Do you need more improvement? Does it seem like you and your team have hit the wall? Consider thinking of improvement as growth. Growth has limiting factors and sometimes more of the same will not create growth, or improvement.

A long time ago in undergrad nutrition the lab assignment was to conduct an experiment about growth in chicks. The experiment involved feeding groups of chicks rations of varying composition. One element of growth involves protein synthesis, which as you know requires amino acids. The test diet on our trial was deficient in one of the amino acids. The experiment showed that despite free access to unlimited feed, the growth rate of the test group was stunted.

The professor used an analogy known as Liebig’s law. While originally conceived to explain soil nutrient composition and the growth of plants, some such analogies are universally helpful. In the chick growth study, the limiting amino acid was the shortest barrel stave; the one that limited the rate of growth. Adding more of the other amino acids or other dietary requirements will not improve growth. You cannot fill the barrel past the limiting stave.

Complex systems exhibit similar dynamic characteristics. The discipline of systems dynamics uses archetypes or generic structures to help explain difficult challenges when concerned with system performance. Liebig’s Law is similar to the limits to success archetype. One key take away lesson from this archetype is that more of the same things you've been doing does not necessarily give you more of what you want.

 

What might be some limits to improvement? Number of people improving quality? Time? Improvement knowledge and skills? Cultural characteristics, such as an aversion to following standards?

You might apply this analogy to a specific improvement or your unit’s improvement work in general. What is your limited amino acid for improvement as growth… and what could you do about it?

Liebig's barrel image is in the wikipedia commons here.

While in London on vacation I made a point of seeking out all things Nightingale. Unfortunately, the museum was closed for renovations. There were two striking memorials I did visit: one at St Paul's Cathedral and the other at Waterloo Place, pictured here.

Florence Nightingale's contribution to quality improvement was nothing short of breakthrough. Two facts I learned while in London suggest a persistent Nightingale Challenge to guide improvement.

First was her work improve hygiene practices in military hospitals resulting in a dramatic reduction in the infection-related mortality rate among wounded soldiers - from 40% to 2%!

Second was her interest in making statistics visible and understandable. Apparently in order to advocate for improvement in military procedures she needed to persuade Queen Victoria and felt that a report composed of text and tables of numbers would not be convincing. The coxcomb graph (animated on this page) was an attempt to turn data into a picture that could be easily understood. This graph has not stood the test of time, and a simpler presentation of the same data is probably appropriate. The point is she recognized the need to make data understandable and convincing.

So, the Nightingale challenge is twofold: set out to accomplish dramatic improvement by setting stretch goals, think 40 to 2. And, use meaningful data that answers important questions displayed in a simple manner such as run charts annotated with change; tell a story that anyone can follow.

Is changing behavior necessary to make improvement? Often. So how do you do it? Why not try fun? But medicine is serious business you say? ... Relax... lighten up and let the creativity flow. You may just make a behavioral breakthrough.

Below are two short videos that illustrate the fun theory. These are instructive and entertaining. Not bad examples of improvement science either - they've included measurement to test their change and the hypothesis that making something fun can change what people do - for the better.

"This site is dedicated to the thought that something as simple as fun is the easiest way to change people’s behaviour for the better. Be it for yourself, for the environment, or for something entirely different, the only thing that matters is that it’s change for the better." It is sponsored by Volkswagen; they are sponsoring a competition.

Remember, even wacky ideas can be the start of some clever and effective change.

 

In an earlier post I commented on the danger of workarounds; how getting the work done despite persistent problems creates a pernicious condition that is vulnerable and wasteful.
Anita Tucker provides a nice perspective here at Web M&M. From the article:

 

"... health care professionals typically work around the immediate issue without engaging in additional steps to prevent recurrence. This pattern of behavior, called first-order problem solving, seems successful because patient care continues in the short term. However, the downside of first-order problem solving is lack of communication, which hinders real improvement from occurring for several reasons." Read more.

Suspension of the people involved in error rarely (ever?) makes systems safer. Such action is based on the myth that people can, should and must be perfect. It is perpetuated by societies' general call for punishment when someone does something wrong.

In a tragic event such as this one in which an infant died, there are causes at the sharp end - where the care is provided, the exact instant when an error occurs. There are also causes and contributing factors that are distant from the event itself - decisions and designs that establish the resilience or fragility of a system to inevitable human failings.

Apparently the term ghastly was used to describe this error. The real ghastly part of this story is what's behind the response of administration and the journalism that paints such a portrayal.

Why in the world is an error such as this one still possible? And, why is it still seen as appropriate to respond this manner to such a tragic error?

People who care about improvement in healthcare have been forming networks to collaborate, learn and build success for many years. I have had the pleasure to work with one of them, the Quality Healthcare Network. It's based in Toronto, but reaches out globally to find people to learn from and challenge thinking. Here is the latest from their channel on YouTube.

 

The fundamental idea of error-proofing is to make errors impossible. I while back in a creativity session focused on improving adherence to hand hygiene cleanser use, I jokingly suggested that automatic door openers be activated only by the use of a hand sanitizer dispenser. This was in the wake of SARS in Toronto, so hand-hygiene stations at all hospital entrances were the new thing. The safety concept deployed in this idea is that of a forcing function - the next step (entry to room) cannot be performed until a necessary safety precaution is followed. The idea brought howls of laughter, always a cue that an idea is either too wacky to be considered or on a new track to innovation. That was about 5 years ago.
Well, someone has done it.

 

Creativity is vital for improvement and I ask this question during creativity sessions to help raise people's awareness of their own thinking. An article in the Globe and Mail cites recent research (Abstract) providing evidence to why the answer to this question is rarely "in a meeting". It may not surprise you that the answer is typically something like "in the shower", "when cutting the grass", or "driving a quiet road". NO ONE has ever volunteered: "in a meeting". But that's exactly where we're called upon to do some of our best thinking!

Back to the research. I'll cut to the chase with a quote from the author:

"When your mind wanders, a different kind of thinking occurs. When you aren't trying to solve problems deliberately, it provides more mental space, you make connections and let your mind go wherever it wants," said Prof. Christoff. "Driving is the perfect activity for letting your mind wander because it is highly automatized and requires only a small part of our attention. When you daydream, you may not achieve your immediate goal, say reading a book or paying attention in class. But your mind may be taking that time to address more important questions in your life." The research method is actually a fascinating application of fMRI for those who are curious - way over my head.

Next time your team needs better thinking, leave the meeting and defer until everybody gets a chance to daydream on it. I'm now a Daydream Believer (sorry, couldn't resist).

My work with as leader of the Vermont Oxford Network's NICQ project has taken a giant leap forward into the world of Web 2.0. NICQpedia is an online community of practice that uses wiki and social networking tools to support the improvement work of the 54 interdisciplinary teams in NICQ 2009. The site will be available to all 800 plus worldwide NICUs beginning in 2011.

The wiki side of the site already has dozens of pages supporting improvement across nine topic areas that include respiratory care, encephalopathy, design and discharge management. Participants have provided early positive reviews, but the proof will be in the application and use both as a source of improvement knowledge and a repository for improvement stories. Stay tuned.

Proceedings of the Healthcare Systems Ergonomics and Patient Safety Conference (HEPS) held last summer in Strasbourg FRANCE are available for download: index of the scientific programme.  I presented a paper on our work in the NICQ collaborative - Systematic Application of Human Factors and Ergonomics in the Neonatal ICU.

I presented at EDMONTON IV: The 4th Annual Conference on Enhancing Safety in Home, Community, and Long Term Care on March 24 to 25, 2009, in Winnipeg, Manitoba. Here is a back page with references and resources pertaining to my presentation.

A deliberate and methodical process can greatly enhance the development of new ideas. New ideas are almost always a requisite of dramatic improvement. Dr. Edward de Bono coined the term lateral thinking which is based on how the mind works as a self-organizing system. I became intrigued with his work a number of years ago and often return to both his creative thinking tools and the six thinking hats. There is no better operating system for deliberate creativity. Here is a recent interview with him:  

THE global leader in quality is widely accepted to be Toyota. The physical order of their production environment must have something to do with this… and I have always felt there has to be more to it that simply creating and maintaining a tidy workplace with tools and materials aligned with process.

 

Recent research in the social sciences may be on the way to elucidating a mechanism that relates physical order to behavior. This research which focused on civil disorder such as graffiti, litter and unreturned shopping carts “found that, when people observe that others violated a certain social norm or legitimate rule, they are more likely to violate other norms or rules, which causes disorder to spread.”

OK, this might be a stretch but, could untidy, disorganized work environments influence compliance performance, rule or procedure following? And if so, could work materials organization and visual order improve safety and quality in unexpected ways? Food for thought.

Measurement is ALWAYS necessary in order to make improvement. But, sometimes hard data is hard to come by. I’m a weather watcher and it occurred to me that there is a wonderful analogy about measurement in the story of the Beaufort Scale - a method for measuring the strength of wind.

As you might imagine, in the early days of sailing it was important to be able to communicate the strength of the wind but the tools for accurate empirical measurement had not yet been invented. So, in 1805 Sir Francis Beaufort created what came to be known, creatively, as the Beaufort scale.

The Beaufort scale enables consistent determination and communication of wind speed based on observed conditions. There are 12 levels of wind strength on the Beaufort scale. A number 3 is also called a gentle breeze; sea observations include large wavelets, with crests beginning to break and scattered whitecaps; and on land leaves and smaller twigs are in constant motion. I have one of those amateur weather stations and it registers wind in kilometers per hour and cites the Beaufort scale number. I find myself referring to the Beaufort number and very seldom do I look to see the actual speed.

This concept can be applied to improvement in cases with you cannot measure the results of change directly, you may be able to create your version of the Beaufort scale. With care, a scale could be created and managed by a team for observations which lack a formal metrics. Not all change is improvement, make sure the changes you make measure up!

I've often been dissappointed with the quality of flow diagrams used in healthcare improvement. BUT I totally understand: a) I'm a bit of a geek when it comes to software and b) some of the software tools are just way too complicated - or worse, people try to use WORD or PowerPoint! Here is a diagram I made online in a couple of minutes. I'll be exploring more about how this tool works and post more later. I'm not promoting this particular tool - maybe I've missed other such online tools - but this makes lots of sense, especially for collaborative improvement work.

Simply, the essence of collaboration:

 

Interruption and multitasking are fundamental sources of error, that probably have a common mechanism in the brain's function as a sequntial processor. Both require switching; sequential processing means that we truly cannot multi task as far as attention is concerned. Attention in task performance is like a spot light - it can only shine on one part of a task at a time.

Interruption is an externally and culturally aligned behavior characteristic of the cultural norms established in a clinical area. It is likely influenced by relationships; for instance are you more or less likely to interrupt a friend in the middle of a task as compared with someone you don't really know? Hierarchy probably has an effect too; would you be more or less likely to interrupt someone who you perceive is lower on the hierarchy? What about patients and family; do they know when and how to get your attention safely? Do they know when you are involved in something and should not be interrupted?

Recently a friend shared an incident in which a breast milk administration error occurred even though this NICU uses a bar-code process. Upon review of the circumstance, interruption was probably a key contributing factor. The nurse was interrupted during the process and returned to complete it, missing the code scan which would have detected the wrong milk. This had become a well entrained task, repeated correctly many times, but with attention diverted the switch back to the task resulted in error.

John Medina's latest book includes this and many other little-known facts about how the brain works based on his years of working in the field. He also has a blog and a few entries on YouTube.

 

 

Healthcare workers are generally very skilled and proficient at making things work. This is highly valued when working in systems of all kinds that don't always cooperate, especially when a life is on the line. Kudos to those so skilled in using their ingenuity to make a deficient or faulty system or process function well enough to get the task completed. But I'd like to point out a flaw that needs serious and widespread attention. Behavior such as this, works around the problem and does not truly solve it. This perniciously creates a situation of dependency; a kind of addiction to the heroics of in-the-moment problem solving. Until the problem is solved, it will resurface for another workaround by the same or other ingenious person.

This can be examined in light of a systems archetype called "shifting the burden". The pattern is familiar and I've drawn out the causal loop diagram. The symptoms of an immediate problems are resolved quickly - the workaround enables the work to proceed in an oftentimes incomplete or risky manner. Usually there is fundamental corrective action that needs to be taken; requiring investigation, observation, devising and testing changes and measurement - in other words, improvement. All this requires time, and many people who work IN healthcare processes are stretched to the limit just DOING work that often requires ingenious workarounds. And the vicious cycle continues - back around to working around the problem.

The heroic workaround will live on until the pattern is broken, and this can require a significant commitment of time and money. Some organizations are making this investment, but many remain addicted to the pernicious workaround.