What a fishbone can do for your patients?

Inpatients not getting the medicines on time or discharged patients waiting for hours before they can leave the room..Not uncommon you would say and you could even list a hundred other things that dont work in your hospital or clinic. So what does a fishbone have to do with getting it right? Lots i would say..it could be the key to rallying everyone to work on this problem and getting to the bottom of the problem. So what i am talking about? Well if you havent worked much in quality improvement, you may not have heard of it. If you have worked in quality improvement, it is probable that you have used it but you could still be underestimating the power of the fishbone diagram. Before i sound like a preacher extoling the power of an image, let me try to explain what it is and what i can do? Well it is a diagramtic representation (in the form of a fishbone) of all the possible causes for a particular problem. Here is an example ..

But what is most important is the way it is created and that is where quality improvement workers can go wrong. The power of the fishbone does not lie in merely listing out the reasons and giving direction to the efforts of the project team. The real power, when this tool is used properly lies in bringing together people from disparate parts of the organization to come together and focus on a problem they knew was happening (and often blamed the other divisons or departments for). And now they see that the cause of the problem is spread all over and there is something that each one can do about it..

The difficult conversation...

What do you do when a senior colleague, boss or supervisor continuously executes a clinical intervention in a clearly inappropriate manner? You know this is not the best that the patient could have got. It could even be extremely damaging. Are you going to be the whistleblower and risk your job and career? Or are you willing to take the risk for much sought after societal attention? This is indeed a difficult situation and one that can cause immense mental stress. You may not be the only one aware of the situation but circumstances dictate that you are best placed to initiate remedial action. I have been in this position and the only way to tackle it is through communicating the issue without being insensitive. But this cannot happen in a vacuum. It can only take place in the background of a relationship of trust and mutual respect. In fact the nature of your relationship is the key. If you seem judgemental or accusatory, then you will reach a difficult to cross roadbloack. Communicating the positives in choosing alternative modes of action is the best way to let the person know that change is worth considering. At no point should it feel that the person is being blamed for his actions. Keep in mind that change in practice is the objective of the conversation, not a change in the person's values. This can help keep emotions out. Also speak tentatively leaving room for the other person to put up some resistance. Hearing out the other persons' version will reinforce his or her belief that you are out to help not blame.
But sometimes, no matter how you try, the background of mistrust, the lack of confidence in your perspective or plain obstinancy can derail any effort. However you will know that you tried and continuing negative outcomes could at some point in the future trigger a recollection of what you were trying to say.

Why only aircraft? why dont we have black boxes in our hospitals?

Another air crash and many lives lost. The level of media attention and the resources put into investigating these crashes are not unlike those of other industrial disasters. Then why is it that we do not see an equally interested society when it comes to healthcare disasters taking place daily. The reason I think is that most people do not know that there is such a thing happening. The truth is however disturbing. According to the Institute of Medicine, medical errors are a leading cause of death.So what do we do to tackle this?
I think the fundamental problem lies in patient care quality and patient safety not being a strategic imperative for business planners and hence not an essential requirement in resource management for service delivery. I think the establishment of public monitoring systems could result in a radical shift in healthcare business thinking. This could result in establishment of publicly discernible high standards of patient safety becoming a sought after core competency for hospital planners. However the keywords are 'publicly discernible'.

There is no place for a TV on my desk!

For the doctor who has been busy seeing patients, the computer screen may seem like something blocking his view of the patient. And nurses just dont have a desk in front of them much of the time. So what happens when the smart new IT guy comes and places not just a monitor on the desk but also asks him to use the keyboard and throw away the pen.The first thoughts are - where is the time to do all this? And what's in it for me and my patients?
While these questions seem unimportant when taking a 30000 foot high view which most prefer to take, look closely from a few feet away and it will be come apparent that answering these questions are the key to getting people to use the information systems and electronic health records. So the IT budget should include ways to win over the personnel by making sure they are able to use it comfortably, the information exchange well integrated into their workflow and most importantly use quantitative examples to convince sceptics of the usefulness of the systems to improve the lives of those using them and most importantly patients. In conclusion I would say, yes to the IT guys and the men in black who are carried away by the technology but request them to take the doctors with them on their trip through utopia. Published case studies provide us with interesting lessons on how to approach this issue.

Who says you cant make doctors dance on the ward beds?

The greater power of intrinsic motivators such as a larger purpose in life or even the power of identity over external motivators such as financial incentives is not new information..yet its interesting to hear Dan Pink speak on this subject. And those in healthcare can find some direction from him in their constant struggle to bring about change. Strategists in senior hospital management and especially those coming from other industries should take a closer look at motivation science. They never really try to understand what motivates doctors to do what they do. They need to accept that the reasons for doctor "intransingence" start all the way from medical school and to change them requires something more than diktats or small change. During their training doctors are essentially groomed to work autonomously and this manifests strongly in their attitude toward any attempt to control or manage them within an organization. This is why i believe that to bring about change in the ways of a doctor led team, one has to win over the heart and soul of the doctor. Strategy will remain on paper if this simple truth is not understood.