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...)