An Improvement Wake-Up Call

Contributed by Jonathan Small
NICHQ Senior Director of Communications.
Originally posted February 2012.

Jonathan Small
Jonathan Small

It never ceases to amaze me what I learn from my children, especially the youngest ones – my eight-year-old twin daughters. I’ve been working in the quality improvement field for longer than they’ve been alive. But now they’re the ones teaching me about it!

Until two weeks ago, every weekday morning brought the recurring challenge of trying to get these two seemingly responsible third-graders to school on time. How complicated could it be? We set their alarm clock so they would have a whole hour to get dressed, eat breakfast, prepare lunches, wash up, and get out the door and down the block to school. It should have been enough time. But far too often, they arrived late. And the last few rushed minutes of getting them out the door were among the most irritating and stressful times in our relationships.

Their latest progress reports listed 18 “tardies” for each of them – and always just an agonizing two or three minutes late. My wife and I pride ourselves on being prompt. Surely we could get our children to shave a couple of minutes off their morning routine. But we just couldn’t push any harder.

Every system is perfectly designed to get exactly the results it gets, say the improvement experts.

So, we decided to change the system. We did the only logical thing we could think of – we set the alarm clock for fifteen minutes earlier. We reasoned that the extra time would be more than enough to make up for the difference. I had no doubt that this was the right solution. But no! The girls simply lingered in bed longer and were more irritable and less cooperative. Still arriving late. Still stressful. Still “tardy” noted on the progress reports. Our first Plan-Do-Study-Act cycle was a failure – and we had all lost an extra fifteen minutes of sleep to boot.

Now, I’ve been working in quality improvement for more than a decade, and I’ve been a parent even longer. I was determined to find a way to improve our performance here.

Then my wife had a brilliant idea – ask the girls to solve the problem themselves. I began thinking about the quality management principle that the frontline workers (not management) are in the best position to identify possible causes of a problem and find a solution. My wife had empowered our “frontline workers.”

Their recommended solution, however, was preposterous, so counterintuitive that it was almost laughable. The girls suggested that instead of setting their alarm clock earlier by fifteen minutes, they would set it fifteen minutes later. Ridiculous. That would leave them only 45 minutes to get to school. If they couldn’t get there in an hour, how could they possibly think they could get there in 45 minutes?

They reasoned that if the alarm clock went off later instead of earlier, they would pop out of bed and kick it into gear more rapidly and efficiently. Ha. Just an excuse for sleeping 15 minutes longer and getting to school 15 minutes later.

But we decided to try it – just for one day. It was a small test of change with no risk – after all, what was one more “tardy” at this point?

And what do you know: they made it to school on time. So we tried it again the next day. Same result. Since we made that change two weeks ago, the girls have not been late to school even once! No more “tardies.” They are less irritable (probably due, in part, to the extra sleep) and more in control. So far, we are holding the gains.

So, what did my eight-year-old children teach me about quality improvement?

My wife and I never would have thought of this solution ourselves. It was completely counterintuitive to us. Yet, it was as clear as a new day to the people who mattered most in this process. And when they were empowered to solve the problem, they came up with a solution that worked – for them. And now, they own and care about the results more than ever, because it was their idea and they have a stake in seeing that it’s successful – if for no other reason than it allows them to stay in bed an extra fifteen minutes each morning.

We learned that sometimes the best thing a parent (manager) can do is get out of the way and let the child (worker) solve the problem.

Next on the agenda: let them figure out how to keep their room clean. Believe it or not, that’s working too!

DIY Quality Improvement

Originally Posted December 2013.

Karen Sautter Errichetti
Karen Sautter Errichetti

My husband and I spend a lot of time at The Home Depot. Ever since we started restoring our new “old” house, we’re on a first-name basis with everyone who wears an orange apron. When a customer asked me recently where she could find plastic washers and I knew the exact aisle to which to send her, I began thinking maybe it was time to take a long vacation.

For anyone who has gotten lost in Home Depot or any big box home improvement store, you’ve probably found yourself in the building materials section. That’s where they sell “the big stuff”: roofing, gutters, drywall, lumber, composite decking, joint compound…all the things typically appreciated only by professionals. It’s not the kind of place you would tend to find a computer geek like me. But it’s my favorite place in the store. Someone get me a big cart because I’m tackling the world today!

Why do I do this to myself? My father would tell you it’s because I am his daughter. My father is the kind of person who makes something from nothing. He had never built a house before, but he decided to build the family home I grew up in, including all the plumbing and electricity. He turned a 1932 Ford into a flatbed truck with a plow. (This may in part explain why I was never late to school on a snow day. Thanks, Dad!)

It is my father’s fearlessness in the face of the unknown that has made me believe throughout my life that I can do anything if I just try it. The worst thing that can happen is that the results of my first few attempts might not turn out the way I had hoped or expected. The first time I plastered a wall, for example, it looked dreadful. The second wall was marginally better. But by the third wall, I started seriously considering moonlighting as a plasterer.

Quality improvement works the same way. We must be fearless when we are not getting the results we had hoped for or expected. The change needed is often big, daunting and expensive. I’ve learned that the trick is to not think about the odds. Improvers need to remove the word “impossible” from our vocabulary. If we find ourselves saying, “I can’t make providers use this new process,” or “I don’t have the resources to build a new data system,” we need to ask what we are most afraid of. Fear of not being successful tends to fulfill that prophecy. If we just try something without fear, given time and practice, we can achieve the “impossible.”

Nelson Mandela once said he “learned that courage was not the absence of fear, but the triumph over it. The brave man is not he who does not feel afraid, but he who conquers that fear.” When I stepped into my grandmother’s 1860 colonial house, I was afraid that I could not do all the things that needed to be done to make it a home. But I made myself believe that I could fix plaster, sister joists and install a new shower so I could make my dream of being the fourth generation to live in that house a reality. My parents and husband have embraced that same spirit and with every stroke of the putty knife, we are getting closer to success.

I try to bring this fearless philosophy to my work each day as a technologist and leader at NICHQ. I am always trying new things to ensure our customers can be confident in beating whatever odds they face when making improvements in their own organizations. Most recently, my team has been testing new strategies to improve the performance of our online data service, the Improvement Lab. We also initiated a new private intranet platform that is blossoming into a space and transforming communication across our organization.

My father and I tackled drywall this past weekend. Next, I’m thinking it’s time I did something about those leaky windows. So back we go to The Home Depot for some shiny new toys—now if I could just convince them to give me the “Friends and Family” discount!

Like Halloween Every Day

Contributed by Rachel Sachs Steele, MEd
COO and Vice President of Business Development.
Originally posted November 2013.

Rachel Steele
Rachel Steele

I love Halloween. For one day every year, I get to try something new, look totally silly, celebrate fear and play with possibilities, all without the usual external or internal constraints. Can you imagine what life would be like if we had that freedom all the time?

Wouldn’t it be great if we were able to take risks without fear? If we had the opportunity to look at what we are doing, evaluate our actions openly and try new ideas until we find the best outcome? And how about having a whole community of people taking risks, embracing crazy ideas and experimenting with new approaches together?

Guess what? No trick here — this “imaginary” world exists.

While wearing sparkly wings and a silly hat this year with my 3-and-a-half-year-old niece, I noticed many parallels between Halloween and collaborative improvement work. Being part of an improvement effort is a humbling experience. We walk out into the world knowing we’re going to look silly, but trust we won’t be judged — because others will look silly too. And then there is the scary stuff: when we push ourselves and others to improve, we expose errors and inefficiencies, identify root causes, and test new ways of operating.

And guess what happens when we test new ideas? We are going to fail. That’s how we learn.

One may argue that Halloween is a low-cost game, but when taking risks in a professional setting, mistakes are not typically encouraged and change can be difficult. And, as if exposing ourselves to failure isn’t scary enough, when we embrace the idea of trying and failing for the sake of improvement, we must also confront the fears and limitations of the larger systems in which we work. Let’s not forget that improvement will prove, without a doubt, that we don’t know everything and — yikes — we may need to let go of something we once thought essential to make room for the new and better.

These are scary concepts for many of us, but the beauty of improvement work is that we get to encourage and celebrate “failure” as an important part of learning. Improvement work requires us to embrace our fears and understand that fears represent risks and risks represent opportunity. And because we do improvement work in collaborative environments with others who are also trying, risking and stumbling, we’re not alone. Over and over again in NICHQ’s work, we see amazing examples of project teams taking risks that result in tremendous leaps forward.

Sure, confronting failure is daunting, but it’s also exhilarating to see opportunities and find better ways of doing things. It’s our obligation as leaders and as people to find and release things that no longer get us the results we are seeking and make way for better. But let’s face it, things are going to change regardless of our own level of comfort and no matter how hard we try, we won’t ever be perfect, can’t predict the future and can’t know what we don’t know. So why not have some fun with it? Join us in improvement work: jump in, try something outside the norm, and experience, in a way, the freedom of Halloween anytime. What we learn in the failing can surprise us — and ultimately pave the way to meaningful and lasting improvements.

When Did Breastfeeding Become a Choice?

Contributed by Jennifer Ustianov, RN, BSN, IBCLC
Project Director and Perinatal Content Lead.
Originally posted August 2013.

Jennifer Ustianov
Jennifer Ustianov

Years ago, a moment was forever etched in my memory. As a young student nurse, I watched as a new mother wiped aside her tears of happiness and relief in those first few precious seconds after the birth of her first child, gathered her inner strength, and then quickly and lovingly moved her child to her breast. It was natural. It was beautiful. It was timeless. I knew much less then than I know now. But I knew one thing for sure in that moment—I knew when my time came, I would breastfeed.

When does the decision to breastfeed first form in the consciousness of a young woman’s mind? What influences that decision? Is this decision made prior to becoming pregnant, during the first months of a pregnancy, after giving birth? Or is it made as we grow and absorb everything that influences us in our day-to-day lives?

As a maternal child nurse who has practiced for over 30 years, I have come to appreciate the challenges that families face and the many conflicting messages and demands on their time. We live in a modern world with modern world pressures and modern world technologies. I get it! The decision to breastfeed (or not) is complex these days. And it carries with it burdensome social stigmas and judgment. Expecting mothers can spend hours reading about, discussing and contemplating which method of feeding a newborn is best for child, mother, father, family and lifestyle.

In just a few decades, we have seen a notable shift in our cultural perceptions about breastfeeding. What was once the only way is now one of the options. Our choices have evolved over years of social influences that have encouraged and challenged us to consider alternative approaches.

These choices are now real and viable for individuals. But at the societal level, these individual choices are contributing to poorer long term outcomes for our next generation. We now have strong evidence to prove what was never a question for our great and wonderful grandmothers. Breast milk is our most perfect food, and it is almost always best from a health perspective.

I know the tides are beginning to turn. Recent reports show breastfeeding rates are increasing in the US. The journey back to a more supportive breastfeeding culture has begun in this country. But I wonder whether there is more we can do to accelerate this process, so that from this generation forward there is no question and no need to choose.

I believe two elements will drive this change:  influence and knowledge. Influence is the door; knowledge is the key.

As health professionals, our power to influence is clear. We can change attitudes and perceptions one person at a time and we can influence practices and systems to make the healthy choice the easy choice. It is our duty to question practice, change the status quo and improve the outcomes of an entire generation.

But influence is adrift without knowledge. When a mother and father truly understand the health benefits of breastfeeding, or the functional need for skin-to-skin time, or the amazing miracle of a baby’s self latch, they get it! Once health professionals witness and re-learn the power of the uninterrupted stages of newborn behavior in the first minutes and hours, the amazing and inherent responses of a mother’s body, the magic of the quiet skin-to-skin responses between a mother and her newborn as the infant searches and finds his mother breast unaided, they get it! They remember, re-engage and renew a commitment to participate in nurturing the next generation of healthy, happy children, parents and families.

I dream of the day when there will be no need to improve the breastfeeding rate in our country. Until then, I challenge us all to share our influence and knowledge about breastfeeding with one person, one mother, one teenager or one family. Together, we can restore breastfeeding to its proper place in ours and any society.

Happy Breastfeeding (this) Month and always.

Beyond Bullying

Contributed by Tom Dahlborg
Vice President for Strategy and Project Director.
Originally posted January 2013.

Tom Dahlborg
Tom Dahlborg

In the online December issue of Pediatrics, researchers from the Rudd Center for Food Policy and Obesity at Yale University recently shared outcomes from their study, “Youth Seeking Weight Loss Treatment Report Bullying by Those They Trust.”

The study design included a survey of adolescents to better understand bullying behaviors, including the location, frequency, duration and types of bullies involved.

The study found that:

  • 64 percent of those surveyed reported getting bullied at school (with the risk of bullying increasing relative to the child’s body weight).
  • Most of the kids suffered bullying for at least one year (78 percent) while over a third (36 percent) had been dealing with bullying for five years.
  • The most common bullies involved were the child’s peers (92 percent) and even those kids that they considered friends (70 percent).

But one of the most disturbing findings to me is the fact that these children also report being bullied by physical education teachers and sports coaches (42%), parents (37%) and classroom teachers (27%).

I should not be so surprised. I have personally encounted an incident of an adult bullying a child I know well, but until I read this study, I assumed that event was an aberration and that bullying of this kind was nowhere near as prevalent as highlighted in this study.

About 12 years ago we lived in a picturesque community on the coast in what seemed the ideal neighborhood.

In this neighborhood lived a five-year-old boy who was overweight. He loved to run, play and have fun, and one day he was outside playing with some of the other neighborhood children when they all decided to go inside a neighbor’s home. As they walked up to the door the mother of one of the boys greeted them and let them in one by one until she saw this child and yelled, “You are too big to come in and play. Go home!”

This would be devastating to anyone, never mind a five-year-old child. The tears and the pain he felt were heartbreaking. As was the pain felt by his parents. And the impact of this bullying along with many other examples this child endured in this neighborhood lasts to this day.

Now contrast this experience with one I witnessed repeatedly at a dance class for young children in the same community at around the same time. The dance instructor truly connected with each of the children in her class. She set expectations, she encouraged, she shared compassion and empathy for those challenged to perform and honored these children for their individual gifts, regardless of their body types.

My daughter was one of the lucky children in that class. She began dancing at a very young age and developed a special relationship with this teacher, a bond and a trust which she cherishes to this day. Years later, now as a college freshman, she has decided to continue to dance as part of a healthy lifestyle. She has taken it upon herself to research schools of dance and to fund the program of her choice.

My daughter loves exercising (with dance being at the top of the list) and maintains a healthy body image, self-esteem level and perspective on life, thanks in large part to the influence of this teacher from years ago.

Quite a dichotomy between the neighbor’s approach with the five-year-old boy and the dance instructor’s approach to her students…and both will have lasting influence on these children.

Now that I have the opportunity to work for a quality improvement organization with a vision of ensuring each child achieves his or her optimal health, and to process this information through the lens of my own experiences (personal and professional), my heart still breaks for those children harmed by bullying…AND I see great opportunities for improvement:

  • To meet children where they are while also educating adults as to the impact we can all have on children (both positive and negative).
  • To bring this perspective to healthcare and expand current thinking around patient-centeredness (child-centeredness) and the patient-centered medical home.
  • To evolve the medical home concept to a neighborhood perspective where patients and families, neighbors and friends, and coaches and teachers are all engaged to learn and grow and help the children of a community achieve their optimal health (by addressing bullying at all levels as well as many other barriers to children’s safety and optimal health).
  • To ensure that each child is recognized as unique, and receives appropriate interventions and support that will best position the child to achieve his or her optimal health.

NICHQ has helped lead the patient-centered medical home evolution since the 1990s and continues to do so. Currently, the US healthcare system is struggling with optimizing behavioral health integration into the medical home. We must continue our improvement efforts and to evolve and expand our thinking in this arena even more.

These are invigorating times to be working in healthcare quality improvement with a focus on children. We have a great opportunity to change communities for the better through evolved medical home concepts and I am excited to be part of this ongoing work as NICHQ continues to lead the way.

As a healthcare leader, a coach, a friend, a husband and a father, I have seen the positive impact we can have on children from both a systemic perspective and on a one-to-one basis. At NICHQ I am blessed with an opportunity to do both.

Got Data?

Originally Posted October 2012.

Karen Sautter Errichetti
Karen Sautter Errichetti

I admit it. I am a total data geek. I’ve never met a number I didn’t like, an algorithm I didn’t want to dissect, or a math problem I didn’t want to solve. As the grand-daughter of a mathematician, my love for all things data is no surprise. When other kids played outside, I amused myself by calculating the number of jelly beans in a glass jar or estimating the circumference of the apple I ate for lunch. I even took Calculus over the summer in high school…just for fun.

My colleagues (and occasionally my friends and family) often ask me why numbers are so important to me, mostly out of concern that I’m turning into a computer. In response, I always find myself quoting 16th century British naturalist and slightly irreverent scientist Sir William Turner: “You may have heard the world is made up of atoms and molecules, but it’s really made up of stories.” It is not the numbers that I find so interesting or important, but the story behind those numbers that inform how we think about real-world problems, what causes those problems, and how we can apply evidence-based strategies to solve those problems.

As leaders in quality improvement (QI), NICHQ asks teams participating in our projects to collect data to track their improvements on the complex problems that face children and their families in our health and healthcare systems. Yet for many new participants, data collection feels daunting. It takes time and resources, which are often precious commodities in the systems in which they work. How do we get beyond these barriers? Here are some ideas from this self-proclaimed data geek to inform our thinking around data collection:

  • Think of data collection as its own change strategy. We often suggest that teams work to improve their data collection and monitoring process as part of their work in a QI project. Improving your data infrastructure will empower everyone in your system to examine data and apply it to shift the system toward positive change for children and families.
  • Get your own data geek. Add someone to your team who enjoys the process of data collection and the evidence it produces. Teams with a data manager responsible for measuring change during process improvement are more successful in affecting change than teams without a data manager.
  • Demonstrate “face validity.” Does your team have a hard time believing the measures you are tracking actually reflect what is going on in the field? Demonstrate that the measures you are using to track progress actually measure what they are supposed to measure. In research, this is similar to a concept we call “face validity.” If it feels right, it is right.
  • Pick your own measures. If you are doing something in the field that isn’t captured by your measurement strategy, create your own measure! Talk with your team leader or your project’s Improvement Advisor about creating an optional measure to track progress aligned with your testing.
  • Remember that data are people too. It is so important to remember that data represents the people for whom we care and want to care for better. I have a big sign up in my office that says ”I am n = 1,” which basically means that the individual experience is the basis for measurement. Every data point collected is an encounter, a visit, a care process, a person, or a family that your quality improvement process touches. Remember your ‘n’ is not a number.

As NICHQ’s Associate Director of our new Department of Applied Research and Evaluation, my lifelong fascination with data translates into an everyday exercise of telling stories about improvement through data. I am always in awe of the amazing strategies that teams in the field apply to collect and use data to inform their journey toward improved systems of care for children and families. You don’t have to be a data geek to appreciate that just a few data points can change someone’s world.

And now for the NICHQ math puzzle of the week! If Train A leaves Boston at 8:30am at 16 miles per hour and Train B leaves Chicago at 9:00am at 18 miles per hour, at what time will they meet?

What I Learned about Physician Autonomy at the ATM Machine

Contributed by Shikha Anand
Director of Strategic Alliances and Initiatives and Obesity Program Director.
Originally posted March 2012.

Shikha Anand
Shikha Anand

“Every system is perfectly designed to get the results it gets.” This is a common adage among improvement experts. I heard this phrase for the first time about a year ago, when I was somewhat new to NICHQ. While I considered myself a systems thinker, this only partly resonated with my view of my clinical practice. Like many other primary care providers, I was frustrated with the systems that support my practice, but still believed that I myself was completely responsible for – and in control of – the results of my work with patients.

A few weeks into my work at NICHQ, I went to the Automatic Teller Machine (ATM) at my local bank. I withdrew money, got my card and went on my way. As I walked away, I recalled that in younger years, I very often rushed away from an ATM having left my card in the machine. That hadn’t happened to me in a long time and I wondered why. I am busier now than ever before, and as my mom always reminds me, haste makes waste. So why had I not lost a card in years? As I reflected, I realized that the reason is that the ATM now makes me take my card before giving me my cash. And I would never leave without my cash. The system is designed to prevent this human error, and so I’ve now managed to keep a single ATM card for almost 5 years.

At that moment it dawned on me that my decisions, both inside and outside of clinic, are as much driven by the system that supports me as they are by my personal behavior.

As a medical professional, I have been trained to take pride in autonomy and the art of medicine. Like my peers, I distill large amounts of data and use it to better the lives of others. I use cultural context and health behavior change techniques to help families improve their health. The results I have achieved with underserved families have allowed me to believe that by changing my behavior, as an individual provider, I can change the care I deliver. But the well-worn ATM card in my wallet challenged me to think otherwise. Perhaps the system played a bigger role in my behavior than I had previously thought. While I knew this to be true from my quality improvement work, it remained in direct conflict with my medical school teachings – that, as a physician, I am the primary driver of the care I deliver.

Similarly, we physicians blame ourselves for our mistakes because we feel that we own the care of our patients. As a pediatrician, I order lots of vaccines. Occasionally, I forget to order one. When this happens, I tend to lose sleep. I believe that I own the missed vaccine and had I slept better/ read more/ studied harder in medical school, this would not have happened. What I often neglect to take into account in those moments is the role the system played in the process. In one example, the patient that I was attempting to see in a 15 minute interval was a 13 year old who had immigrated from Haiti two weeks prior after witnessing the unwitnessable and had more physical, mental, oral, and social health needs that could possibly be addressed in the time we had together, even IF we spoke the same language.

But the goal here is not to lament about the system that supports primary care. It is to aspire to a way forward that supports individual autonomy, while preventing human error – say, on a bad day for scheduling or sleep or health reasons – from impacting the lives of patients.

Call me naïve, but I think the team-based care endorsed in the medical home model may be the way forward. Before I came to NICHQ, I led a pediatric department that was undergoing medical home transformation. The change was difficult, as change often is, especially change that impacts every facet of the way we do business as pediatricians. However, by asking the staff we worked with every day to play critical roles in data gathering, decision-making, and double-checking, we as providers were able to preserve our autonomy and also have a safety net for the days in which our processes were challenged by the constraints on the system or by our lives outside of medicine.

Over the past year, I have been privileged to bring this experience to my role as the Project Director for NICHQ’s current medical home learning collaborative. I have been helping practices transform their systems to engage their care teams and provide evidence-based care that supports patient and provider autonomy while reducing harm.

In this system, providers’ feelings of isolation as solely responsible for patients is replaced by the knowledge that we are part of a functioning team that is supported by a larger system. Now that is a system that is designed to achieve results.

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