Good Standards Gone Wrong
Mark Jaben, MD
Today at your department meeting, a new program is announced. Called 'pull to full,' it is described as a best-practice proven to decrease door-to-doctor times and increase patient satisfaction scores. Your director made the point that this was not an optional program, but rather something administration expected to be implemented. No longer will you be sitting around all caught up while patients are sitting around in the waiting room. It will be better for the patients and better for you. It will be to the docs to 'encourage' the nurses to follow through.
The nurses understand that patients out of sight are a safety issue, but they argued that it made little difference whether the patient waited in the waiting room or in a bed if the nurse was tied up with an ill patient and unavailable. At least in the waiting room, the triage nurse could keep an eye on them. A month earlier, the nurses’ workload had been increased to 5:1, and they wondered how they could possibly attend to another patient placed in one of their beds if an ill patient was requiring their focused care. With the decreased staffing, there weren't other nurses to help pitch in during those situations, even on the increasingly less frequent shifts when they were actually fully staffed. And at night, where there were even fewer nurses scheduled due to the low productivity numbers, how could they possibly manage this? Although the influx of new patients slowed after midnight, those remaining in the department kept them plenty occupied well into the morning. What went unsaid was the frustration staff were feeling, that somehow they were being made the scapegoat and bearing the brunt of the financial challenges the hospital was experiencing.
Fast forward three months to the quarterly ED/ administrators meeting. Average door-to-doc time was, indeed, reduced from 37 to 34 minutes. Patient satisfaction scores, however, were unchanged. The administrator present hardly flinched; she had other more pressing issues on her plate now. The nurse manager tried to explain that the nurses were trying to do “pull to full,” but some just refused to go along and others were just too lazy- the administrator did recall the staff just sitting at the desk when she passed through the department checking on things. They would have to try something else. Staff would just have to work harder.
So what happened? Why did a proven “best practice” not result in the improvement everyone wanted?
The fallacy of “best practice” lies in the belief that your circumstances mirror exactly those of the situation where the “best practice” produced its results, and if so, it should just be 'plug and play.' We think this way because the brain's preferred problem solving routine is to first look to established patterns of recognition and response for the 'answer.' This takes less energy and gives us a 'truth' we can act upon. Our brain will even deny clearly conflicting data to stick with this plausible story, unless there really is convincing evidence to the contrary.
This strategy works quite well, unless the brain encounters a new or novel situation for which it does not have an established pattern. In this case, trying to force a pattern onto a situation that doesn't exactly fit invites the risk of mistake, error and a decision that may not be the best one available. We depend on our prefrontal cortex to weigh the evidence and recognize when the pattern is not quite acceptable. Only then will the prefrontal cortex bring its vast power of analysis to bear and entertain various possibilities while searching for an acceptable response. We are unaware of most of this process; all we perceive is that satisfactory response our brain has decided upon. If none are found, only then is our brain willing to expend even more energy to be creative and innovate a totally new way of responding.
Like those established patterns in our brain, it takes much less energy to just adopt the “best practice.” This appears to be easier up front, but is problematic because few situations are exactly the same. Each ED has its own unique features. Best practices are not an answer; they are a starting point- another of the many possible responses that must then be evaluated against those unique circumstances. If it does not fit exactly, then trying to implement it can lead to problems, a failed attempt, and wasted time.
But if it still seems promising, then maybe it can be adapted. To discover that requires the input, involvement and participation of everyone who will be impacted by it. A problem is like a prism; it has many facets and you, individually, can only see one. To get a full view of the entire prism requires learning what each person sees in their facet. This requires collaboration and a respect for each person’s view as a legitimate and important factor in understanding what makes your circumstances unique. This does take some up front effort that many people consider unnecessary, but, as crazy as it sounds, taking the time to embrace the resistance you observe- by seeking it out, honoring it as possibly valid, and committing yourself to reconciling it- provides the path to unlock the full view of the prism- for you and, as importantly, for them. And, paradoxically, the time spent doing that results in way less time to figure out if the standard works or not.
However, no one will participate with you in this effort if they do not find you credible- someone with their interests at heart and committed to teasing out the viable options, even if they are not immediately recognizable. This takes a commitment to always use the ''right' data (see Good Metrics Gone Wrong and Good Metrics Back on Track in the previous newsletters) and always pursue the 'right' standards.
And, like data for successful improvement, how we select the standards we use and our ability to successfully involve everyone in devising them depends on the credibility of our relationship with those affected by those standards. The loss of credibility and trust that results when we do otherwise often derails even the best intentioned improvement efforts.
“Pull to full” can be an excellent technique when there is the space and the staff available for that next patient. It can help you stay ahead of the arrivals and avoid overload to an extent. But once 'full' –which includes not just having all the spaces occupied, but also by having all the staff occupied with an ill patient or two- it cannot get you caught up to restore the capacity to see that next patient. That requires other decisions and another strategy to address the overload and preserve patient flow. The challenges with “pull to full,” as well as any standard, are the important features in your circumstances that must be worked out to get the standard on track.
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