Several years ago I was in a workshop facilitated by Paul Plsek. Paul has a great way of cutting to the chase. In the introduction to flow diagrams he asked the question: "What percentage of your work day is spent doing real work?" He defined real work as all the things that add value to patient and families' care; when everything goes perfectly, the first time. Then what's non-real work? All the things you do that do not add value, the problems you deal with, wasted time, errors, mistakes, time you spend searching for things, bureaucratic processes... etc. In other words: waste. I was amazed at how low the percentage estimates were for real work - no higher than about 80% - many much lower. That stuck with me and I've repeated that pop-quiz many times, with similar results.

 

Of course, this is not formal rigorous study, but I believe people are never too far off with their intuition on things like this. The UK's NHS now has a program called Releasing Time to Care which "focuses on improving ward processes and environments to help nurses and therapists spend more time on patient care thereby improving safety and efficiency." Apparently this follows a period of intensive development and testing. Other examples that reinforce the need to reduce waste can be found in the emerging stories about the application of Lean to healthcare (such as ThedaCare, the Pittsburgh Way and Virginia Mason, who've turned their pioneering work into an institute).

The diagram shown here is a gross simplification, but provides the basis for our improvement opportunity: how to eliminate B, move the time saved to C or D and design and execute systems that reliably optimize time spent on A.

 

On a recent trip to Europe I was struck by how different some things are and wondered how they may actually be better... and why we seem stuck in our North American ways. A great example of this is the traffic roundabout.

When you first drive up to a roundabout you think: this is crazy, how can this be a better idea than stopping? is this really a safe idea?

I've had lots of experience with the intersection roundabout (traffic circle) from trips elsewhere and was reminded of how they really are superior to the stoplight based on experience AND key performance indicators. So why are there so many in the UK and Europe and so few in North America? I suspect a primary reason is history, not logic or evidence. Research has shown them to be safer, more energy efficient and  save travel time. (Two scholarly reports here and here and a very enlightening and entertaining presentation at TED 4:20 min video)

 

My "ah ha" experience when driving in Portugal may be similar to insights one could gain by examining a different NICU or a different clinical area. Such exposure can make you wonder why you do what you do, the way you do it. So, if one was to go on a field trip to a different land to get ideas about how to improve - where would you go? When I read this report, I thought: probably nowhere in North America. The US and Canada are 7 and 6 respectively out of seven (yes, last place) on measures of quality, safety and cost! 

 

Here's an idea. I periodically read an ad farm tour to a far-off land advertised in my local  farming journal. I put this down to some fancy kind of boondoggle - but maybe farmers really gain new knowledge by seeing the other side of the world. Another trend: eco-tourism - in which the tourist visits with keen attention to ecology, local economy and carbon footprint. So, along these lines I propose a new form of tourism: healthcare QI tours in which the tourists visit far-off lands with open eyes and ears to do some serious benchmarking for improvement. 

In this magazine article Jonah Lehrer cites the work of Kevin Dunbar and others who study how scientists study things - how they fail and succeed. As we work to raise safety and quality improvement work to scientific standards, we might do well to understand what he has learned and how it could be applied to sharpen our improvement acumen. This article is worth reading - I think you will easily see some possible pitfalls of improvement as with science. From the pitfalls come some simple messages about learning from failed improvement, modified from Lehrer's summary:

1. Check your assumptions. Does the result you observe contradict your theory? How might you change your hypothesis?
2. Seek out the ignorant. Ask someone who is unfamiliar with your improvement what think - explaining it to them will help you see it in a different light.
3. Encourage diversity. Form a diverse team around quality improvement work and value all input. Include family and non-clinical team members.
4. Beware of failure-blindness. Be careful that you do not filter the result you see with bias and preconception.

Here is a link to an eBook I just edited. I also wrote the chapter: System Safety in the NICU. This book captures the work of the Vermont Oxford Network's NICQ project.

 

Just published in Clinics in Perinatology

Abstract:

Human factors analysis (HFE) presents a formidable contribution to quality improvement (QI) in the neonatal intensive care unit (NICU). The science behind the fundamental principles concerning the design of work systems that match the needs of the people who work in them is sound and is applied widely in other safety critical situations. Early application of HFE in NICUs has shown the usefulness of these methods for frontline teams working to improve quality, reliability, and safety. The inclusion of human factors considerations in the design of structure and process has the potential to improve outcomes for patients and families and to improve the comfort and usability of work systems for providers who work in them. New technologies and continual change must be informed and designed through the application of HFE methods and principles to realize the full potential of QI.

In Switch, the authors present examples of successful big changes - like improving child nutrition in impoverished Vietnam or reducing nurse turnover but they also implore the reader to apply the same principles to their own personal, n-of-1 improvement. Improvement is a such a common human aspiration it's fitting that fundamental principles have universal application from a personal to a global scale.

In a recent article about safety and quality improvement education in medical school the authors point to a successful strategy they've used for several years. Students are given an assignment to carry out a personal improvement project that includes areas such as exercise, diet, or study habits. "Students use process diagrams, fishbone diagrams, and run and control charts; carry out PDSA cycles; and make daily measurements (miles run, colas drunk, or minutes of study) so they can link their process to outcomes." They even have a personal improvement workbook freely available. (download here)

Those of us keen on sharpening our improvement habits can do so by turning the improvement process in on ourselves. If you can internalize sound improvement method in your own changes it may bring added resolve and discipline to your NICU team's quality improvement work.

A different twist to the words of Mahatma Gandhi... "Be the change you want to see in the world."

Several years ago I attended a lecture by Kurt Vonnegut.. During the talk he used a chalkboard to graphically explain using a story arc why people have such a need for drama in their lives. Recently I stumbled upon a blog post that describes this Vonnegut lecture nicely and it occurred to me that the use of a story arc could be a valuable way to reflect on and improve improvement.

Below is an story arc based on an imaginary improvement - it's not a real graph, but rather a conceptual one on which we can consider some typical quality improvement stories. It might be possible to use this as a language to aid collaborative learning and to discover ways to improve your improvement practice.

 

First, the axes. The x-axis is elapsed time - this could be days, weeks, months or years, but typically would be in the order of months for most improvement reported in NICQ. When evaluating your improvement performance you might consider time to achieve aim (T1). What are you doing during this stage of improvement? How long does it take to get to the first real test of change? What strategies do you use to determine what to change? Or, your might ask: during T2 what happens to create A, B or C? what can we do to be sure that C does not happen?

 

The y-axis is normalized to correlate with your key outcome measure, it's not the actual measure. I've set the limits as poor and excellent, which are relative and qualitative. The important points on this axis are what I've called aim and acceptable. The aim is a milestone level of accomplishment that's the target for an improvement initiative. It's different than acceptable in that, for instance, you may agree that any infection is unacceptable and the only real goal must be zero, but for practical or motivational purposes you are willing to set an aim below this point. In other cases aim and acceptable may be the same. Acceptable may also prompt "acceptable to whom?" Good point, a parent may have a different answer than staff. This axis is also germane to how much of a stretch goal the aim provides or, once an aim has been achieved do you 'raise the bar' to set a further improvement aim.

 

Over time an improvement moves from the setting of aim through testing and making change (T1) to reach a point at which the aim is achieved. T2 is a period of stability necessary to conclude you've made improvement (special cause). Condition B represents a stable level of performance at or above the aim. Condition A is what one might call continuous quality improvement. Condition C is a regression or slip to below the aim and back to the pre-improvement level (see discussion in this article). Is condition C a function of how the improvement is made (e.g. the change relied exclusively on education) or some fundamental flaw in culture (e.g. lack of practice discipline)?

All improvement stories have an arc for which these dimensions are important and every team has a range of experience to learn from. Take the time to reflect on your stories in these terms - learning from experience to become better improvers. What makes one improvement an A and another a C? Is a B a C waiting to happen? Should all improvement be A? How can you manage the improvement you're working on now so it's more likely to be B or A? What does a current story of yours look like right now? Where are you on an improvement story arc, what shape is it?

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).

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.