DailyKaizen

Thank you to Group Health patient Donna Kerr for writing down her experience. Please let us know what you think. I think I would like to continue to see patients involved in every event.

Day4: Transforming the Commonplace

We are in our last day of the work of this Quality Improvement Support Team. The changes in the system have gone live in this medical center (to enthusiastic applause); now reports are beginning to walk in the door. During the first three days, I characterized and tried to figure out how this improvement process works. Today I want to tell a small story. It is about something that just happened here in Conference Room C.

10:22 a.m. Nurse S walks into the QIST room to report to the system builders that the SmartSet (here, information for the patient) did not appear with the blood pressure alert (BPA) that fired for a hypertensive, diabetic patient. The builders took down the information necessary to investigate the case and thanked the nurse for letting them know.

11:17 a.m. The EMR support staff confirmed that the builders’ correction in response to Nurse S was up and working.

Commentary: That is precisely what we hoped would happen. A member of the clinical flow staff spotted a problem and made the effort to report it. Though predictable in this context, what just happened is remarkable!
The organizational commonplace would be for a change to be instituted, for the staff member to observe the glitch and then remark to a colleague that the failure was so predictable. Further comments in private might excoriate the very improvement effort, for example: “How dare they think that they know how to improve upon what we do!” That is, a mistake would occasion finger-pointing. Instead, because the process values perspectives of the flow staff, treats errors as important sources of information, and makes it clear that the system builders’ role is to help the flow staff, Nurse S came to the QIST room with her report. In organizational life, this represents a transformation of the commonplace.

This QIST is finishing its business, as is my participation. Ted, thank you for your invitation to share my experience as a member participant. Writing my observations has helped me see. I hope that I have done this laudable improvement process justice. Congratulations to you all and thank you for taking care of my healthcare system.

Written by Donna Kerr, Group Health patient:

I am participating in this Quality Improvement Support Team as a patient participant. However, in doing so, I do not check my own professional expertise at the door. Patients are, of course, not only patients. As a patient, I am keenly interested in understanding what accounts for this wonderfully effective process for strengthening my healthcare system. Having entrusted my healthcare to this organization, I want to understand the “magic” of QISTing well enough to explain it. As a person who also has leadership and hands-on experience in the development of institutions with quality measures in mind, I want try to figure out how QISTing works. (Here’s follows what I am learning, though clearly I may have relearning to do and would appreciate feedback in this regard.)

It is obvious to me that QISTing doesn’t just happen. What looks like magic is not. The assemblage of the pertinent clinical, informatics and organizational expertise reflects both a commitment by top-level leadership and considerable advance work. In turn, a decision at the top to commit the resources doesn’t just happen.

Courage in leadership. We QISTers have been focusing on supports for the treatment of hypertension this week. As a patient, it has occurred to me that if I were to have consistently elevated blood pressure, I might not want to acknowledge the numbers. Having hypertension with all its dangers would not accord with how I want to view myself. Indeed, wanting to see myself as a highly competent, vigorous person in charge of my own fate, I might well be inclined to ignore the unwelcome BP numbers. Similarly, I can imagine that the leadership of my healthcare organization might not want to attend to HEDIS numbers that do not bespeak the quality of performance claimed in the branding, boilerplate for donors, and self-images of administrative competence. Hence, one of the necessary components for QIST to work is leadership’s courage – the courage to acknowledge inconvenient, unflattering facts and the courage to commit the needed resources.

Bundling clinical and informatics expertise in both the team and the process. This is one of those times when saying the obvious has a purpose. QISTs are supported by an organizational entity entitled the “Clinical Information System.” The success of this entity depends crucially upon the fact that it brings together clinical and informatics expertise. Several correlative facts might not be so obvious – facts that remind us that QISTS have distinct uses and limits:

(1) QISTs can address only problems that lend themselves to extant information or information categories; they regard populations and not individuals. Put otherwise, their solutions would not regard me and my particular concerns, but populations and categories of health data and diagnoses.

(2) QISTs produce solutions exclusively in the form of computer-managed information.

(3) QIST solutions do not call for acquiring new clinical knowledge, but instead ask clinicians to bring to mind things they already know when thinking about individual patients. QISTS do not probe clinical judgment or occasion further education.

(4) The Clinical Information System succeeds in using the QIST as a tool only in measure that it constitutes a team that puts clinical and informatics together in describing and modifying actual work flows around the selected issue.

(5) The QIST work plan does more than bring the pertinent expertise to the table to generate a solution; it also includes a process that test drives the solution in the context of local clinical work flows prior to system-wide implementation. That is, the pertinent clinical expertise includes, of necessity, those who are themselves immersed in and responsible for work flows.

Tending relationships. While leadership and clinical-informatics expertise are essential elements of the QIST “magic,” there is a third essential leg: careful attention to the relationships among team members. This thoughtful attention to relationships is necessary and not just nice, though participating on a QIST clearly feels good! Persons are invited to be a part of the team precisely because they have expertise and experience pertinent to the work flow that is under the microscope. Engagement of that expertise requires tending the human relationships.

The process will succeed only if team members feel that the environment is safe for speaking the truth about work flows, that their contributions are valued, and that part of everyone’s job is to honor the contributions of others. In other words, it is not some disembodied QIST process that produces the needed solutions; it is persons standing in relationship to one another who get the job done. Lest this point risk seeming too vague, I hasten to add specifics. I find extraordinary the genuine solicitousness, the expressions of appreciation (including applause) and the sense of collective energy that permeate at least this QIST’s work.

What is being built here is not just better healthcare delivery around a specific issue, but also a healthier healthcare organization. That makes me pleased to be a member both of this team and of this healthcare cooperative.

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.

Donna Kerr, a Group Health member, has accepted my invitation to be a guest blogger during her time with us in our Olympia Medical Center:

A Learning Organization – an introduction

At Ted’s invitation, I write this entry as a guest. I have the splendid fortune to be participating this week as the patient on a primary care Quality Improvement Support Team (QIST). The team is focusing on changes in the information system to support an effort to ensure that no hypertensive patient goes inappropriately untreated. The team includes physicians, “flow staff,” information-system builders, administrators, professional improvement staff and me. The goal is to design a solution, to develop an effective modification to the information system, and to have it “go live” for local testing prior to global implementation.

I am witnessing an organization that is learning from experience. This primary-care QIST, a cross-functional team, is engaged in a focused discussion of the problem that has been identified through HEDIS data. That leadership might discuss such a problem is not by itself predictive of an organization that has the capacity to learn. The crucial pieces are (1) that key medical and informatics staff are involved, (2) that the perspective of each participant is being heard and valorized; (3) that some clinicians actually acknowledge errors, even in the presence of me, a patient; and (4) that the point of the QIST is to define and implement a solution in light of information gleaned from the errors and with the goal of improving patent care.

I celebrate the capacity of this “lean”-inspired system to define a problem created by practice and to learn from this experience. This is truly extraordinary in organizational life, where the destructive practices of obfuscation and denial are commonplace. In particular, I am heartened by the fact that my healthcare organization has a culture that supports learning – a culture where it is apparently safe to own problems, recognize limitations in knowledge or its application and acknowledge mistakes. As an educator who has also led organizational development, I appreciate how very difficult it is develop an organization with the capacity to learn from experience. As a patient in this healthcare organization, I could not be more pleased.