Health care is ready for the seven levels of change
Start by doing the right things
By Duke Rohe, FHIMSS
Performance Improvement Specialist
M.D. Anderson Cancer Center
Houston
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You can’t find an environment that has a nobler mission than a hospital. How well or how poorly it operates has a significant impact — directly to the patient’s outcome and indirectly to his or her pocketbook. I truly believe we are not short on employees with great ideas; we are just short on environments to receive and place these ideas into operation FAST. Having worked at St. Luke’s Episcopal Hospital, an organization known for its innovative culture, and M.D. Anderson Cancer Center in Houston, a hospital unparalleled in the care its patients receive, I have seen real-world illustrations of the seven levels of change in health care. Here are some examples:
Level 1: Doing the Right Things
Focus is so important in a hospital setting. The complexity of a situation, patient conditions, overlapping symptoms, and the situation’s urgency, often cause energies to be spent in less than effective areas. At one hospital, before starting any major effort, its query mantra started with three questions:
- What are you trying to achieve?
- How will you know you got there?
- How do you plan to get there?
If the answers to these question cannot be stated clearly, don’t begin. And this is repeated throughout the project to focus and refocus.
In a customer service initiative in a phlebotomy (blood collection) area, phlebotomists established their vision to be vastly better than any similar service. Although their services inflicted pain on their customers, they were going to be known for minimizing patient discomfort and anxiety. They created "Inspiration Alley" — one-page character- building reading pieces framed and placed in the line of sight of the draw chair. Oh, and if your birthday is the day of your draw, just like in a restaurant a "special" phlebotomist comes in wearing a birthday bow to sing "Happy Birthday."
Roadblocks are only means for creativity to the phlebotomists. There were small holes in the walls of some of the draw rooms due to equipment movement. The funds weren’t available in the budget to fix them immediately, but the staff didn’t let that stop them. They called the leader of the pediatric unit and "commissioned" the cancer children (M.D. Anderson is known for its Christmas cards) to paint little pictures around holes (such as a ladybug). Of course, the children signed their fine artwork for all the adults to appreciate.
Level 2: Doing Things Right
Unless your process or work area is designed for things to be done right, sustained quality is a dice throw. The Japanese concept of visual control, the art of putting instruction (right way) into the point of action, was well employed in one hospital. A most memorable visual on an obstetrics floor was a diagram of a teardrop placed on the door of the moms who had lost their babies at childbirth. Beneath the teardrop was "Please check with the nurse station before entering." Instead of the usual inquiry of "How is your baby?" all caregivers would walk in with empathy, and guests were cued in before entering. Small idea . . . big difference in terms of caring service.
Level 3: Doing Things Better
In health care, if you are not doing things better today than you were yesterday, you are losing ground. One hospital created a "super unit" concept. This would be a prototype concept unit for new ideas. Extra support was provided in turning ideas into action. Some worked; some didn’t. To be implemented, all the idea had to do was create a two-year payback on paper. If the implemented idea proved successful, it was passed on to the other 30 units for adoption. In the first year, 10% of the workload of the super unit was reduced. In three years, there were five super units competing to come up with the cleverest improvements.
Sometimes the smallest ideas are the most memorable: In the operating room suites, the compliance for testing heat and pressure of the instrument sterilizer wasn’t up to par. A special strip indicator was supposed to be dated with a special heat-resistant pen and placed in the morning run, but it wasn’t getting done.
The manager inserviced the staff, stressed its importance, and followed up, yet the change was minimal. Then someone said, "Let’s do something different." They purchased a plastic holder for the indicator strips, bought an adhesive pen clip from the local grocery store, and adhered them both to the sterilizer. Everything needed was obvious and close by. Compliance immediately jumped to 100%.
Level 4: Doing Away With Things
Have you ever been to a Red Tag sale, where they tag items for quick sale to get them out of the way? In Japan, they use red tagging as a means to do Level 4 change.
In a collective environment, people tend to accumulate unnecessary things. They don’t throw things away, because they don’t know if someone might object or if it may still have use. Surgery suites in hospitals are notorious for getting new equipment and abandoning the use of older equipment without making the decision to get rid of it. There is a fear of possibly throwing away something that still may have value.
The surgery department in one hospital let physicians and staff know they were going to have Red Tag Day to clear out supplies and equipment in their way. Appointed staff, equipped with red tags, went around to every OR room and hallway, and for every item asked the local staff two questions: 1) Is this item needed? 2) Does this item need to be here, and in this quantity? If it failed either of these two tests, the item was tagged.
Tags were everywhere. After all areas were swept by the appointees, the tagged items were removed and placed in a red tag holding area. (The room was filled.) Physicians and staff had a week to make a case for why the item should be returned to its place. After that, the remaining red-tagged items were tossed/sold if they were not needed (Question 1) and stored away remotely if not needed in that quantity or that place (Question 2). Once the OR cleaned house like this, it repeated the process over time. Just like dusting, red tagging never ends.
Do you want to see how clutter sneaks up on you? Open up the top drawer of your desk and tag all items that don’t pass the two "tagging" questions above. The best statement for "doing away with things" was coined by Holly Uverity of Office Organizers in Houston: "Remember, clutter is just the physical manifestation of indecision."
[This article is the first in a two-part series. Duke Rohe is performance improvement specialist at M.D. Anderson Cancer Center in Houston. He may be reached at (713) 745-4433. To access tools related to this series, visit the tools site: www.durationsoftware.com, then click Improvement Tools.]
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