Data Collection: WHAT you measure and HOW you measure it

Data collection is one of the fundamental principles of systems-thinking and quality improvement. Being evidence-based is the buzz phrase in most quality and safety initiatives, and reams of data are collected on many things. There is often the notion that the more data we have, the better the improvement will be. This mindset frequently results in less than optimal results since quality is much more important than quantity. In data collection, the most important consideration is the identify What needs to be measured and How this will be measured. The “what” and the “how” can only be identified if a system or process is first made fully visible and understood. Then we need to identify the critical process elements (the critical 20% creating 80% of the results) and go to the source, with frontline care providers who actually do the work, to capture the information. Distinguishing between the formal from the informal process at work rears its head again.

What follows is an example of data collection that tracks the formal process rather than the informal process. In this hospital OR, efficiency and improvement focuses on time intervals manually entered into a computer, ideally in real time. Multiple time intervals are measured and the only one that is focused on at the quality improvement level is the time that the patient is in the room; for the first case of the day, 7:30 is the goal. As you read this, ask yourself whether the collected computer data reflects the “what” and the “how” to improve the OR environment.

Formal System: Computer Recorded Case Times

Set-up Begin: 7:18
Room Ready: 7:20
Patient In: 7:23*
Induction Complete: 8:22
Incision Made: 8:51
Ready to Close: 12:49
Surgery End: 13:40
Ready to Transfer: 13:40
Time Out: 13:42

*This is the only time deemed important: Patient In after 7:30 is documented as a late start

Informal System: Nursing Account of Same Case

This is not a litany of complaints. This is not one OR person “blaming” others, this is merely a commentary on one case, that unfortunately is very representative of what we are doing every single case.

Room 9, a relatively simple Dr. “X” spine procedure. 0730 on Tuesday.

We did not have a 6AM person setting up our rooms. The room did have a Jackson table with a Wilson frame on it. There were no dressings for the Wilson frame, and no face pillow. There was no “crank” for the Wilson, and the only one in the drawer in Room 10 was the wrong one.

Our float person was covering another room until 8AM.

The regular computer was not working. I had phoned the help desk two weeks earlier about the problem, it was never fixed. Today it was a problem because our films were from an outside hospital, and they were on a disc. Three phone calls to the help desk eventually brought a technician to the room. NIC notified.

Case was not booked with a C-arm. Dr. “Y” notified Dr. “X”’s office about the importance of doing this. Two phone calls to X-ray. The radiology tech was very gracious and did manage to secure a C-arm for an hour or so.

No microscope in Room 9. We claimed one that “J” and “B” were with (labeled Room 11) and eventually were able to locate the matching monitor, not in our area.

Two individual lights in the OR lights were out…call Bio Med.

Dr. “X”’s spine set contained two rongeurs that were caked with old bone. I bagged and tagged them, notified the NIC, she notified “K” from Quality Control and I ordered a Laminectomy I and II from Central Processing. I visited clean holding twice to collect them. The needed instruments in that kit were also dirty.

“K” came asking for the “slips” from the offending kits.

My room had one step stool. I borrowed another from Room 10, which was very soiled with blood and bone. I borrowed another. The care assistants did clean up the first one.

The arm board attached to the Jackson table broke as anesthesia attending slid it higher on the table. The patient’s arm did not fall. Located a care assistant who was dispatched to find another arm board.

My room (cabinets) were poorly stocked and in disarray. There were three incomplete Neuro prep kits, no body part for the hair clipper, no 1” paper tape, no gelfoam, 15 boxes of random sutures on the shelves, the Neuro sutures were depleted.
I had one ring stand only, and a broken lid on one of the trash containers. At 12 noon there were no towels on the exchange cart, nor were there any 60cc syringes, or 1000 drapes. Those were just the items I went looking for.

When my case finished, I took the patient to the recovery room, went to preop to see the next patient, and returned to the OR to start setting up…I was not able to clear the old sutures out of the cabinet, or gather supplies to re-stock the rooms. I did ask the supply room to come and make a list, but I never saw that happen. My apologies to the person who relieved me at three o’clock… and I guess that’s where we’re at… it’s a mess… I’m sorry… but it just isn’t getting done… run in and out of the adjoining rooms… scramble for what you need… borrow one of these… and lend something in return.

I know you can read between the lines… everyone of these simple “items” represents one more phone call… more waiting… time out of the OR… time away from the surgery… distractions and a hurriedness.

Help.

Questions: (What you measure and how you measure it)
1. Does the formal system reporting that quality improvement is based on reflect the informal system at work?
2. By computer, the patient was in the room before 7:30 and will be recorded as an on-time start – is this measure indicative of a quality process where no improvements are necessary?
3. With all of the running around that has to occur to get the patient in the room, do you think that the room was actually ready at 7:23?
4. Do any of the other recorded times suggest possible areas for improvement?

This example has a lot of lessons in it. Next time we’ll look at the implications of this work environment on staff satisfaction and patient safety.

Everything is Connected: Authentic Communication with Patients, Families and Staff

I was inspired to address this topic after receiving this blog comment:

I was struck by your statement, "The simple reality is that it takes a compassionate and supportive work environment to create a foundation for teamwork, a methodology for applying systems improvement that is simple and accessible, and quality improvement has to be returned to the frontline people with the support of leadership." Your initiative with the Peer Support program seems to be a step in the right direction toward this "compassionate and supportive work environment," but by your own description the members of that environment were not initially receptive, suggesting that at baseline there appears to be a general lack of supportiveness and dearth of compassion in place. Have you learned from your training and experience other PRACTICAL means (besides formalized Peer Support) of fostering a "compassionate and supportive work environment" that might be helpful to people in other environments who are also interested in creating better foundations for optimally functioning systems?

As I develop further as a systems-thinker I marvel at how everything is connected. This blog comment gave me an AHA! about the link between efforts to implement authentic communication around adverse events (i.e. disclosure, apology and support) and the challenge to create a compassionate and supportive work environment.

As we all know, the culture of healthcare remains very fearful and defensive around the management of adverse medical events. While many hospitals advertise robust policies for disclosure and apology in order to be in regulatory compliance, most organizations do a very poor job of implementation. In the process of communication with patients and families around these events, there is an inherent compulsion to have every contingency covered before any conversation is initiated with a patient or family (it took me five months of active engagement to organize a meeting between my patient and the hospital administration following my adverse event (see May 2 posting); it happened then only with great reluctance and trepidation).

Patients and families will tell you that they don’t expect all the answers when communication is initiated, but that they do expect updates in real time as the information becomes available. The cultural mindset to overcome on the provider side is that we want the communication to be pragmatic, comprehensive and finite (a project) while patients and families want an ongoing process of authentic communication. We want to use empathy (we don’t want to express how we feel) and patients look for sympathy (they want to know that we feel). When we communicate with such misalignment, anger and eroded trust on part of patients and families is the norm.

This same cultural mindset impedes our attempts to create a compassionate and supportive work environment. We exercise the identical pattern of poor communication with each other every day without realizing it. I had such an experience when I was doing some quality improvement consulting at a hospital. As is the case in most hospitals, there had been many previous improvement projects at this institution where leadership had failed to follow through with the recommended changes. There was a tremendous amount of anger and skepticism on part of the staff with yet another initiative when we began. However, our engagement managed to re-instill excitement into the improvement process, largely because we had empowered and supported the teams comprised primarily of frontline staff to identify and to solve the problems themselves. Respect and authentic communication set the standard. The teams worked hard and came up with some very significant system-based improvement ideas. At the end of our engagement, we submitted the teams’ recommendations to the hospital leadership for review and approval, while the teams anxiously awaited their response. While most of the suggested improvements were relatively small investments, there were some larger investments that had to be taken into deeper consideration before leadership could make a decision.

What the hospital administration decided to do was to hold off on any communication to the team participants until all the issues were resolved. Weeks passed without any communication and as would be expected, the increasingly frustrated frontline staff began to validate in their minds the usual pattern of “no follow through” by hospital leadership. Meanwhile on the administrative side, action was being taken to implement the recommendations! In spite of our repeated encouragement to leadership that they at least acknowledge the tremendous work that the teams had done and that they simply communicate some kind of a real time status report, they refused and finally requested that we leave them alone. The trust and enthusiasm that had been painstakingly developed with staff was replaced with anger and cynicism towards administration; as one of the nurses put it, “another blown opportunity for leadership to shine.” Even with the subsequent implementation of some of the recommendations the damage caused by poor communication was largely irreparable.

The parallels between the communication challenges around adverse medical events and improvement initiatives are striking. It is a vivid example of our cultural aversion to authentic communication, and the unnecessary harm that this causes to patients, families and staff. It is also a great example of the interconnectedness of systems: a poor communication process in one domain manifests everywhere else. Finally it is reflective of the principle that the only way to create sustainable change is to see a system or process in its entirety before problem solving: we have no chance of exercising authentic communication around adverse events with unless we understand and exercise authentic communication in the work environment. If we don’t treat ourselves with respect and authenticity, we don’t treat our patients with respect and authenticity.

Food for thought:
1. Authentic communication is a process, not a project
2. Authentic communication is compassionate communication (even when tough love is required)
3. Authentic communication is effective communication
4. Authentic communication has no boundaries
5. Authentic communication is a platform for change

Basic Care Made Visible: The Angry Patient

One of the frequently overlooked issues in the quality and safety movement is the importance of the fundamentals of care. We have a tendency to look at high profile issues like ventilator associated pneumonia or medication reconciliation (both of which are important) while forgetting that basics of patient care must be in place first. If we don’t see the connection of basic care processes to the high profile issues, we are effectively treating symptoms rather than root causes. As insiders, we forget how much workaround we do to get the basics done. Patients as outsiders are able to see what for us has become invisible as the following story reflects:

I enter Mr. Smith’s room for a post-operative pain evaluation. My introduction and query into his level of pain are met with a cold, silent stare. I ask him again how his epidural and PCA are working for him. Initial silence, followed by a reluctant response: “I’m very angry, not at you but at the hospital for the way I am being treated here.” I sit down on the window ledge and ask him to share what’s going on. He informs me that up until last night he thought the hospital was the “best thing since sliced bread” but that after this morning that’s no longer the case. He has no complaints about the nurses and physicians providing the care and what he shares is his frustration and anger about the lack of attentiveness that has resulted from staff being stretched way beyond their capabilities. He notes that his nurse is taking care of so many patients, many sicker than he, that she has no time to clean him up, to change the sheets, to assist him with walking. He notes how earlier in the morning his IV pump was reading “low battery.” Since he hadn’t gotten any responses to his nurse call button before, he asked his sicker neighbor to push his button. (“The poor guy,” he says, “he’s been waiting to get an MRI for two days”). The nurse showed up just as the pump started to alarm due to power failure. Fortunately the pump needed to be simply plugged in so that the batteries could recharge, and as the nurse started to leave the room, the patient noted that all of the infusions were blinking “reset.” “I don’t think I missed out on getting anything, but what if I hadn’t noticed or been able to call the nurse back and tell her?” His nurse walks into the room carrying a chair as the patient and I chat. “Look at that,” he says, “nurses should not be spending their time moving furniture!” She smiles and as she hurries off to do something else says, “I do it willingly.” “Willingly or not,” says the patient, “she shouldn’t be doing it.”
This reminds the patient of another earlier experience. He recounts how he was sitting in a chair and that his oxygenation was too low on room air. His nasal cannula tubing would not reach the wall oxygen source from the chair and the nurse went off to find extension tubing. She was gone for 20 minutes, looking for the tubing. She finally came back, and having been unable to find the extension proceeded instead to rearrange the furniture so that he could sit closer to the wall with the regular tubing. She then started to change the bed sheets without turning the oxygen on, again having to be reminded by the patient. He’s incredulous. “She’s probably one of the best nurses here, and she’s great, but she just has too many things to do at once to keep priorities straight.” Finally he says, “I have to do something about this, I don’t know what, but I might have just found something new to do with my life.”

Food for thought: Notice how the experience encompasses multiple basic care processes in the areas of:
1. Quality of Care
2. Patient Safety
3. Patient Satisfaction
4. Staff Satisfaction

The only way these connections become visible is with a system-based approach to problem solving.

Sub-optimizing the Patient Medication List

Hospitals frequently end up implementing suboptimal systems that actually result in a more dangerous patient safety environment. Healthcare is so inundated with poorly stratified safety guidelines and regulations that hospitals rush to initiate endless improvements in order to remain in compliance, without understanding the implementation challenges and without follow through. The results are initiatives that look great on paper at the executive level but that are completely dysfunctional at the level of patient care. Let’s look at an example.

LGR was under pressure to implement an electronic pre-admission Patient Medication List (PML) to reduce the incidence of medication error. A task force was put together to develop an IT-based process that would enable care providers seeing patients in the surgical pre-admission test center to enter the patient’s home medications into the computer; this record would then be printed as a separate sheet and placed into the patient’s paper chart behind the new PML tab for straightforward, easy access. Here’s the formal system:

1. Patient comes to the surgical pre-admission test center with their list of home medications.
2. The care provider evaluating the patient enters the medications into the new computerized PML template.
3. The PML is printed out and placed into the paper chart behind the new PML tab
4. The PML serves as an easy cross-reference during admission for any new medications added.
5. On discharge, the PML is referenced to ensure that the patient continues with their usual medications as appropriate.

Here’s what actually happened when the PML was launched (informal system). Computer entry of patient medications into the PML worked well enough in the pre-admit test center, provided that patients actually knew their detailed medication histories. Because the medications were now listed in the PML, the medication section of the history and physical form (H&P) was now simply noted with “see PML.” By the time the charts were assembled and the patients were on the floor recovering post-operatively, only 70% of patients seen in pre-admitting had copies of the PML in their chart. Further, only 25% of charts had the PML tab, resulting in the need for caregivers to search through the entire chart to find the PML, when it was present. With time, it became so frustrating to look through the chart for the PML that many caregivers stopped looking at all. They’re almost back to square one except that now there is no medication list in the 30% of the charts at all because the H&P says, “see PML.” You would think that caregivers could at least go online to look at the electronic version of the PML; however, access to the PML was restricted to a subset of users. So, while LGR is now in compliance with the PML guideline, appearing to be a leader in patient safety, here’s the suboptimal result that replaced the existing process:

1. In-chart documentation of pre-admission medications has dropped from 100% to 70%.
2. The PML process as developed works only 25% of the time! (PML in the chart & behind the PML tab).
3. There is now a double standard for documenting pre-admit medications since none of the surgical patients admitted directly or through the emergency department have a PML (not part of the roll-out).
4. Caregivers are so frustrated by the inconsistency that they largely forego looking for the PLM at all - it’s easier to ask the patients directly about their meds.

Food for thought:
1. As currently implemented at LGR, the PML has increased the potential for medication error by as much as 30% and it is now systematized with an IT interface. We frequently forget that while computer automation can improve safety, it is not the magic bullet. Computers are tools and not solutions: if the underlying process is not understood in its entirety, we will only automate what we already have, or make it worse.
2. The process is only understood if the people doing the work are involved! In addition to the IT folks we need to include caregivers doing the pre-operative assessment, the people involved in chart assembly and the caregivers taking care of patients during their admission.
3. Closing the implementation loop is critical. Too frequently, we launch an initiative and assume that the execution will follow to completion on its own as we run off to address the next guideline.

Sub-optimizing the Paging System

There are so many challenges in healthcare needing immediate attention that it can be overwhelming to know where even to start. What frequently happens is that a particular department or division will take it upon themselves to make an improvement that benefits their area, without recognizing the impact that this change has on a broader scale. When an improvement occurs that benefits one area to the detriment of “outside” process participants, this is called sub-optimization. Sub-optimization looks great as a formal process but in the informal process (i.e. the way it plays out in the front line of care) it quickly becomes unmasked. Not only does sub-optimization make the overall process worse but it also creates an immediate work-around. Here’s an example:

A large healthcare network reached a point in its growth where the computer-enabled paging system could no longer accommodate abbreviated callback numbers with only five digits. The decision was made to make a change in the system that would require users to enter the full ten-digit number into the callback field. Advanced warning of the change was made by email and on e-bulletins several weeks in advance to launch so that care providers wouldn’t be caught by surprise. So here’s the formal improvement:

1. Care provider goes onto the computer to page someone
2. On the paging screen, they enter the ten digit callback number
3. The person paged calls back using the ten-digit callback number
4. Communication as before!

Easy, straightforward and user-friendly, right?

Here’s how the launch went: When the new system was activated, frontline care providers quickly realized that they could no longer enter callback numbers to a significant number of phones because they didn’t have ten digit numbers! It turned out that in at least one of the network hospitals about one third of the phones are on internal phone lines with only five digits. Further, many of these phones are the ones that are next to the computers from which pages are sent and many are located in patient care areas where emergency contact may be critical.

Fortunately, frontline care providers are accustomed to “improvements” made without their input and quickly devised a work-around (informal process). The paging system is alpha-text capable, so almost immediately people started to write the five digit number in the text box, leaving the “improved” number entry blank. Of course, now everyone is largely ignoring the “improved” number entry site for all of the numbers, and they continue to abbreviate all numbers into five digits as before.

Sub-optimization occurred, at least in part, because the changes to the paging process were made without vital input from frontline caregivers who use the system every day. Without their input, the paging process was not visible in its entirety and the correction made was only from the vantage point of the IS/Communications department. The new and “improved” system is now worse than it was before. Not only has inconvenience been systematized, but it has also introduced an element of risk into the paging process for patients and staff when critical calls need to be made. Frontline care providers recognized this immediately and made the necessary work-around. Of course this work-around is also sub-optimal because it reinforces the likelihood that the wrong number will be called at another hospital (remember the initial reason for doing this change?)

So in the end, a lot of effort and resources went into what is now a suboptimal change because the right people weren’t at the table. It always takes far more effort to fix sub-optimization - it doesn't take long at all for the work-around to become very comfortable! I wonder if IS/Communications is even aware that a work-around is in place.

Formal vs. Informal Care Process: MRI

We touched on systems that we deal with in our daily lives outside of work. Now let’s look at an example of a formal vs. informal system in the hospital setting. (Reminder: the challenges that we face in healthcare are universal, and the purpose of this forum is not to separate out one institution from the next nor is it to finger point at individuals or departments. There will only be two references to hospitals, the larger hospital (>500 beds) as LGR, and the smaller hospital (<500>)).

Formal System: LGR provides anesthesia coverage for challenging MRI cases. This includes patients with severe anxiety and claustrophobia as well as patients with severe pain or co-morbidities that require extra attention. The formal system is set up as follows:

1. Anesthesia provides MRI coverage one morning per week on Thursdays.
2. The requesting service books the MRI case in advance with Radiology and with Surgical Scheduling so that the patient is officially on the anesthesia schedule
3. The outpatients are seen in the pre-admission test center on a day preceding their scheduled MRI; inpatients are evaluated the night before by the on-call anesthesia team.
4. The patients arrives at MRI about 30 minutes before the scan with complete paperwork
5. The anesthesiologist assigned to MRI reviews the chart, checks the anesthesia equipment set up by the anesthesia tech, and off they go.
6. The MRI cases are completed by 11:30AM and the anesthesiologist then proceeds to interventional radiology to provide similar afternoon anesthesia services.

Here is a description from the vantage point of the anesthesiologist of the system as it actually plays out at LGR. It’ not quite the same!

Informal System:
0730: There is construction going on in one of the MRI bays at LGR – it’s very noisy from the use of Jack Hammers; everyone is yelling to be heard.
0730: The patient arrives, upon chart review it is determined that there is no laboratory data. The MRI scan requires the use of contrast, which requires a baseline creatinine level to be drawn. There is no record of any recent laboratory work in the computer (looking in two IT systems: inpatient and outpatient); the patient had been seen in the pre-admission clinic 2 days earlier and blood had been drawn only for a coagulation profile (PT/PTT/INR). This lab is not necessary for this study.
0740: The patient is approached by the nurse and the radiology tech about the lab issue. The patient informs them that he presented a form with the necessary lab data when he presented to pre-admit clinic. No such sheet in the chart. The patient is now angry that LGR could lose this information. He now will have to have labs sent before we can do the study. He wants to talk with his referring neurosurgeon in person.
0750: The resident and attending anesthesiologist meet with the patient, acknowledge his frustration and suggest that to save him an additional needle stick that they can draw the blood sample through the iv. They also review his history and come up with an anesthetic plan to keep him comfortable during the study.
0810: The nurse contacts one of physician assistants to personally transport the blood sample from the MRI area to the lab after it is drawn. She arrives, apologizes to the patient and informs him that she will go to pre-admit clinic to find out what the problem was with the lab process. The patient says that he would love to go with her and give them a piece of his mind!
0820: The patient is taken out of the waiting area to the MRI patient prep area and placed on a stretcher. The resident starts the iv and draws a blood sample for the PA to take to the lab as arranged.
0830: PA goes to the lab – even though the sample is labeled “super stat” the result will take about an hour to obtain.
0908: The second MRI case is an inpatient scheduled for 0930. The tech asks the attending anesthesiologist (attending) whether she should delay the transport of this patient from the floor to MRI prep given the delay. She informs him that transport is usually arranged the night before for scheduled inpatients. He suggests that they hold off on sending for this patient until 10AM – given the unpredictable nature of transit time this will provide plenty of leeway so that this second patient has arrived by the time they’re ready; transport usually takes at least 30 minutes.
0910: The tech calls transport and is informed that the patient had never been scheduled with them (had they been on time with the first patient this second patient would not have arrived!). The tech asks that the patient be sent for at 10AM. She then calls the patient’s floor to inform the nurse that the patient will be coming down at 10AM.
0914: The attending receives a text page from Angiography to please call. He speaks with the nurse-in-charge, who inquires whether they will be able to start their scheduled case with anesthesia at 1130 as booked. The attending informs him of this unlikelihood given the delay. Fortunately, their schedule is flexible and he asks that they call him when they begin the second case so that he can send for the Angio patient.
0928: The nurse looks online for the necessary lab result for the first patient and it is still not entered. She calls the lab for the result and after a minute of waiting is informed of the lab value: It’s a go.
0930: The patient is taken into the MRI scanner, monitors are placed and sedation is given.
0942: The patient requires more sedation than expected, so while the resident remains with the patient the attending goes to the OR pharmacy to retrieve additional medications (OR pharmacy is at the other end of the building).
0943: The attending encounters an outpatient who is lost and requests assistance in finding the nuclear medicine clinic. He has a sense of where it is but given the poor signage, he offers to take the patient there himself. The clinic is halfway back to MRI. The patient is very thankful.
0945: The attending heads back to the pharmacy. Along the way three elderly family members stop to ask him who the third member of the Three Stooges is: Mo, Curley and? Without hesitation he answers “Larry” – he knows this data cold! They all have a good laugh.
1000: The MRI scan finally begins. The patient is well sedated, however, the pulse oximeter that they rely on to measure the patient’s oxygenation malfunctions repeatedly, resulting in continued scan interruptions, going into the scanner, pulling the patient out of the tube, readjusting the pulse oximeter, sliding the patient back in the scanner, leaving the room. Finally they get an intermittent signal by securing the pulse oximeter to the patient’s finger with a piece of tape.
1001: The second patient arrives to MRI – apparently they sent for the patient immediately disregarding the call requesting a 10AM pick up. This patient will now spend at least an hour on the stretcher waiting for her scan.
1013: The attending goes out to see the second MRI patient. Although the case had been scheduled the day before and should have been seen by the anesthesia call team, there is no pre-procedural assessment, no consent. The nurse informs him that she has the necessary paperwork for him to complete this but that she cannot stamp them up with the patient identification because the patient’s black ID card did not come down with the patient’s chart. She has called the floor and asked them to send it down.
1015: He reviews the chart in the meantime and begin to fill in the pertinent information
1028: The black ID card is hand delivered to him by one of the radiology patient care assistants
1104: The first case is complete, They’re 1.5 hours delayed. The patient will be recovered in Day Surgery and this recovery area requires discharge orders to be completed by the service performing the surgery or procedure. Radiology has never incorporated this requirement into their care process, so the attending asks the nurse to page the neuroradiology fellow to please go to day surgery to complete the paperwork. The patient informs them that he and his wife have traveled by train to get into the city and that they have to catch the outbound train at 12PM. Given that the scan was supposed to be completed at 0900, he thought that they’d have plenty of time. He tells us he’s leaving in 30 minutes whether we like it or not.
1109: I sign out the patient to the recovery room nurse and we realize that the patient’s chart has been left behind in MRI. I offer to go get it.
1141: Next patient in the room for MRI. Pulse oximeter continues to malfunction in the same way, adding approximately 25 minutes of additional time to the study.
1304: Patient taken out of the scanner. In the meantime the attending is down in Angio getting the patient ready for the procedure there. The resident pages him to inform him that the recovery room is full and that they will be on hold in MRI with this second patient if she has to recover there as originally planned. He inquires whether they might bypass the recovery room given that the patient has already met discharge criteria (alertness etc.). Fortunately they are out of the main OR and can exercise this work around option. The attending calls the resident back and inform him that this would be fine.

Think about the impact this informal system has on:
1. Levels of patient and care provider frustration
2. Efficiency and scheduling
3. Safety
4. Cost
5. Other?

This informal process has been in place for years and is so routine that it has become invisible!! Nobody thinks twice about this process – it’s just the way it is. Until we see it, dig into the core causes, and take a frontline system-based approach to correcting the issues, nothing changes; it’s the heroics of the people at the front who keep things running to the best of their abilities.

Systems Are Everywhere

Dear Friends,

What is a system?

Making systems visible: As I mentioned earlier, I had to completely re-learn my concept of what a system or a process is. I always thought of a system as something that was “out there” that I had to access in order to take care of my patients – the computer system, the blood bank, pharmacy, blood bank, the paging system. These are indeed all systems and what I slowly started to appreciate was that systems and processes vary in size and shape and that most importantly I was intimately involved in numerous systems myself. A system or process is a way that we do things in a repetitive manner to accomplish tasks at hand. Whether large or small, what’s amazing is how invisible they become once they are in place. Here’s an example: Every one of us has a specific way that we start our work day, every day, but how many of us recognize this and actually think about what we’re doing? How many times do you hit the snooze button before getting up? What’s the first thing you do when you get into the bathroom? You brush your teeth the same way every morning without thinking about it and if you want to challenge this idea, try brushing with your opposite hand or start the brushing at a different tooth location.

Formal vs. Informal systems: Another fundamental system concept that I had to acquaint myself with is the difference between formal and informal systems. The formal system is how the process is supposed to work; the informal system is how the process really works. The formal system is the one in the written manual, instructions and guidelines; the informal system is the one based on what actually works. It’s very rare that a formal and an informal system are the same. How many of us brush our teeth according to the instructions on the toothbrush box and on the tube of toothpaste, or the way the dentist tells us to? What’s important to note as well is that while the formal process is documented, the informal process usually isn’t – it gets passed on and modified by word of mouth. Two things happen to informal systems or processes as a result: each individual modifies them and they become invisible!

Why are these things important? What I realized is that just about everything I do has some sort of an informal process associated with it that has become invisible; in fact, I can run most of my daily routine on autopilot! This is all well and good if things are working well, but what if they aren’t? If I can no longer see the process because it’s become routine, how am I going to make an improvement that sticks? Chances are I’ll go back to the formal process and focus on making the changes there because it’s documented! But this isn’t going to do a great deal of good is it because the formal system isn’t the underlying process that’s driving the activity – it’s the informal process! The first order of business is to recognize that there is an informal process running the show and that is needs to be made visible in its entirety or nothing will change!

I can imagine what you’re thinking. “What does this have to do with improving healthcare?” We need to start seeing systems and processes in our non-work environment to appreciate the intimate pervasiveness that they have on our daily lives. When we recognize that we perform most of our daily routines on autopilot (invisibly) then we can start to look at what we do on a daily basis at work. So here’s your homework: look at a particular aspect of your daily home routine and write down how you do it – it’ll open your eyes!
Next time we will start looking at healthcare.

With love and respect,
Rick