Tag Archives: Systems Change

Systems Level Healthcare Improvement Starts with Individual Relationships

Tom Dahlborg
Tom Dahlborg

Recently, I was invited to a meeting of experts to discuss how best to improve patient and family engagement in healthcare at a system level.

As I walked in to the meeting room, I was pleased to see I was slated to sit next to the meeting co-chair, who I had met previously and wanted to get to know even better. As I walked out to stow my luggage, one of the meeting coordinators approached me and let me know that they were moving me because another individual required access to a plug (which happened to be right behind the seat I was initially assigned to).  Oh well I thought … I will simply connect with the co-chair later in the day.

Interesting how fate works.

Shortly thereafter I realized I would be sitting next to a brilliant patient advocate, who also happens to have a chronic degenerative neurological disease. (I will refer to him as Neal.) And throughout the day, Neal showed all of the following symptoms of the disease:

  • Tremors
  • Bradykinesia
  • Rigid muscles
  • Impaired posture and balance
  • Loss of automatic movements
  • Speech challenges

As the meeting began, I became aware of Neal’s breakfast. How he appeared to struggle with his fruit. How the juice cup in his hand flailed precariously close to being dumped on him, on me, and/or on the table. And I realized I had no idea how to help. I had no idea whether Neal wanted help. Would I offend him by offering help? What was Neal’s preference?

As the day went on, Neal confided in me that he was getting tired and I noted his symptoms worsening. He stood up abruptly and his chair, which was on wheels, flew backward so I grabbed it and held it for him. I saw him stumble and thought he would fall so I reached out and held his arm.  Neal brought out a pill container and I thought he was having some difficulty extracting his pills, but decided to hold off at first on offering assistance. Again, I wasn’t sure what he would want and whether he was finding my persistent questioning, e.g., “Can I help you?” “How can I assist?” “Can I get that for you?” bothersome. He retrieved his pills on his own. He then began to lean toward me and I asked again “can I help you,” but received no answer.

A bit later Neal handed me a can of soda and asked me to open it for him, which I was happy to do. And yet as I did so I noticed he also had a cup of ice and based on what I was witnessing I was thinking there was no way he would be able to pour the drink into his cup without spilling. And as I was about to ask him if he wanted me to do it (feeling more comfortable after a number of hours together), Neal leaned over to me and asked me to do so for him.

It’s interesting what thoughts go through your mind during these times.

Feeling that at any moment I could be wearing Neal’s drink, I made a pact with myself that if it does happen I will not show any manifestation of being startled, I will not immediately get up and go clean my suit, but rather I will take it in stride and ensure that I do not cause any sort of scene which would adversely impact Neal. Or, in other words, I will do my best to treat Neal how I would want to be treated in lieu of not truly knowing Neal and his preferences.

At the end of a long day I noticed Neal circling me. He came near and then circled away. He came near and then stumbled (and I supported him) and then circled away again. He then stopped nearby and we made eye contact and he simply said, “Tom, I want to shake your hand,” which we did and I responded, “Neal, it was so great to meet you.”

During a long commute home I continued to process these events.

I was blessed to be sitting with my new colleague. I was fortunate to be further reminded throughout the day of how important it is to develop relationships, to develop trust, to share openly and honestly, and to understand one another’s whole story, preferences, goals, desires, and so much more … and especially so in healthcare. I learned that the more I got to know Neal and understand his preferences the better I felt and the better I was able to respond accordingly and meet his needs more effectively.

Want to improve the healthcare system from a systems perspective?

Develop systems which allow for time, continuity, relationship, trust, authentic sharing, the telling and hearing of the patient’s whole story at each healthcare encounter. Create system change which positions clinicians to use tools such as emotional intelligence and motivational interviewing to ensure optimal sharing and comprehension. And not only collect data from these encounters, but rather turn the data into information and the information into wisdom by co-creating with the patient and family care pathways that are 100 percent aligned with the now understood preferences of the patient. Lastly, develop systems which track progress toward achievement of the co-created care plan (measure the impact).

If we are going to truly

  • engage patients and families,
  • improve patient satisfaction, engagement, activation,
  • improve clinician satisfaction and retention,
  • ensure resources are not wasted (save healthcare dollars), and
  • profoundly change and improve the healthcare system,

then we must.

Yes, Neal, it was so great to meet you. Thank you for allowing me the opportunity to learn from you.

The Secret Ingredient to Fixing Systems Problems

Cindy Hutter
Cindy Hutter

In full disclosure, I didn’t see this firsthand. The photo was passed on to me with the caption, “You had one job.” Instead of the chuckle it was intended to elicit, the message made me a little irritated. I started to think of all the places where there was a breakdown in the system that allowed these mislabeled products to hit the grocery shelf.

No matter how automated a factory is, surely someone must have noticed that the incorrect packaging was being used on the hamburger buns. Did a factory worker raise a red flag? If she did, was it ignored? As the stock boy was unpacking the hamburger rolls at the local grocer, didn’t he notice? Was he on such autopilot that he genuinely missed it? Or did he simply think it wasn’t a big enough issue to care?

What about every other stock boy or girl at all the supermarkets that received the mislabeled products. Did none of them notice? If someone did notice and called the manufacturer, did the company care? Did the bun company call back the mislabeled products? What happens if someone eats one of those buns and has an allergic reaction because the product inside was not as advertised on the package?

Yes, the difference between a hamburger bun and hotdog bun, which most likely are made with the same ingredients and the same process, sans the shape, won’t likely cause harm. However, what if that mislabeling was on a product that contained peanuts? Or a household cleaner with toxic ingredients? Or even a medication? These might have serious consequences.

Working in a quality improvement organization, we view undesirable outcomes as the byproduct of poorly performing systems. We teach that to uncover the problem in a system causing the unwanted result, you need knowledge or information.

It sounds simple enough. Of course you need knowledge and information to get to the root of a problem and make a change that will hopefully result in improvement. But more often than any of us like to admit, decisions get made without enough knowledge.

For example, I bought a Kindle because I thought it would help me to read more. It hasn’t. Whether I have a hard copy or an electronic copy of a book isn’t the issue; it’s carving out time to read that is the problem. If I had spent even a few minutes asking myself questions about why I don’t read enough, I could have saved the money I invested.

Or to go back to our bun example, the bun company’s vice president of operations may decide the root of the problem is a shortage of hamburger bun bags at his factories. But, even after the additional bags arrive at the factories, the mislabeling issues continue. A little knowledge seeking, perhaps talking to some of the workers, would lead him to the real problem: workers can’t detect the blue and green colors that are meant to distinguish the hamburger and hotdog bun bags or simply can’t read the language.

The mantra in quality improvement is “every system is perfectly designed to get the results it gets.” Regardless of your system of choice—your workplace, your home, your community—you’ll need knowledge to improve the system and get the results you want. It’s impossible to be a change agent without being a knowledge seeker first.