Why It Matters
“Whether it’s trying to get your kid out the door faster in the morning or trying to detect sepsis more quickly and manage it more effectively, the same tools work."
About 10 years ago, an Institute for Healthcare Improvement (IHI) team was working with a hospital that routinely used physical restraints on patients in their intensive care unit (ICU). The patient mix was complex, and the hospital team felt that they needed to use restraints to keep the patients from harming themselves or others.
Jesse McCall, MBA, Senior Director at IHI and an improvement advisor, recalled how the IHI team urged the hospital staff to rethink their approach. They cited abundant evidence that the use of restraints can be harmful. They discussed their own experience in testing the removal of restraints. They talked about the success they achieved and the failures from which they learned. “Restraints are not good for staff and they’re not good for patients and families,” he said in a recent interview. Moreover, “unless it’s in an extreme situation, they’re not necessary.” But for the staff, change was difficult. Using restraints was common, and they were worried about the consequences of stopping.
To McCall, this was a perfect opportunity to apply the science of improvement. In addition to reducing variation and errors in health care, quality improvement can also apply to a much wider range of situations. “Improvement skills can help you solve any number of problems, from complex things to simple things,” said McCall, who is the lead faculty member for IHI’s Moving Quality Improvement from Theory to Action program.
The key is starting small and testing changes by using Plan-Do-Study-Act (PDSA) cycles. The IHI team persuaded the hospital team to forgo restraints with one patient. IHI helped the team develop a plan to address their concerns: check on the patient at regular intervals and provide meals and toileting at specified times. “That first day they were scared and nervous. What’s going to happen? Is this person going to get hurt? Are we going to have staff running to the bedside to help them?” But, in the end, he recalled, the patient was safe and the first day of testing was successful.
Improvement work can yield remarkable benefits for both patients and staff. “You as one person or a small team can have such an impact,” said McCall. “And basic improvement tools enable us to do that.”
Initially, some staff members may fear that improvement work will merely add to the burdens that the health care workforce has been experiencing, potentially exacerbating burnout. But, McCall argued, the opposite is the case.
One cause of burnout, he said, is when staff members are frustrated by the systems they work in and have been trying unsuccessfully to make changes, sometimes for years. “You think you’re going to put all this work into changing something only to have it go right back to where it was,” McCall explained. But if staff can effectively drive sustainable change — which improvement methods enable them to do — the result can be energizing rather than enervating.
IHI Moving Quality Improvement from Theory to Action
Again, a key element of the approach is starting small. McCall said that seeking a “big bang change” in the hope that transformative improvement will happen quickly can lead to frustration and burnout. An improvement approach, by contrast, entails breaking up the challenge into manageable portions, iteratively testing, learning what works and what does not, and building confidence. Using improvement methods “gives people agency,” McCall stated. “It gives them the power and intention to act.”
As for the hospital team working to reduce the use of restraints, they learned from their experience with the first patient, and the next week they moved on to three patients. A week later, they scaled up to one whole side of the hallway, and then to the next side of the hallway. “They built their confidence that it was possible, and they built their confidence that they were doing the right thing,” McCall remembered. “It was wonderful to see that fear of change or fear of the unknown gradually go away.”
For McCall, teaching improvement is also empowering. “My favorite thing about teaching improvement is giving people a set of tools they can use to solve pretty much any problem they have,” he said. This can include contexts far outside of health care. Once, McCall worked with a student who wanted to improve her ability to improvise in jazz. “Jazz is a very creative pursuit,” he noted. “How can we apply science to that?” The student’s initial goal was to improvise for five minutes and 30 seconds without tripping up. At McCall’s urging, she broke that time down to 30-second intervals. Then she strung those 30-second intervals together and ultimately succeeded in improvising for a longer period. Breaking big problems down into manageable pieces is another hallmark of the science of improvement.
“Whether it’s trying to get your kid out the door faster in the morning or trying to detect sepsis more quickly and manage it more effectively,” said McCall, “the same tools work. They’re practical. It’s a human way of learning. And it’s an amazing thing to see that excitement in people when they see it start to work.”
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