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.