Sunday, February 3, 2013

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.







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