process, i.e. delegating the decision for catheter removal from urologist to nurse.

That was pretty good work for a 5 minute session.  And a classic case of jumping to solutions without first looking at the system!

On Thursday morning, we reconsidered the PI in light of new information from nursing staff.  While physicians may be writing the order by 0730, catheters may not actually be removed until 0900 or 1000.  This is because nursing shift change happens around 0730 and the day shift start their work with administering medications and helping patients prepare for breakfast.  It’s a very busy time for them.  However, if catheters were consistently removed by 0800, perhaps it wouldn’t be necessary to develop a new process to remove them at 0500.

That was our 5 minutes for PI on Thursday.  We decided the next step would be for the ward’s quality improvement nurse to collect data as to when catheters were actually being removed.  TURP is a common enough operation that we may have 3 or 4 men on the ward over the next 3 days.  I’d like to see this data on a simple chart that we’ll post in our meeting room. 

After rounds finished on Thursday, another nurse approached me with some research she had been doing.  A colleague of hers worked with urologists in another part of the hospital and mentioned that one member of our group sometimes expedites voiding trials by instilling saline into the man’s bladder via the catheter just before removing it.  This cuts down on the time needed to fill his bladder the “natural” way.  This would be simple to do on the urology ward.  I’ll bring this idea forward in our next PI huddle this week.

Hidden agenda: On Friday of last week, we received a memo from our health region administration that, due to GI virus-related ward closures, our hospital is running “over-capacity”.  This means, among other things, that surgeries may be cancelled.  We’ve been encouraged to discharge patients promptly (yet, of course, appropriately).  If we can demonstrate rapid changes to our care processes without the need for a formal RPIW, perhaps this PI model can help other wards deal with their patient flow issues.

I’ll keep you posted.