Performance Improvement Tip of the Day: The Power of the Feedback Loop

This article from WIRED magazine about the power of feedback loops nicely helps illustrate how this simple biological mechanism works to improve personal performance, and can be harnessed to improve the performance of teams and systems.



Dr. Joseph Kvedar, Director for the Center for Connected Health at Partners, talks about the feedback loop in this wonderful YouTube video. He talks about using the key feedback elements below to help patients change their behavior. However, the same feedback loop and elements can also be used in motivating behavior change for practitioners. When implemented wisely and within the construct of a well designed management system, this loop is a powerful contributor to improvement.

(1) Active Reflection: This occurs through the appropriate use of data, presented in a meaningful way, at the right time in order to make the intended recipient/ audience actively "sit up and take notice".

• This is the concept behind the TrendWatch presented earlier. 
• Critical information is displayed on one page - an important concept that ensures adequate visualization of the overall initiative. 
• This allows individuals and a team to understand how their performance is linked to outcomes and where their collective performance sits in the context of initiatives undertaken to improve performance. 

(2) Sentinel Effect: The idea that someone may be watching you can change your actions.

• Monitoring data regularly, providing feedback, and generating reports all create the signal to individuals and teams that their behavior is being monitored. 
• In my experience, this is sufficient to drive most individuals to change "undesirable" behaviors. 

(3) Social Norm Bias:

• This is the mechanism that drive the power of the SMART Profile system presented earlier. 
• Producing a Profile and sharing it regularly with team members provides the impetus for team members to gravitate their behaviors towards the "social norm" or "team average" or "benchmark". 
• When combined with the monitoring of data, provision of feedback, and generating of reports, profiling helps to keep desired behaviors in place. 

(4) Ability to Take Action: The individual must be able to take action to change the behavior that the feedback is intended for. Many improvement efforts fail because the feedback loop that they generate is on "irrelevant" items, or behaviors that any particular individual is unable to change, i.e., they may need to be changed at the group/ team/ systems level.

(5) Consequence: Consequence is ultimately what makes all of the above strategies successful when implemented within a "system". In most cases, consequence is a theoretical possibility and no consequential action is actually undertaken. However, the possibility must exist of consequence, which in the context of healthcare performance improvement may include the following:

• Coaching 
• Supervision 
• One-to-one meeting
• Letter on file 
• Censure 
• Peer review 
• Suspension

Can Standardization Cut Costs & Improve Quality?

A couple of articles in today's USA Today identify a growing - and seemingly controversial - trend at US hospitals: standardizing approaches to clinical care delivery in order to reduce costs.

Medical cost-cutting also can improve care

Hospitals try to find savings, cut unnecessary care

There is nothing really new here to drive the controversy as numerous healthcare organizations around the country are implementing Lean, Toyota Production System, or other methodologies in order to reduce waste. Some of that waste comes in the form of avoidable costs - which it would be good to remove from the system. 

The controversy lies in the insinuation that this cost reduction comes at the expense of patient care or improvements in quality. In reality, numerous organizations have demonstrated that standardization of clinical processes leads to both improvement in quality as well as reduction of costs.

• Virginia Mason Production System
• Intermountain Health - Brent James 
• Institute for Healthcare Improvement - Breakthrough Collaboratives

Doctors worry because they feel that their decision-making authority will be taken away from them in the process of "standardization"; but if you study the improvement efforts closely you realize that the common thread is that doctors and frontline staff are integrally involved in the standardization efforts, without whom the efforts would surely fail. Once the team has determined, with a lot of careful input and thought process, that "one particular approach" makes sense for their organization in order to improve quality AND reduce waste, individual physicians and staff would certainly be encouraged to implement that approach. 

As clinicians will readily point out, the "one size fits all" approach doesn't work in medicine. That's when professional judgement is truly needed - knowing when to deviate from the standard approach, and personalizing the protocol or treatment to the individual patient and the particular scenario. However, the fact that we need to deviate from a standard should not be an argument against the development of standards, merely the recognition of the limits of standardization. 

The real message of the critics of standardization should be that organizations pursuing standardization need to be vigilant in also building in appropriate mechanisms for deviation from the standard.

Leadership & Business Model Failing to Support Patient Safety & Quality

In this post by Paul Levy, former CEO of BIDMC, and staunch patient safety advocate, points out the failings of healthcare leadership in creating a culture of safety.

Juxtapose his call-to-arms with this Letter to the Editor written by the Illinois Hospital Association stating that "hospitals .. firmly believe in providing the highest level of safe, quality care to every patient" (which comes on the heels of a fairly damning report recently in the Chicago Tribune about lack of investigation about patient safety concerns at Illinois hospitals).

I can't think of any healthcare entity or practitioner who would not stand behind a statement similar to that issued by the IHA - after all its what we all believe healthcare should be about (and it is the politically correct statement to make). Healthcare institutions and leaders are not deceiving us when they say they believe in quality and safety, and that they are working towards improving these outcomes. Yet the industry is still collectively failing to meet the needs of patient safety and quality. How then do we explain the gap between "what we all believe" and "why we are failing"? I would point first to a few logical disconnects:

• belief does not equate to action
• belief does not equate to the right action
• belief does not equate to primacy of belief
• belief may not equate to sufficient action

We can justify our belief in patient safety by committing some resources to the activity, and undertaking a few choice initiatives. However, this does not necessarily lead to the outcomes that ultimately everyone is concerned about - demonstrable improvements in quality and safety, and organizations driven by the same. The rate of improvement that these activities can sustain may not even keep pace with the increasing complexity of the healthcare delivery system, which continues to yield unfortunately visible, dramatic signs of failing the patient.

As Paul Levy states, quality and safety have to be " internalized it into .. decision-making and process improvement efforts". However, this approach is also vulnerable to the following challenges:

• quality and patient safety are as yet not adequately measured
• institutional leadership is generally constrained by the rules of the industry
• societal leadership has to change the rules of the game 

If the primary objective for hospitals is revenues and volumes, healthcare executives will inevitably subjugate patient safety to these business drivers. Our healthcare institutions need to be rebuilt with the ideas of maximizing patient safety and quality first, and restructuring the business model around quality and safety. Pay-for-performance (P4P) programs, quality measurement, public reporting, value based purchasing are all initiatives that support the "quality and safety movement", however, are not sufficient to transform the industry and its leaders to "think quality first". They are seen by many within the industry at worst as "bureaucracy", "regulatory burden", "added costs", and at best as "nibbling around the edges". Attempts to measure additional dimensions of quality and to increase transparency are generally met with similar immediate reactions. The industry is not generally rushing forward to embrace and evolve into a quality-driven model. This is largely to be expected, as the current business model does not allow for the typical healthcare institution to be "built around quality".

The Accountable Care Organization (ACO) concept is generally a push in the right direction - at least it is an attempt to create more of a platform for quality while reducing the model's demand on volume for profitability. However, the dimensions of quality measurement as yet are significantly limited - is the patient's experience of safety truly measured by patient satisfaction surveys? are physicians' views about quality incorporated into the "core measures"? are nurses' concerns about safety incorporated into "hospital acquired complications"? And even though the ACO model changes the focus from "doing more for every patient" it subtly subverts the business incentive to "do as little as possible (within the limitations of measurable quality) for every patient" and "sign up more patients (through hiring more physicians) to join the ACO".

In order to drive real transformation of the industry - rather than just "payment reform" - a true "quality-driven" business model needs to be developed. As opposed to the "volume" or "frequency" turnstile, we have to develop a "quality and safety" turnstile. Quality and safety should be measured at the level of the individual patient, and drive the payment mechanism only if deemed adequate. Institutional leadership can only rise to the challenge if the rules of the game are changed at the societal level.

No Ego in Performance Improvement

This recent blog post by David Witt in Blanchard LeaderChat stimulated me to think about the role of ego in performance improvement. There are lots of authors writing about this topic recently - my favorites being Deepak Chopra's "The Soul of Leadership" - which coincidentally talks about the potential of soul-driven vs. ego-driven leadership; and Jim Collins' "Good to Great", which talks about "level 5 leaders having a unique combination of intense will combined with personal humility". 

Performance improvement is ultimately all about leadership, so one is compelled to think about the impact that ego-driven leadership can have on improvement efforts. I think the issue is the same as identified by David - ego can drive ambition and results (a la "the activated internal champion"). However, when it comes to creating sustainability, generating buy-in, and managing behavior - all critical aspects of performance improvement - its ultimately the "team-player" that wins out. 

The leader (or PI Specialist or Project Leader) who can "channel her ego" into building the following performance improvement components will not only achieve success in short-term goals, but also has a greater likelihood of sustaining the gains.

• Culture Aspects
• "No blame" 
• Feedback provided constructively
• Accountability provided fairly
• Systems Aspects
• Multidisciplinary team drives problem-solving
• Platforms for awareness 
• Forums for education 
• Channels of communication 

Let’s All Feel Superior: Individual Failures Require Leadership, Systems, and Culture to Bind

I read this op-ed piece from David Brooks in the New York Times with great interest. While talking about the Penn State scandal, Brooks identifies several fascinating psychological constructs that we use as individuals to avoid taking the "right action":

• Normalcy Bias - "shut down and pretend everything is normal" 
• Motivated Blindness - "don't see what is not in their interest to see" 
• Bystander Effect - "the more people are around to witness the crime, the less likely they are to intervene" 
• Self Deception - "we attend to the facts we like, and suppress the ones we don't" 
• Blind Spots - "when it comes time to make a decision, our thoughts are dominated by thoughts about how we want to behave; thoughts of how we should behave disappear" 

His key point is that we're in denial of "the underside of our own nature", which I would have to believe is likely true. However, as Brooks also points out "in centuries past people built moral systems that acknowledged this weakness .. they helped people make moral judgments and hold people responsible amidst our frailties." I would argue that this is the real weakness. Human nature has not changed, but society has evolved into such a complex organism such that the systems to keep "human nature in check" are not functional.

But this is ultimately what is means to be a leader - whether spiritual, political, or organizational - and to create an organizational culture: help to guide human nature - despite its many failings, blind spots, self deception, and biases - to achieve a purpose and pursue actions that no individual would undertake on his/ her own.

Many of us see these individual failings consistently in our healthcare organizations, which have largely been build around the notion that failure of behavior is an individual failing. Sometimes these individual failings are just as egregious as the examples used by Brooks when staff, managers, and executives "stand by" and allow for actions to be taken that lead to patient harm in the guise of "its just the way things work around here".

However, as many industry leaders have been pointing out - particularly the stalwarts for patient safety - individual behavior may contribute to a failing, but it is not the cause. The system (i.e., culture or society) that allows that behavior to be manifest is the cause. If we want better behavior, decisions, actions or ultimately the outcomes which result from these behaviors, then we have to work with greater diligence to build the leadership, systems, and culture that will allow individual failings to be overcome or at least held in check. The likelihood of harm is just as great, and not at all excused because the victims are sometimes unknown, or because it happens within a building and not on the street.

Hospitals Reduce Bloodstream Infections: Performance Improvement in Action

This article from The Tennessean provides a nice overview of gains made by hospitals in the state to reduce bloodstream infections related to catheters - a hospital-acquired condition that can be deadly. The secret to their success? They applied principles of performance improvement:

• The State Department of Public Health started collecting data across institutions.
• US Department of Health and Human Services established a benchmark for all hospitals to aspire to.
• Hospitals started following a "safety checklist", including the following elements:
• thoroughly wash hands
• wear sterile protective garb
• avoid putting catheters in the garb
• cleanse the infection site 
• remove catheters as soon as they are no longer needed
• Centennial and Methodist University Hospital committed to transparency by posting their numbers on their own websites.
• Vanderbilt increased awareness about the initiative by posting signs counting "days since the last infection".
• Vanderbilt developed an "antibiotic stewardship program" to closely monitor use of antibiotics which has helped to reduce the incidence of multi-drug resistant pathogens.

It is gratifying to see initiatives like this taking hold as other states have also been reporting positive outcomes with their collaborative efforts. However, there is a lot of improvement work to be done! Federal and state officials should provide a greater impetus to such initiatives - lead more collaborative efforts, aim for higher targets, and try to achieve the gains faster. The hospitals that have not achieved gains at the same rate as others may need more assistance from the state or other agencies in setting up their performance improvement systems.

Performance Improvement Tip of the Day: A "SMART" PI Project Checklist

In this "list-obsessed" world of ours, its hardly a surprise that one would create a "Checklist for Checklists". In healthcare, the call has gone out from Drs. Peter Pronovost and Atul Gawande to introduce Checklists as "patient safety tools". They are particularly useful when dealing with complex systems, and for reminding personnel of "basic operations" that can't be forgotten. When used properly, Checklists can ensure that necessary aspects of care are delivered, and free up highly trained personnel to think about when to deviate from a Checklist, and focus on higher level decision-making.

As we make our performance improvement teams more results-oriented, the Checklist becomes a useful tool to help keep the projects themselves on track. This helps to remind our project leaders about the steps they need to take in order to ensure that project goals will be met.

The "SMART" PI Project Checklist below - in keeping with our "SMART" theme - helps to provide a relatively simple, easily implementable framework for delivering improvement. In this context, "SMART" reminds us of the following:

• When designing Goals, Feedback, and Profiles, keep them "SMART" in order to ensure efficiency and minimize the likelihood of resistance or conflict. See prior blogs on each of these topics for more details.
• The "SMART" PI Project ensures that we:
• "Specify" ownership of the project.
• "Monitor" results in an ongoing fashion, and ensure that others in the organization help us with the monitoring.
• "Analyze" the current system in order to properly develop Goals, identify Barriers, and identify the Critical Processes that need to be undertaken in order to deliver results.
• "Redesign" the system intelligently building in decision support to ensure reliable outcomes, and enhancing safety mechanisms to catch problems real-time.
• "Train" ourselves, our staff, and our leaders to deliver better results using proven "behavioral management" techniques of Feedback and Profiling.

While this list can be individualized for the needs of particular institutions, the elements included are generally those that I find essential in delivering results. As you work through the list, you are introducing greater reliability into the system and establishing an increasingly mature culture of improvement.

"No one wants to be an Outlier" - Spine Surgeons at BIDMC Use Performance Improvement Tactics to Reduce Waste

This initiative at BIDMC to reduce waste in spine surgery is a great example of a "performance improvement system" (in this case they used Lean) to improve outcomes (in this case clinical utilization). A similar "performance improvement" approach can work in improving quality, mitigating risk, and improving patient safety.

The article identifies the following "performance improvement tactics" that should be integral components of all improvement projects:

• Examined how much they used and spent (review and monitor data)
• Questioned why each device was being being used (ask why five times)
• Studied reasons for wastage (undertake root cause analysis)
• Asked surgeons, operating room personnel, industry representatives, and nurses to help them identify waste (seek multi-disciplinary input)
• Compiled lists of who had been wasting more instruments than others (create profiles)
• Shared lists [of waste generators] with each other (create report cards)
• Awareness campaign (educate)
• Physician leadership prompted change (get support from leadership)

The key behavioral drivers that project leader, Dr. Kevin McGuire, Chief of Orthopedic Surgery, identified are "physicians are competitive in nature" and "no one wants to be an outlier". Understanding these drivers is key to understanding some of the performance improvement tools and how to deploy them effectively.

Performance Improvement Tip of the Day: Hierarchy of Clinical Decision Support

As we construct checklists, order sets, and various other tools to help guide clinical activity, there is a hierarchy of decision support that patient safety and quality improvement experts need to be aware of.

HIERARCHY OF CLINICAL DECISION SUPPORT
Level	Description
1	No decision support provided
2	Education provided re. clinical decision,  but no decision support at point-of-care
3	Decision support provided at point-of-care, but not integrated into workflow
4	Decision support integrated into clinical workflow, but optional
5	Decision support mandatory to complete,  but "opt in" required to activate
6	Decision support is the default option,  with "opt out" required to de-activate
7	Decision support automatic, e.g., initiated by protocol, with parameters built in for safety

In general, as you implement higher levels of decision support, the likelihood of the "right" action being undertaken increases as the dependence on the clinician making an "active effort to choose the right action" decreases. However, at the same time, clinical autonomy in decision-making is also reduced, which is often perceived as  "administrative" or "heavy-handed" by physicians. As such, it is wise to embark upon the "hierarchical" journey with caution, full support of the medical leadership, and a clear sense of what the "medical culture" and "institutional culture" will be able to support.


Over the course of future blogs, I will provide some examples of these decision support levels in practice.

Improving Surgical Safety: Time-Outs, Use of Checklists, Systems Improvement

This article in Hospitals and Health Networks provides some interesting insights into successful interventions undertaken by many hospitals to reduce the likelihood of "wrong-sided surgeries" - an event so infrequent, that it is hard to muster an institution's scant resources to address. However, a number of institutions referenced in this article did exactly that.

One of the most helpful lessons from this article are the reasons that The Joint Commission found as the leading "root causes" for this "never event":

Operating Room

• Lack of intraoperative site verification when multiple procedures are performed by the same provider 
• Ineffective handoff communication or briefing process 
• Primary documentation not used to verify patient, procedure, site and side 
• Site mark(s) removed during prep or covered by surgical draping 
• Time-out process occurs before all staff are ready or before prep and drape occur 
• Time-out performed without full participation 
• Time-outs do not occur when there are multiple procedures performed by multiple providers in a single operative care 

Organizational Culture

• Senior leadership is not actively engaged 
• Inconsistent organizational focus on patient safety 
• Staff are passive or not empowered to speak up 
• Policy changes made with inadequate or inconsistent staff education 
• Marketplace competition and pressure to increase surgical volume leads to shortcuts and variation in practice 

The article also identifies the following interventions that seem to have been effective in different settings:

• Implementation of the WHO "Surgical Safety Checklist" to ensure critical aspects of the impending surgery are reviewed (Safe Surgery 2015) 
• Implementation of "Time-Out" to ensure surgical team synchronization (Minnesota) 
• Improving communication regarding the scheduling of surgeries (AnMed Health Women's and Children's Hospital, SC) 
• Support from Hospital Association and local hospital leadership (South Carolina Hospital Association) 
• Insistence upon use of evidence-based standards (Pennsylvania Patient Safety Authority) 
• "Labor-intensive practices" - including staff support, physician support, meetings, observations, a role for everyone (Lifespan, RI) 

These are great examples of "good-old-fashioned" performance improvement - get leadership involved, create a multi-disciplinary team, measure the critical steps in the process, share the data with staff and medical staff, implement the evidence-base, ensure that not implementing the evidence-base is not an option.
There are many other interventions that can also be implemented to help improve surgical safety. Some of these may not directly impact the likelihood of "wrong-sided surgery", but they can have a major impact in the greater endeavor to make surgery safer.

• Pre-Operative Checklist: Helps to standardize a number of items that need to be in place before a patient is "cleared for surgery", including: 
• Cardiology Evaluation (required in high-risk cases to ensure patient's cardiac condition is appropriately treated prior to surgery) 
• Pulmonary Evaluation (required in high-risk cases to ensure patient's respiratory function is appropriately maximized prior to surgery) 
• Anesthesia Evaluation (identifies risk for complications of intubation, anesthesia, and surgery) 
• Administration of Beta-Blockers (specific medications that can reduce risk of cardiac complications) 
• Pre-Operative Testing, including Labs, EKG (to ensure that there are no latent underlying conditions that need to be treated prior to surgery) 
• Prophylactic Antibiotics (medications to prevent infection) 
• VTE Prophylaxis (medications to prevent blood clots) 
• Plan for Peri-Operative Pain Management (a proactive plan can improve pain control, and post-operative recovery) 
• Post-Operative Checklist: Helps to standardize a number of items that need to be implemented and monitored post surgery, including: 
• Monitoring of Blood Loss and Fluid Status (can be signals of underlying complications) 
• Monitoring of Pain (can be a signal of an underlying complication) 
• Monitoring of Cardiac Rhythm (can alert to underlying cardiac complications) 
• Monitoring of Bowel and PO Status (are signals of overall recovery from surgery) 
• Sepsis Screening Protocol (monitor signs to alert for impending infection) 
• Prophylactic Antibiotics (medications to prevent infection) 
• VTE Prophylaxis (medications to prevent blood clots) 
• Removal of Foley Catheter within 24 to 48 hours (can reduce the likelihood of a urinary infection) 
• Intra-Operative Pause: 
• The "Time-Out" is a process by which all team members stop what they are doing prior to surgery so that they can all get "into synch". 
• The Intra-Operative Pause similarly provides a break during prolonged procedures so that team members have a chance to "re-synch". 
• Severity of Surgery Assessment: 
• A formal means to improve communication prior to surgery about the potential for complications. 

I'll provide more details about some of these interventions in subsequent blogs.

Pay-for-Performance to Improve Quality at Rhode Island Hospitals

Reflecting a move underway in many parts of the country - including with the federal government - insurers are now looking to compensate hospitals and providers more on the basis of quality measures/ outcomes rather than simply for the delivery of service. Part of the drive to do this is simple cost containment - it gives the insurers a means to keep the growth of healthcare costs pegged at general inflation. The other main driver is to improve quality - despite developing a world-beating medical-industrial complex in the US, the system has become so complex, the need for coordination of care so intense, that many providers are failing in their ability to deliver high reliability for relatively simple, non-controversial, "evidence-based" clinical care processes. Many of these failures in the undertaking of "process measures" also add up to failures in "outcomes measures" (the ultimate objectives of delivering care) - including readmissions, mortality, and complications.

This article in Providence Business Journal demonstrates how Blue Cross Blue Shield of Rhode Island is working with hospitals to incentivize them for quality. One of the points that this article doesn't make is that the data for how most hospitals are doing is publicly available on a website developed by the federal government: Hospital Compare (www.hospitalcompare.hhs.gov). Its important for consumers to know this as "transparency" and "consumerism" are two of the big movements driving improvements in quality and safety in the US. 

While the overall objectives of the BCBS of RI initiative are commendable, the measures that the incentive payments are targeting are mostly process measures. From a quick review on Hospital Compare, many of the state's hospitals are already doing well on these process measures. There do appear to be opportunities to improve the "patient experience of care" measures state-wide, however, whether these measures are a true reflection of quality is being actively debated.

The real need is tackle the more complex outcomes measures, which certainly appear to be an area of opportunity at some of the state's hospitals, particularly for readmissions:





The good news is that groups like Rhode Island Quality Partners and Rhode Island Quality Institute are working on improving systems to improve "transitions of care" which can lead to reductions in readmissions. More work like this needs to be supported so that the healthcare system can meet the needs of the public in a high reliability, high quality, and high patient safety manner.

Complication rates (also reported on Hospital Compare) appear to be a challenge for some hospitals in the state. I'll write more about that in a subsequent blog.

Performance Improvement Tip of the Day: The "SMART Profile"

As you can gather from previous posts, SMART is a recurring acronym from our "performance improvement perspective".

The SMART Profile is a tool that can help you generate a sense of who the “top performers” are for any performance measure, who the “outliers” or “low performers” are, and how each individual practitioner ranks within his/ her peer group. When prepared with an eye to the SMART elements below, this tool can provide an important impetus to behavior change.

PPII SMART Profile Tool

Physicians in general are data-oriented and competitive. The SMART Profile comparing an individual's performance to others in their professional peer groups provides a helpful reference for the individuals to know where they fall "within the ranks". Those on the "Top Performer Reports" are supported and reinforced to continue their positive behavior, while those on the "Low Performer Reports" are motivated to improve their performance.

Performance improvement staff often worry about the negative ramifications of Profiles and the potential for "angry physicians". However, most individuals do not react negatively - particularly if the profiles follow the SMART paradigm. Those rare individuals who do get upset about the profiles generally become quite compliant once they have blown off steam and understand how these contribute to the overall improvement effort. 

It is important for PI Specialists to understand that behavior cannot change unless one provides some "framework" for the same. SMART Profiles are an important means to establishing such a reference.

These Top Performer and Low Performer Report Cards were provided courtesy of Physician Performance Improvement Institute. 

Performance Improvement Tip of the Day: Standardization of a PRN Protocol

A simple example of standardization - a short list of PRN (as needed) medications that were most likely to be ordered for inpatients.



What led to the development of this initiative?

Physicians were frustrated that they were getting calls at all hours of the day - and particularly night - for relatively "simple issues".
Nurses were frustrated that they could not give their patients relief for "minor" and common symptoms - for which many of the medications were over-the-counter, until they heard back from the physicians. The delay in some cases could be hours.
Patients naturally bore the impact of this, not getting timely relief.

It took some work to come up with a set of medications that the medical staff and nursing staff could agree upon to be administered for most patients without a direct medical evaluation. However, once the "PRN protocol" was created, and integrated into the General Admission Order Set, it immediately led to a reduction in what was perceived by all staff to be "unnecessary phone calls".

Patients received care more promptly. The "first-line" treatments for "minor" symptoms could now be initiated by nursing judgement, and rarely led to a request for "second-line" treatments.

Standardization by using a common set of medications also improved safety by reducing the complexity of the system, by increasing clinical familiarity, and by having parameters and precautions "built-in" to the order.

It allowed the communication between nurses and physicians to rise to a "higher level of practice" rather than to consume their valuable time chasing each other about the routine.

Caveat: Even "minor" symptoms can turn out not to be minor, particularly in patients admitted to a hospital. Clinicians are right to be worried about over-standardizing care through the use of protocols, however, a well-developed protocol when balanced with continuing exercise of clinical judgment can streamline the care process dramatically.

Medication Errors Affecting 2000 Patients at Lifespan Hospitals: Need to Improve Care Transitions

The issue of medication errors affecting 2000 patients at Lifespan Hospitals in RI is understandably catching the media's and public's attention.

Although the apparent explanation offered by the hospitals is "software error", the article in FierceHealthcare quotes RI State Health Director, Dr. Michael Fine: this represents a "risk in the handoff process" and requires a "more robust team approach for care transitions".

It may be a relatively subtle mistake that was made - substitution of time-release medications for shorter acting formulations, however, a robust "care transitions process" that the article alludes to could have provided a safety net to catch mistakes made by a software glitch:

• At the time of discharge, it is a common expectation at US hospitals that a formal "medication reconciliation process" be undertaken. 
• Many, if not all, hospitals struggle with medication reconciliation due to the complexity of the task. 
• However, the minimum requirement that all institutions should be able to uphold is that the physician discharging the patient review all discharge medications explicitly, and indicate whether each should be continued or not. 
• The nurse discharging the patient should also review the medications ordered by the discharging physician, providing a "double-check" of the medication reconciliation process. 
• Prior to discharge, the discharging nurse (or delegate) should review the discharge medication list with the patient in order to ensure that the patient understands which medications to take and the indication for each.  
• While many patients may not be in a position to question a subtle substitution of formulations, the aware patient and/or representative family member can often be a "triple-check" in the medication reconciliation process. 
• Subsequent to discharge, the patient's primary care physician and visiting nurse (if involved) should review the discharge medication list to ensure clarity regarding each medication prescribed. 
• These clinicians may be at a disadvantage at determining which medications may not be appropriate since they were not involved in the inpatient care, however, their astute judgment can be a "fourth check" to protecting patient safety. 
• The corollary discharge documents - usually a discharge summary, medication list, and "referral form" - should be completed in a timely manner by the inpatient clinicians and communicated reliably from the hospital to the outpatient care providers. These documents can provide an essential link in the communication chain to ensure safe patient care. 

For an error not to be caught by any of these "safety mechanisms" does imply that there are more serious issues than a software glitch, and Dr. Fine is right to identify that the "care transitions" process needs to be carefully reviewed and may need to be redesigned.

Performance Improvement Tip of the Day: Embed the Desired Practice into the Clinical Workflow

This document illustrates a very simple improvement principle - in order to ensure that the desired practice is undertaken, embed it within the clinical workflow.

In this example, ordering of DVT prophylaxis was embedded into the tool that clinicians used to admit all patients - the General Admission Order Set. Multiple prior iterations of a separate "DVT order sheet" were tried but failed, because it was "yet another document that clinicians had to remember to grab".



Once the desired practice was built into this order set, the resultant ordering of DVT prophylaxis improved considerably. The issue in this case was not that the clinicians were unaware of the need for DVT prophylaxis nor that they were resistant to the same, but simply that the appropriate reminder (AKA checklist) was not presented to them at the time when they were most likely to write this order. A simple reminder, including the most common orders for DVT prophylaxis, provided at the most clinically opportune time gave the clinicians the precise "decision support" they needed to ensure safe practice.

The DVT Prophylaxis section is highlighted here:


We also included "decision support" on the reverse-side of the paper-based orders so that staff had an immediate reference handy to support their decision-making:

Could Performance Improvement Systems Reduce Communication Errors, Malpractice Payments?

From this recent article in FierceHealthcare, failures to communicate have resulted in 40% increases in malpractice premiums from 1996 to 2003.

Some of the common reasons cited for communication breakdown: "Physicians and patients might not receive results, report findings may be delayed, and there may by lengthy turnaround time. Together, these three communication failures across all specialties totaled $91 million in payouts in 2010, compared to $21.7 million in 1991."

Automation is touted as one of the potential solutions to this issue, which it certainly is. Automation can take out the human element from the workflow equation, which generally improves the reliability of a process (as long as the workflow is otherwise designed properly). However, automation has its limitations as well:

• The wrong fax numbers may be entered in the system, thereby sending documents either to wrong parties, or to a document neverland. This can create more quality and risk issues.
• Changes to the system can lead to breakdowns in other parts of the system, requiring constant vigilance.
• Not all parties use the same technologies thereby making the connectivity more problematic.
• Automation can convey the false-sense of reliable transmission, but it is generally unidirectional, and as such, may not be able to ensure that the recipient has actually received the document (no matter if the fax machine confirms that it was sent) nor that the matter is handled with the same urgency as the sender intended. 
• In the "clinical emergency arena", nothing beats the direct phone call, provider to provider, to ensure that the communication and intended actions do not fall through the cracks.

Beyond issues with automation, however, the biggest opportunities to improve communication lie in developing and implementing reliable systems for communication:

• Are there clear protocols for which tests and what test results are considered critical, thus, requiring "critical communication"?
• Is this list as appropriately narrow as it can be, and are the cutoffs for the test results truly clinically meaningful? 
• Having a comprehensive list can dramatically increase the number of times "critical communication" is expected to take place, and increases the likelihood of "communication fatigue" or "overload".
• Is there a clear process for "critical communication"?
• Is there a reliable system for training and re-training all staff in the "critical communication" process?
• Is the process for "critical communication" as streamlined as it should be?
• Are there staff involved in the process that don't need to be?
• Are the key steps in the critical communication process being monitored and measured?
• How often do the steps breakdown in the critical communication process, and when they do, what action is taken to address the systems or staff issues related to the breakdown?

Unless an organization develops a performance improvement framework for critical communication - implementing systems, defining protocols, redesigning processes and workflow, and monitoring data - it is unlikely that any technology or automation will resolve the communication breakdown.

Tackling Delirium in Hospitalized Patients with a Structured Approach

This is a great article in the New York Times by Susan Seliger about the hazards of delirium in hospitalized patients. Delirium in this setting is not uncommon, but is poorly understood and addressed by clinicians and organizations. Unfortunately it is fraught with perils for patients.

Fortunately, there are protocols and systems that can be implemented to reduce the likelihood of delirium.

Dr. Sharon Inouye, who is referenced in this article, helped to pioneer the HELP (Hospitalized Elder Life Program) that seeks to reduce delirium by increasing social interactions with hospitalized elders. The goal of this program is to return patients to home close to the functional capacity that they came in to the hospital with. One of the hospitals that I have worked with implemented this program very successfully.

Other strategies to improve delirium include reduction of the medications that can lead to delirium, improving ambulation, and attention to hearing, visual, and eating impairments.

Alcohol withdrawal - unfortunately also quite frequent in elders - is a fairly common cause of delirium in the hospitalized patient, and can be tended to with careful history-taking, as well as protocols for close monitoring.

Undiagnosed or untreated pain is often a common cause of delirium, which somehow continues to evade clinicians. Sometimes clinicians get stuck between the "rock and hard place" of treating the pain with narcotic medications which can then in turn also lead to delirium.

Ultimately, this "hospital acquired condition" can also be mitigated by taking a systematic, performance improvement oriented approach to identifying patients at risk, implementing strategies to reduce the risk, and monitoring outcomes closely to ensure that the intended interventions are indeed in place.

Performance Improvement Tip of the Day: "Outcomes Driven" Meeting Agenda

The meeting agenda is probably one of the most commonly used tools in project management. However, how this tool is used can make a big difference in the effectiveness of meetings, as well as the coordination of the overall performance improvement project.

The "Outcomes Driven Meeting Agenda" template below integrates performance-enhancing features into the staid meeting agenda in order to create a powerful project management tool:

• "Roles" of team members - Leader, Facilitator, Scribe, and Time Keeper - are assigned at the outset in order to keep the agenda flowing. 
• "Time" is allotted for each agenda item in order to guide the discussion, and to keep the team from getting "stuck" on a particular item. 
• "Discussion Type" is a unique element that allows the team to know what the nature of the discussion will be, so that the discussion is more directed. 
• Info = Share Information 
• Proc = Process Information 
• Con = Need Consensus 
• Dec = Make Decision 
• "Desired Discussion Outcomes" is my favorite feature in this tool. It allows the project leaders to envision and lead the team to the desired outcome for each agenda topic. 

Adapted from Mike Hauser and Brian Stancampiano, Quality Solutions Group, Sanofi Aventis.

Respectful Management of Serious Adverse Events + Daily Safety Check-in

Combine the thinking of: 

• the paradigm proposed by Jim Conway, Frank Federico, Kevin Stewart, and Mark Campbell of the Institute for Healthcare Improvement about a framework for respectful management of serious adverse events in this article from HealthLeaders Media 

with: 

• the concepts proposed in this article from Patient Safety and Quality Healthcare by Carole Stockmeier and Craig Clapper about instituting a "daily safety check-in" 

and you start to get the makings of a powerful real-time and retrospective risk mitigation and patient safety system, which incorporates the following elements:

• Proactive, immediate, and retrospective responsiveness
• Heightened awareness of risk
• Early resolution of problems
• Accountability
• Leadership presence at the frontline
• Involvement of the frontline staff in safety
• Furthering the culture of safety
• Team-based approach to improving safety
• Development of a structured plan for dealing with safety issues
• Structured risk assessment and mitigation

Thanks to the vision and insights shared by the authors above and for their leading the charge to develop a patient safety system we can all be more proud of.

Performance Improvement Tip of the Day: Providing "SMART Feedback"

One of the most essential aspects of behavior modification is feedback - its critical to auto-regulation in all systems: biologic, social, and behavioral. If a practitioner does not find out that an action is undesirable, then she cannot correct it.

Most organizations are not familiar or comfortable with providing feedback. They find that it takes too much time, or the culture of the organization is not "ready for feedback", or they are not sure of how to go about setting up a feedback system, or they are worried about how the recipients will react. The purpose of feedback is not to chastise or blame, but to re-orient, teach, guide, and engage.

Feedback isn't about occasional meetings with the department head, or annual performance reviews. Those are too far removed from individual actions to be meaningful. Feedback is about providing critique about a specific action, in a time-sensitive manner so that the memory is still relatively fresh in the recipient's mind, and can be acted upon soon enough to change outcomes.

PPII has designed a SMART Feedback Tool to help performance improvement specialists structure their feedback in order to gain the greatest engagement and responsiveness from their practitioners:

PPII SMART Feedback Tool

Other "COOL" elements to add to the SMART Feedback structure:

• C - Consistent - to establish a "culture of feedback" and fairness.
• O - Ongoing - to ensure that the performance of a behavior is reinforced and hardwired.
• O - Opportunity - for the recipient to provide further input into the issue or request clarification.
• L - Learning-oriented - the best feedback provides a framework and opportunity for learning. 

This SMART Feedback Tool was provided courtesy of 

Physician Performance Improvement Institute.