Monday, March 18, 2013

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!

Sunday, March 3, 2013

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
Immediate (pt incontinent)


0910 (removed by doc)

0940 (removed by doc)

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...)