To quickly recap, fishbone diagrams are a quality improvement tool that identify the causes of a particular problem. They are an excellent way to document brainstorming at the onset of quality improvement projects. Components of a finalized fishbone diagram can be incorporated directly into ensuing process maps and/or checksheets.
Fishbone diagrams, like any form of brainstorming, should be generated by a team. Contributions from multiple perspectives increase the likelihood that all significant causes will be identified.
What are ways to efficiently obtain such widespread contribution?
1. From providers: fishbone-feedback publications might work, since practitioners typically stay well-read (requirement of the field). When appropriate, this may also facilitate long-distance contribution. And how about convincing QI-ignorant practitioners to participate? Is it sufficient to lead only by example?
2. From patients: post-encounter surveys might work (grounds for summer projects, galore). Another way might be purposeful listening, such as prompting feedback during an encounter. Shh, taboo...can providers ask for patient critique?
3. From policy makers: any suggestions for ways to extract ideas across this two-way glass?
-Brian Blaugrund
I was reminded of this article:
ReplyDelete“When I started in practice, I wanted to do the right thing,” he told me matter-of-factly. “A young woman would come in with palpitations. I’d tell her she was fine. But then I realized that she’d just go down the street to another physician and he’d order all the tests anyway: echocardiogram, stress test, Holter monitor — stuff she didn’t really need. Then she’d go around and tell her friends what a great doctor — a thorough doctor — the other cardiologist was.
Gaining productive customer feedback is difficult in any industry as its selective for extreme viewpoints. Reforming your business for the small minority of your customers rarely works in other industries. However, inviting patients to participate in a session such as today could be very different feedback.
Policy makers would certainly enjoy giving input. And there are experts who could inform our thinking within the government. A productive dialog needs to be maintained if we expect to have influence when there's an issue we truly wish to push back upon.
In the retail industry, we understand the clothes we put on, yet designers determine new styles. In medicine the gulf of knowledge is far wider and we should remain confident that our colleagues will continue to have many of the best insights.
That's not to say we should put wax in our ears, lest we be led astray by patients and politicians. Probably one of the greatest gains from engaging patients is to ensure that a change we embark upon doesn't reformulate something which patients had generally liked.
True, the most vocal customers are usually the ones with the most extreme viewpoints (good or bad)... but in an age when a large percentage of people check online reviews for many of the services they seek, those extreme customers can make or break a small business. I'm sure small private medical practices are as subject to this phenomenon as restaraunts, auto mechanics, or a variety of other small business types.
ReplyDeleteProviding interactive forums for patients/customers with extremely negative views to give their feedback might be thought of as a protective measure to prevent them from pursuing what sometimes seem like online smear campaigns against your business. However, that's a pretty cynical way to look at it. Instead, those patients could be thought of as magnets who have already done the work of finding the needles in the haystack for you: errors should be relatively rare in most practices (hopefully), so these patients could provide a means to find and sample some of those errors without the tedium of combing through reams of data. In other words, you almost have a data set that gathers itself. If nothing else, these errors might illuminate some of the low-hanging fruit to pursue early in a QI campaign.
And you're right, Mark... there is always the possibility that our perception of what made a patient's experience "bad" differs dramatically from their perception of the same event!
Patient involvement in root cause analyses also helps with patient education. When a patient is asked to evaluate the care they have received, they begin to understand that care better. I agree with Mark, the information gap between providers and their patients is vast, and many times patients won't understand the big picture. However, I think that attempting to bridge the gap is important. Patients have become an integral part of the health care team, and their input is valuable to any root cause analysis and valuable to their understanding of how the system works.
ReplyDeletePart of the problem of using these QI strategies for a patient population seems to be the nature of the service we provide. Most patients will deem the success or quality of their care based on whether they "get better" or they feel sufficient work has been done to exhaust all potential for underlying medical issues, like the example Mark gives. Can you really view patients as "consumers" in this sense, able to rate the quality of their care?
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