Good Standards Back on Track

Mark Jaben, MD

Jaben 2014Your leaders have decided that “Pull to Full” is just what the ED needs to improve patient satisfaction. After all, the faster they see the doctor, the happier they will be. It seems straightforward and shouldn’t be hard for staff to just do it. Others have reported its success. We need to do it- it is not optional. But, is it really that easy? And is it really that straightforward?

In fact, the leaders don’t actually manage the minute to minute flow, but, rather, depend on front line staff to implement the standard. And as we saw in 'Good Standards Gone Wrong,' front line staff had a different perspective. What might have made these efforts successful?

Each of our interactions can be thought of as a customer/supplier interaction, in which one person supplies what another person needs. Usually, it is the customer who determines the specifications of that transaction. In healthcare, our day is filled with interactions in which we are both customer and supplier at the same time with each other. For instance, the doctor may need an accurate radiology test result, but he or she also supplies the necessary information for the radiologist to read the study accurately. When we are both customer and supplier at the same time, who controls the decision?

Many leaders and managers see themselves as sellers in a seller’s market, which means they should be the ones to decide the specifications of the transaction because they supply the jobs and should, therefore, determine how those jobs are done. When it comes to improvement work however, this is far from the reality. Improvement work requires people to invest in themselves, and only that person decides how invested they will be. Leaders and managers are really buyers in a seller’s market. They need staff to get the work done well, and it is staff who supply that work and control how invested they will be.

Straightforward conditions involve few people, have few options for response, generally carry a lower risk (but not always), and have a consensus on the best way to get the desired result. For success, compliance with the standard is needed.  Both to get that desired result consistently and to recognize circumstances where the standard did not work.  When everyone follows the standard, it is easier to recognize when a different way is actually better and thus improve the standard. Consider the process of inserting a central line—a relatively straightforward process.  A checklist covering the steps is often really beneficial in straightforward situations.

Complex situations, on the other hand, involve multiple people, each of whom depends on the other to be successful in their individual job responsibilities that entail worthwhile but often competing priorities, and have multiple options to respond. In complex situations, it is often more about how to decide what to do, than just doing it. It is not possible to create a step-by-step guide in complex circumstances. There are just too many variables and permutations for any ‘rule’ to actually give a consistent and appropriate response. Complex situations entail real time decision making by front line staff and a greater degree of autonomy at the point of care. But this leaves leaders and managers at risk for decisions made by others.

The mechanics of just how to act in a “Pull to Full” standard may be straightforward. For example: when and where does registration do its work, when is an appropriate time to have a triage nurse, when and where does the information gathering occur, and who does this if there is no triage nurse. These details are often overlooked by leaders and managers who can't possibly be aware of all the nuances, and, frankly, shouldn’t be aware of all the implications as they have too many other responsibilities. But that doesn’t diminish the importance of working out the details in a manner that works satisfactorily for those who must carry out the standard. Leaders and managers do have the responsibility to make sure the group establishes these parameters and is in agreement among themselves. 

How often do we train staff by telling them what to do once and then expecting they will perform as agreed upon every time? During WWII, the US Department of Agriculture developed a program called Training Within Industry (TWI) intended to rapidly train unskilled workers for manufacturing jobs left vacant by men going to war. It involves a three-step process and repetition with a mentor guiding and verifying that the requisite skills were achieved. What they learned is that it takes more than a ‘see one, do one, teach one’ tactic, but done effectively, it does not have to take all that long. Navigate to the website: to learn more.

Deciding when best to deploy the standard is anything but straightforward. It requires real time decision making about when to start, when to stop, and how to coordinate everyone’s work when the demand changes minute by minute. Rather than a step-by-step approach, this requires guidelines about how to decide: 

  • What is the essential data you will use to make a decision?
  • How will it be gathered?
  • How will it be shared?
  • Who makes the decision in consultation with whom, when and where?
  • How do we evaluate if the decision worked both real time and after the fact.

After this guideline has been followed, staff should be trusted to make those decisions and identify those circumstances where it did not work well. Learning what does not work and chipping away at those unintended consequences is often the path to finding what does.

A real-time huddle is an example of something that supports this autonomy and decision making. Its purpose is to be a brief pause where everyone can gather themselves, re-prioritize the work in light of changing circumstances, and agree on how to proceed in a way that works for everyone in their particular circumstances at that time in the department. Daily or weekly process reviews of what actually occurred and did or did not work give leaders and managers the involvement they need to feel safe with the decisions made by others, and promotes the learning needed to improve together. This decreases the chance that monthly or quarterly meetings to track progress against departmental goals will be confused with improvement work.

Collaboration, not just compliance, is essential. Collaboration involves being seen as a valuable partner who is committed to discovering the method that enables others, as well as yourself, to be successful in job responsibilities no matter how widespread and disparate those incentives and priorities are. No one will listen to you if they do not believe you are listening to them. It requires a commitment to tease out the viable options, even if they are not immediately recognizable. It takes you believing that this is the path to the successful performance you desire in your ED. The key to credibility lies in how we choose and how we use the ‘right’ data and in how we devise the ‘right’ standards.

As you may recall from 'Good Standards Gone Wrong,' the Pull to Full initiative failed to deliver the desired results. Had they taken the time to develop a shared outcome of what was needed, sought out the various views, validated or refuted the assumptions about why this could not work, reconciled the perspectives, and worked out the logistics, perhaps they would have achieved the results they wanted for themselves and the patients.

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