Sometimes what I think we need around here is a big conductor with a very loud whistle. In the 12-plus months I have been making quality rounds with the cardiac surgery intensive care unit, our team has learned many things. But some things we ought to have learned, however, remain problematic. Topping my list today is the need for "buy- in."
Johns Hopkins is a wonderful assembly of entrepreneurs. As so often has been observed, individual initiative is what drives the excellence of Hopkins. However, at times we need to get everyone singing from the same page. And therein lies our dilemma-how do we get everyone aboard the patient safety train performing to desired standards without needlessly quashing the atmosphere of personal initiative that is so much the source of our strength?
Improving our processes-making them simpler, less prone to error, and therefore more efficient and effective-is a goal to be shared by the entire Hopkins community, not only in patient safety. Lessons learned, or not learned, from our Center for Innovation in Quality Patient Care (CIQPR), apply much more broadly and will be important for other major Hopkins initiatives, such as the design and implementation of a new enterprise resource planning (ERP) system.
One of the major impediments to quality in any organization is lack of communication. The CIQPR has shown that improving communication between doctors and nurses leads to improved outcomes in the intensive care units-including reduced length of stay. But getting everyone involved to agree to adopt the new protocols has been difficult.
For example, our unit developed a daily "rounding tool" that provides a spreadsheet summary for each patient-vital signs, laboratory data, etc.-and a list of the daily goals for that patient. Our team decided that each ICU physician should sign the sheet as a way of indicating that she/he understood and agreed with the goals that were developed on rounds earlier in the day. This way we hoped to minimize unsafe conditions that could arise from lack of communication between caregivers.
Two of the four ICU physicians on our unit were intimately involved in the innovations team and helped design the rounding tool. I therefore assumed that with two of our own driving the new process design, it wouldn't be a problem to get the other two physicians to sign on. Wrong, wrong, wrong. We all know what happens when we assume, don't we? In this instance, we find that the other two do not sign the daily goals sheet. Evidently one has agreed to do it but doesn't ever seem to get around to doing it, and the other has indicated that doing so would require too big a change in the way he practices medicine.
While physicians are a highly independent lot, we have to be willing to face up to the fact that failure to work according to protocol will ultimately-sooner or later-result in process failure. The issue here involves not just the trade-off between individual initiative and a prescribed process, but goes to the very heart of institutional decision making. Our methodology for improving safety involves representatives from each of the caregivers in the process-redesign teams. But we can't, for obvious reasons, have every single caregiver at the table. At some point, there has to be buy-in by those not directly involved.
So maybe we need to hire a conductor to get everyone aboard the patient safety train. My guess is he or she will need patience, persistence-and a very, very loud whistle.
Two of the four ICU physicians on our unit were intimately involved in the innovations team and helped design the rounding tool. I therefore assumed that with two of our own driving the new process design, it wouldn't be a problem to get the other two physicians to sign on. Wrong, wrong, wrong. We all know what happens when we assume, don't we? In this instance, we find that the other two do not sign the daily goals sheet. Evidently one has agreed to do it but doesn't ever seem to get around to doing it, and the other has indicated that doing so would require too big a change in the way he practices medicine.
While physicians are a highly independent lot, we have to be willing to face up to the fact that failure to work according to protocol will ultimately-sooner or later-result in process failure. The issue here involves not just the trade-off between individual initiative and a prescribed process, but goes to the very heart of institutional decision making. Our methodology for improving safety involves representatives from each of the caregivers in the process-redesign teams. But we can't, for obvious reasons, have every single caregiver at the table. At some point, there has to be buy-in by those not directly involved.
So maybe we need to hire a conductor to get everyone aboard the patient safety train. My guess is he or she will need patience, persistence-and a very, very loud whistle.
