Year in Review: Healthcare Blunders and Successes on the Road to Improvement

This year has been a year of changes, of errors but also of successes. In review, I wanted to pinpoint on few of the ones related to the quality of healthcare provided, risk posed to the patient and employees as well as on safety related issues. It was a busy year for disease control:

1. The anthrax scare at the CDC

- in June, workers in a high-level biosecurity lab were preparing anthrax samples to be used for researching germs,

Top 3 Best QI Books in 2014

It is almost the end of 2014! As a recap of this year, I was thinking to have a post on the literature on quality improvement, with my top 3 of best reads in this category. In a previous post I was mentioning how quality improvement is a continuous process, where everybody is invested in learning and growing so that incremental improvement is achieved. And learning is an ongoing, crucial activity in improvement.

From all the books I have read on QI in 2014, here are my top 3 picks:

3.  On the Mend- Revolutionizing Healthcare to Save Lives and Transform the Industry by John Toussaint, M.D. 

Toussaint is the CEO of ThedaCare and one of the most important agents in adopting Lean principles in healthcare. This award winning book talks about how healthcare can be improved using proven principles of Lean management. It is full of examples from ThedaCare, a cathalyst centre for quality improvement and innovation in the US. 

Quote: "Patients are goldmines of customer feedback for healthcare improvement" 

The Equipment Room Challenge

Remember my previous post about attempting a 5S organization of the OR equipment room?
This is how the room looked before starting 5S, and after:

After 5S

Before

As you will see from the new photo, there is less equipment in the room. I have used visual controls to assign space for each item on the floor, as well as labels on the wall with the name of the equipment. Equipment was allocated space according to frequency of use and grouped as much as possible by service to make it simple.

Here are the lessons I have learned so far:

To Check(list) or Maybe Not?

You probably read Atul Gawande's 'The Checklist Manifesto', in which he talks about how the safe surgery checklist came to life. I enjoyed the read especially as it seemed to have come to fruition so unexpected and yet so logical. And of course, as with anything related to quality improvement, the part that was the most challenging was yet to come: implementation.

It has been now 6 years since the WHO published the first edition of the Safe Surgery Checklist Implementation manual, and so far it has been widely adopted in hospitals around the globe. Sometimes, regulations and mandates have been used to ensure compliance.

Then, in March 2014, a study in the NEJM conducted by a group of Ontario researchers concluded that the implementation of the checklist was not associated with 'significant reductions in surgical mortality and complications'. And the debate started: what are we to make of this? Although it is a checklist, the obvious fact is that not ticking the boxes is what makes the surgery safe, but performing those actions. Also, implementation of this tool is hard, in an area where tradition is strong, egos are big and change is difficult. When hospitals are under pressure to conduct audits for compliance, how truthful are those audits? Another study looking at the OR and PACU safety culture in comparison with other hospital units concludes that the OR/PACU actually score lower than other hospital units, which means the OR is an area where improvements on the understanding of safety culture is much needed. We first need to understand what a safety culture is, in order to really successfully apply tools to improve this culture.

The Value of Thanking Employees

Last week was the Perioperative Nurses Week. With this occasion, the nurse educators on our unit prepared a series of short events each day, to show appreciation and motivate nurses: from a pledge board, to photos and presentations and even a chocolate fondue! Of course, all these events were possible with the educators' involvement; they brought their own kitchen gadgets, used their time to put everything together and ensure staff is having fun. We all know that healthcare is one of those areas where funds are limited (or inexistent). While this effort is laudable, I was wondering: where is the management? Peer appreciation is great, and it does make one feel great. But how about appreciation from our leaders and management? Why is that so rare and how important is that to the frontline staff?

It appears that actually, two of the top actions that employers can do to value staff are actually...free! Praise from managers and attention from leaders are followed by opportunities to lead. In healthcare, being recognized by your direct manager can make a huge difference. And surprising enough (for those who believe people are only motivated financially), a whopping 78% of employees would work harder if they would be recognized! I can only imagine what this would do on any unit. The nursing profession is based on a deep personal value, of helping people. Because ultimately, team members who feel poorly regarded by the leader are going to have the human propensity to remain disconnected from the leader and the common goal (J. Nance, Why hospitals should fly). 


Click here for larger info graph and more info.

5S for OR Equipment Room

Before picture:

This is one of our equipment room. On the day I took this picture, the room was completely full with equipment, tables, chairs, suction units. It was simply impossible to find an item or retrieve it;  there was no space left for accessing any item in the room.

This seems to be a common occurrence in hospitals: equipment is replaced, and old equipment is not removed from the unit, but placed in a corner. The hallways accumulate more and more items, and transporting a patient turns into an adventure. Patients are always amazed by the amount of items that seem to invade every square foot of space, and also by our ability to steer the stretchers around all these obstacles.

There is a definite need for improvement here. So, I decided to start small, with one room of equipment at one end of the hallway. By using the 5S Lean tool, these are the steps taken for starting this improvement project:

Space Organization in the OR

OK, so I have decided to start a small, easy and much needed quality improvement project on my unit. As many of you know, clutter is one of the biggest issue on surgical floors. Equipment is stored everywhere, on hallways, around corners, behind doors. Tables, chairs, props, accessories...the list goes on an on. Space is at a premium, and no matter where you turn, you incessantly see a piece of equipment. Many times when transporting patients to their theatre, they are amazed by the amount of carts, equipment and supplies on the hallways.

Why targeting this area for improvement?

Here are some areas of opportunity where we can make a difference:
1. Delays: when there is a pull for a piece for equipment, the nursing attendant goes to look for that piece, retrieves it and transports it to the theatre. At the moment, there is no standard placement for equipment, so staff inevitably spend precious time looking for it, then 'digging' it out from in-between other items, and finally transport it. This search = delay = patient/surgical team waiting = OR $$

2. Inventory: OR equipment is expensive. We like to remind each other to be careful with handling it, caring for it. But when it comes to storage, we forget about that. Many pieces of expensive equipment (i.e. laser machines, endoscopic units etc) are stored chaotically between more often used equipment, and end up being moved improperly, getting hit and damaged. This carelessness costs money and creates frustration for staff who have to go around it to retrieve some needed accessory.

3. Motion. This relates to both 1 and 2. Staff perform an incredible amount of unnecessary movement by looking for equipment, trying to relocate or move equipment and transport it where needed. By not having standard, designated places for equipment staff end up tired and frustrated, and are always in a frenzy when they should be able to know and easily retrieve any piece of equipment easily.

Stay tuned for the next phase: Using 5S to organize the equipment room

Shifting Culture in Healthcare

It is a fascinating idea, and it is (and will be) proved to be successful: implementing a new way to achieve better healthcare. From Tommy Douglas to Lean, Saskatchewan ran already a multitude of processes to improve healthcare (listen to podcast here). There is also debate on implementing Lean in healthcare, and many are also skeptical on the results. So how do we shift culture in healthcare?

People have to look at the processes from a patient's perspective, and whether you call it Lean, 4Dx or something else, this will not change the basic idea, that the ultimate person of interest is the patient (and not the physician). Removing waste, removing what is of no value and shift your viewpoint will ultimately make a difference. Sadly, leadership and healthcare management want to 'kill the mosquitoes' , without 'draining the swamp'. That means assigning a person to 'do the improvement work', and come back and report (while being held accountable for failures). But the data out there- and the examples from many Lean organizations- prove that improvement without senior management involvement is difficult, if not impossible to achieve long term.

My opinion on culture shifting: start talking about improvement, talk about tools and what is being done out there. Make nurses aware that they have power to improve their workplaces, and encourage involvement. Healthcare improvement happens everywhere in the world, and it is a real movement, not a fad. We can slow it down, but we can't stop it. So you are either be prepared, or find yourself on a burning platform!

Achieving Ultrasafe Health Care: 5 barriers

Here is a sort synopsis of an interesting and mind provoking article by Amalberti, Berwick, Auray and Barach. It brings back the discussion about how do we compare with ultra safe industries, and how many steps do we have to take to bring us to that much needed point of safety.

Becoming ultrasafe may require health care to abandon traditions and autonomy that some professionals erroneously believe are necessary to make their work effective, profitable, and pleasant.
Reliable measurement of health care and patient safety outcomes is the first challenge for health care benchmarking

The 5 barriers to achieve ultra safe health care are:

The EQ of OR

The term ‘non-technical skills’ came from the European aviation regulator in the 1990s and the concept is now used to underpin training and workplace-based assessment in a number of safety-critical occupations, including healthcare.

In this article Rhona Flin gives a brief overview of three non-technical skills frameworks developed for training and evaluating the performance of clinical practitioners. These are: ANTS for anaesthetists; NOTSS for surgeons; and SPLINTS for scrub practitioners. These acronyms should be more used in the OR. Technical skills are not all that it takes to make the OR safer.

Read the full report here

Welcome to MyORIQ!

      Two steps forward and one step back is acceptable progress, but no steps forward and no steps back is not acceptable.

Why this blog? Because I am compelled to make things better in my profession. To all of you  working in healthcare, the most fiefdom driven environment, I am telling you: yes, improvement is possible! And I refuse to give up. I created this blog to spread 'the quality gospel', keep my thoughts in order, advertise quality improvement ideas anyone could use,  and post projects that were successful (or not) on my operating room unit. 

If you are like me and drank the KoolAid, or if you are a doubter, you are welcome to use this information posted here. Comments and opinions are accepted, as long as they are constructive and related to the topic. I strongly believe in the mantra that 'you are only allowed to complain, if you prove you did or do something about it'. Hoping to make this blog and my improvement work a success, 


Sayōnara,

      Simona