DailyKaizen

Another guest posting from member Donna Kerr:

Second-day notes on QISTing

Here follow some notes on what I am learning about QISTing.

Visibility. Transparency in leadership is one thing; visibility of work is entirely another. An essential and powerful tool of QISTing is the tool of tracking work and its progress visually. When work is tracked from “in queue” to “in process” to completion via cards for all to see, the writing is literally “on the wall.” It is a powerful reminder that though the tasks and organization may be complex, all of the pieces come together. This visibility allows us all to see how our work and how we are doing. Judging from the sense of camaraderie, I also surmise that making our work visible to one another creates the “we” who do the work. Such a context enables even the “lone cowboys” to regard work as held in common.

Clinical knowledge and informatics. While QISTing draws on the system of electronic medical records, it focally addresses clinical work flow. Hence, QISTing is not just another application of EMRs. First, it calls clinicians to get clear about the work to be done – a process that requires much discussion and coming to agreement; second, it requires that the clinicians and information system builders consult to the end of the clinicians understanding the uses and limits of the system and the system builders understanding the clinical-support tools that they are being asked to develop.

Solving locally, applying globally. Centralized planning has, by definition and by history, solved problems globally and required local applications. QISTing takes a different route. It brings into discussion small samples local clinicians and other members of the flow staff together with centralized system builders, regulatory expertise on population-based care and improvement specialists. The goal is to develop a system that will be tested and work locally. If and only if it passes the test in one locale will it be applied globally in the healthcare system. The defining focus derives from lean management, which organizes its activities around the work flow “on the production floor.” Any and all improvements take place in clinical work flow.

The ten-minute encounter. I have a hypothesis that there’s a tacit assumption driving much of QISTing, namely that the physician (perhaps the entire clinical staff) has and will continue to have patient encounters that endure for far too short a time for the complexity of clinical assessment and knowledge. It is this “fact” that drives the definition of problems and the shape of the solutions that QISTs generate. For example, “best practice alerts” are developed as a way to remind a time-short physician of what she or he already knows, but may not have readily at hand in the press of the moment.

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