Sunday, April 7, 2013

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.


  1. Looking for an update! Have you made any more changes since April? Any more pithy stories about QI?

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