But take a look anyway, if you have an interest in process improvement in hospitals. This is a collection of my best posts on this topic.

Thursday, February 8, 2007

Little ideas work, too

As a follow-up to yesterday's posting, I want to give two examples of changes instituted in one of our departments, neurology, that are indicative of ideas that bubble up and help improve access and results. Please understand, I am not saying these are necessarily state-of-the-art or haven't been done elsewhere or are world-shattering in scope. They are simply two examples of creative thinking that originated with the medical leadership that were put into place with no fuss, and that work well for patients.

First, we noticed that people who wanted to see neurologists on a semi-emergent basis, i.e., in a day or two, were finding an appointment lag of several weeks. Why? Because all the doctors were booked well in advance. So our chief of neurology instructed his faculty to leave their schedules open for a portion of each session, to be available for last-minute patient requests. The doctors were worried, though, that they would have wasted clinical time during their days, that those reserved open hours would never be filled.

What happened? Just the opposite. The reserved open hours were always filled with patients with more immediate needs. And, those patients had a much better record of actually showing up for their appointments than people who had made appointments several weeks in advance. And, doctors had a chance to see patients while they were freshly suffering from neurological symptoms, instead of hearing about those symptoms weeks after the fact. End result: Happier patients, better clinical diagnoses, and more productive doctors.

Second, every hospital has a "mortality and morbidity" conference procedure to review cases with adverse outcomes. But what about the normal, day-to-day cases? How do you audit for quality control? I don't mean questions about proper documentation. I mean review of the doctor's decision-making. Even the best of doctors will make mistakes and omissions in the course of treating a patient, most of which are not crucial, but many of which can be instructive if they are pointed out. Here, too, our chief of neurology put in place a simple idea, which he calls a "biopsy" of the medical record. Here's how it works.

Each faculty member in the department, from most junior to most senior, is asked to anonymously review the patient record of a colleague. He or she then offers a "grade" on the quality of the diagnosis and treatment, with minimal or extensive commentary depending on what he or she finds. That written review is then shared with the attending physician on the case.

What is going on here? Let's remember, first, that these doctors are extremely well intentioned and quite expert and really don't need an incentive to treat patients as well as possible. Through this gentle, non-threatening, but direct, peer review process, they are told by an equally expert colleague how they can do better. The reviewer, too, benefits by thinking through an interesting case and reflecting on his or her own practice. Since everybody gets to be a judge and part of the review team, the likelihood of defensive behavior or denial is reduced.

Not a big deal, you say? Maybe not. On the other hand, it is a thoughtful and effective process that is respectful of the expertise of the faculty while providing a gentle nudge towards more consistent clinical excellence. I like how it works, and I like what it stands for: A underlying value system of collegial behavior in service to the patients.

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