25-05-2016
Support

In the first post on daily huddles, I described the way supervisors at two ambulatory surgical centers have tested an agenda and some of the benefits they’ve reported.

Daily huddles also look like one way to promote organizational learning, as described by Tucker et al. in their article “When problem-solving prevents organizational learning” (Journal of Organizational Change Management, 15, 2, 2002, 122-137).

Tucker and her co-authors report on 190 observation hours of nurses in two hospitals, summarizing lessons and implications in the ways the nurses solved problems.

They describe two types of problem solving. (The authors define a problem as an “undesirable gap between an expected and an observed state.” p. 124).

“First-order problem solving allows work to continue but does nothing to prevent a similar problem from occurring….Second-order problem solving, in contrast, investigates and seeks to change underlying causes.” (p. 124).

Of the 120 problem-solving events in the 190 hours observations, the researchers characterized 110 (92%) as first-order.

As the authors note, if staff only engage in first order problem solving, then the problems will continue unabated, changing only in detail, day after day.

Of course second-order problem solving is preferred—but the data showed that first-order problem solving dominated nursing practice.

The authors describe factors to explain their observations. They then offer several fundamental principles to move an organization from first-order to second-order problem solving (pp. 134-135):

(1) Second-order problem-solving must “…be an explicit part of [front-line staff’s] job and enough time allocated for improvement efforts.”

(2) There must be “…frequent opportunities for communicating about problems with individuals who are responsible for supplying front line workers with materials or information.”

(3) “…when the signal is given that there is a problem, proper attention must be paid to it. We must recognize communication as a valid step in the direction of improvement.”

(4) The organization has “…a dedicated person to serve as a system improvement resource.” 

Daily huddles by themselves are not sufficient to move an organization to second-order problem solving. To practice second-order problem solving, the unit supervisor needs skill in process analysis and observation, help from quality improvement specialists to learn and use data tools, and support from the supervisor’s supervisor. The unit supervisor and team members will need additional time outside the huddle to analyze causes and think about countermeasures that then need testing. (principle (1))

Nonetheless, the daily huddle opens the door to second-order problem solving, especially if the organization agrees that the unit supervisor is the immediate “system improvement resource” who aims to help his or her people to do a better job. (principle (4)).

The daily huddle provides time every day for a unit team and supervisor to identify problems--gaps between desired state and actual states. The huddle fosters communication between staff and supervisor, the first-line system improvement resource. Thus the daily huddle begins to operationalize principles (2) and (3).

In our initial experience with ambulatory surgical centers, the daily huddle looks like a solid platform for maintenance of desired protocols and second-order problem solving, helping supervisors and unit teams to reduce gaps between actual and desired performance.



19-05-2016
Support

Thirty years ago, W.E. Deming characterized the job of a supervisor: “The aim of supervision should be to help people and machines and gadgets to do a better job.” (p. 23, Out of the Crisis, 1986, Center for Advanced Engineering Studies, MIT, Cambridge, MA).

Deming also emphasized that aims and goals require methods.

In the last two months, I’ve worked with supervisors in a couple of ambulatory surgical centers to help their people do a better job. The work is part of a project with colleagues at IHI (www.ihi.org) to help the centers sustain changes in their use of surgical checklists.


By What Method?

One method we’ve tested is a short daily huddle for a unit team, led by the team’s supervisor.

By short, we mean less than five minutes. The supervisor (or stand-in when the supervisor cannot lead the huddle) follows a standard agenda, illustrated at left.

Ambulatory surgical centers are busy places. Nonetheless, our colleagues at the two centers have been able to carve out a few minutes each day to focus their team’s attention on safety concerns.

The supervisors report several benefits, worth the cost of five minutes of team time at the start of work.

(1) Every day, there is a specific team time to reflect on and share safety concerns with each other and the supervisor, reinforcing the message that everyone contributes to a safe environment.

(2) The huddle reduces the need for team members to find the supervisor during the day to report non-urgent issues that still require attention.

(3) The supervisor has one time every day to update the team on important non-urgent issues, no need to track down individuals.

(4) Looking back at yesterday’s work and patient cases is a relatively low burden for recall.

(5) Looking ahead at today’s work and patient cases with a focus on safety reinforces safety awareness and vigilance.

In efforts to promote greater attention to safety, we’ve observed that supervisors in ambulatory surgical centers often rely on verbal reminders and requests of staff to be pay attention to safety. The huddle takes this inclination and roots it in the context of yesterday and today’s work and sets the stage for more effective ways to improve safety awareness and practice--ultimately, reconfiguration of work that uses visual cues and error-prevention designs.

Supervisors are linking the huddle to a couple of other management practices, too.  

(1) Visual management:  supervisors are testing a display at their huddle location to track concerns and share safety data.

(2) Observation of work methods:   supervisors are testing specific observation of the way work is supposed to happen—for example, how closely teams in the OR actually follow a scripted “time out.”

In sequencing the introduction of management methods, the daily huddle looks like a good starting point for a unit interested in sustaining specific safety practices. 

With a bit of experience with daily huddles, visual display and observation of work methods come next and are linked to the huddle--ideally, the huddle takes place in front of the visual display and observations of work methods inform the supervisor's view on safety performance.


Why does each agenda item deserve attention?
Agenda Item
Why include this item?
Safety concerns in past day: patients, staff, doctors Daily probe by supervisor. This item gives team members a chance to reflect and state concerns that the team and supervisor need to hear and address.

The concerns include staff and doctors as well as patients to drive the message that a safe environment is safe for everyone and to identify opportunities to keep staff and doctors safe, too.

Example: Operating room RN was concerned about staffing of the sterile processing department during the last case of the day, in case equipment needed and OR team cannot leave the patient. Supervisor promised to align schedule of SPD with surgical case schedule.
Safety concerns for today’s patients Highlight of patients that fall outside of typical pathway, a heads up for team.

Example: patient with severe latex allergy. In this case, not only does the team hear about the specific case but the instance serves as a reminder to the team of the standard methods for allergy.
Review of tracked issues: status Teams are testing a status list on their unit management display. Issues that can’t be addressed immediately are written down so not forgotten and then updates reported.

Example: replacement of temporary sharps containers in the Post-acute care unit (recovery area) with standard containers.
Any other issues? Opportunity to ask questions affecting work flow or anything else. The issues are not discussed or “solved” (that takes too much time) but captured by the supervisor to address outside the huddle.

Example: black/white printer in nurses’ station off-line with network card , need to print to adjacent color printer.
Announcements Opportunity for supervisor to give updates on training or special events—this seems like a “given” whenever a supervisor has a team gathered. However, the point is to keep this item short and use other ways (the schedule board or announcements board) to provide details.

Example: three endoscopes are “down” but have been replaced with loaned equipment, no impact on work today.





12-05-2016
Support

In a post last month, I discussed an article by Bataldan et al. onco-designing health care. I agreed with the article’s authors that we might learn something if we look at health care through the lens of co-design.

A short Viewpoint piece in the April 2014 issue of Health Affairs has a relevant message. (10.1377/hlthaff.2015.1354 Health Aff April 2016 vol. 35 no. 4, 627-629).

Four Mayo Clinic researchers reflect on 10 years of work on shared decision making, which involves providers and patients working together to decide on a course of care. Shared decision making sounds great and seems like at least part of what it will take to meaningfully co-design health care.

The authors say that they, along with most designers of shared decision making, started with the idea that shared decision making consisted of a two-step process: clinicians should summarize the best evidence on options and then have the patients choose among those options.

It turns out the two-step process doesn’t seem to work to help patients actually figure out what to do to advance their treatment and care. The Mayo researchers now believe that conversation between the patient and clinician provides the key to effective decision making:

“Our group has come to understand that the challenge of evidence isn’t simply communicating what we know clearly to our patients—although that alone is a significant challenge. Instead the real challenge is how to use the evidence to discover what’s best for the particular patient in light of his or her circumstances and values. The medium in which this happens is patient-clinician conversation.”

“…conversation in shared decision making….[is] an instrument of care appropriate to the uncertainties of illness and treatment. Shared decision making is called for in situations in which the best option is not clear. These situations threaten the health of the patient, the expertise of the clinician, and the management of response. They are emotional in nature.” (p. 628)

Can you establish, improve and maintain a system that promotes shared-decision making as described by the Mayo researchers?

I think this question indicates a planning and design problem. For that kind of problem, I’ve argued that the Model for Improvement provides a core method (here).

Clarification of aims of care for the patient, definition of measures to know if treatment choices result in experiences closer to desired aims, and ideas for treatment choices and actions, linked to appropriate testing cycles look like a great way to structure a series of conversations in effective shared-decision making.



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