Stakeholder Tables (Thursday)

To quickly recap, there are two types of tables in stakeholder analysis:

1. Effect versus Impact
2. Support versus Influence

The effect-impact table qualitatively assesses the contribution of a particular stakeholder to a quality improvement goal. The vertical axis represents the impact of the stakeholder, in measurements of "low", "medium", or "high". The horizontal axis represents the effect of the stakeholder's impact, in measurements of "negative", "neutral", or "positive".

Are admissions committees subconsciously making effect-impact tables when they predict the effect of an applicant's impact on their program? If so, how easy is it to make an accurate table? If not, what must tablemakers consider to ensure accuracy?

The support-influence table qualitatively assesses the contribution of a particular stakeholder to a quality improvement project. The vertical axis represents the influence of the stakeholder, in measurements of "low", "medium", or "high". The horizontal axis represents the support of the stakeholder's influence, in measurements of "negative", "neutral", or "positive".

Are patients subconsciously making support-influence tables when they evaluate the support of a provider's influence on their health? Since physicians are stakeholders in the quality of patients' lives, what can we learn from putting ourself in someone else's table?

The difference between these two stakeholder tables is subtle. One difference is the ability to specialize the impact-effect table by defining the impact according to the quality improvement goal. For example, when a physician is the target stakeholder, the particular impact may be defined by years of clinical experience, effectively creating a clinical experience-effect table. Or, maybe the impact is defined by average patient-encounter time, effectively creating an encounter time-effect table. Furthermore, multiple definition metrics can be used simultaneously.

-Brian Blaugrund

Fishbone Diagrams (Wednesday)

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

Proactive Checklists

When implementing new technology, organizations often miss their biggest opportunities for improvement, by attempting to translate existing processes directly into a digital format. Before writing a checklist, the process which is being measure should be understood and reconsidered.

There is a natural union between a process map and checklists. By combining these tools, technology can distribute checklist tasks according to a process map and organizational roles. If the process map were to be updated after a QI Physician identifies a method that better guarantees patient safety, then the technology could respond by promptly updating its workflow.

To fully redefine a process requires role analysis. With regard to the process of providing timely prophylactic antibiotics, could pharmacists own a portion of a pre-op checklist? Currently, the pharmacy appears to maintain a responsive role, waiting on doctors to request drugs. However, we already know these drugs need to be ordered when the surgery is scheduled. Could we provide pharmacists with a view of scheduled surgery and allow them to proactively confirm the need for antibiotics?

We might imagine the pharmacist could initiate a conversation with the surgeon to determine if the case will use standard antibiotics or does it require a variation? Once informed, the pharmacy could proceed with filling the orders and coordinate with anesthesia to deliver the antibiotics and transfer leadership of the checklist.



Process reorganization achieves its best results when its implementers consider the new methods to accomplish tasks that are possible using technology. Implementers may find that such considerations are easiesr when they analyze a process using a Hierarchal Task Analysis method. This way, they can focus on the tasks which must be accomplished, rather than a sequence of events which may no longer be required.

During a pre-operative timeout, before surgery commences, many items read out from the checklist may have been better to ask an hour ago. However, an hour ago each member of the surgery team couldn’t have predicted where they would be. It’s unlikely that they would have been in the OR, anxiously waiting their turn to affirm that their task was completed. More likely, they were across the hospital, out of reach of a paper checklist. How do we construct a checklist which takes flight, to reach them where they are, allowing their tasks to be affirmed, even when they are away?

Ultimately, the surgeon takes responsibility for the patient. In this role, they need to be informed of key milestones and prompted when milestones haven't been achieved on schedule. What type of checklist allows the surgeon to make use of the critical moment, rather than tally the score only after the patient has been intubated? How can we transition from a checklist which avoids mistakes before the first incision, to a checklist that is present along the way, ushering the patient towards a successful outcome?

After these revisions, a surgeon might receive a report that details accomplishments and notes tasks that may have been overlooked. We've connected the checklist to the process, and distributed ownership of the checklist across the organization, based on appropriate roles. So, rather than ask people if they finished a task they completed earlier, the surgeon knows to thank the nurse, Michele, for ensuring blood products are on hand. It’s a pleasant way to make a final confirmation that the system has worked for this, individual patient.

Some of the most valuable decisions a clinician makes regard judgments of evidence and choices to adopt new practices. Such decisions require high level cognition and make full use of their medical expertise. After those decisions are made, faithful execution is best achieved by a team and may be best managed by a process and checklist that the physician has previously defined.

Using Checklists for Measurement (Tuesday)

Today we heard from Kathy Masters about the basics of Six Sigma, a statistical system designed to improve efficiency of outputs by minimizing errors. We focused on measuring these outputs, the “M” in the DMAIC. One of the principal ways to measure is the use of checklists in medicine. Dr. Tsai, a pediatric cardiothoracic surgeon, talked about how checklists in the OR have helped to decrease the rate of surgical site infections.

• However, why haven’t checklists been adopted in medicine as they have in the automobile construction industry and world of aviation? What are ways for them to gain widespread acceptance?

Checklists also have drawbacks, as Dr. Tsai alluded to in his comment about having so many checklists that you need checklists to remember all the checklists. Many of the interpersonal aspects of healthcare, like establishing a rapport with a patient, being considerate of cultural and religious concerns and caring for a person’s emotional needs are not readily exportable to a checklist. It is important to recognize that checklists have both benefits and limitations and they must be executed appropriately.

Kathy Luther also mentioned how checklists can be adopted in primary care in the treatment of diabetes. Measuring HbA1c, HDL, and LDL should be done annually for diabetic patients, yet this is not being done. Does a checklist solve this problem? Blue Cross Blue Shield recently started a program called Bridges to Excellence, where physicians are financially rewarded for following guidelines for diabetic and cardiac care.

• Are checklists an effective, accurate, and fair way to measure quality improvement in the primary care clinic?

We also discussed the proper implementation of a checklist in an operating room setting. Dr. Tsai mentioned that in Memorial Hermann ER’s the checklist is done by the surgeon, while other operating rooms throughout the country will use residents, fellows, and nurses to run the checklist.

• Who should be in charge of the checklist? Also, continuing on yesterday’s post on technologies involved in process maps, what technologies could be implemented to improve usage? Are there ways to integrate the checklist with the electronic health records?

First, find your way

Athenian heroes do not win quests without a feat of cunning. In the myth of Theseus against the Minotaur, the hero's greatest challenge is to navigate the Labyrinth. If Theseus can only find his way through the maze, then monster slaying is what epic heroes do best, and we know he'll win the day. As he set out into the Labyrinth, Theseus carries not only his sword, but also the unlikely, a fist full of string; something sharp and something shrewd.

The complexity of the healthcare system is aptly compared to a Labyrinth. Today, Dr. Pratik Doshi presented the first lecture in our series on Quality Improvement by introducing us to Process Maps as a method to define the problems we aim to improve. Dr. Doshi presented two methods to design process maps at our Quality Improvement lecture focused on the Define component of the DMAIC process. The first is a sequential map. It outlines key tasks, interactions, and decision points as identified by walking the process.

Plutarch, the Roman author, maps the process for conquering Theseus’ quest as a sequence of events:

1. Sail to the city of a mad king who demands human tribute from your people


2. Avoid being frisked; smuggle your sword into enemy territory


3. Upon arrival, win the love of the king's daughter


4. Feign martyrdom and assume the place of your countryman in the sacrificial ritual


5. Gain inside knowledge of the maze from its architect, passed by the king’s daughter


6. Receive a ball of string from your lover and lay it along your path as you enter the maze


7. Surprise the fell beast and gain the upper hand in battle


8. Follow the string back; flee island

Theseus lacked the omnipotent position of narrator. He was a hero with a task in front of him—forcefully correct King Minos’ cruel judgment that Athens owed him fourteen of its brave and fair citizens. He would have seen the benefit of the second method Dr. Doshi presented, a goal-oriented process map: Hierarchal Task Analysis. This is the method for Theseus, a man who makes a name for himself by stabbing epic beasts in the throat.

For Theseus, approaching his situation as a sequence of events would be less useful than considering his two requisite tasks: slay the Minotaur, return home. As an epic hero, he already had some sense of how to approach killing monsters, but what of this issue regarding a Labyrinth? Hierarchal Task Analysis could direct Theseus to further consider this problem, rather than charge headlong, and lose himself in a maze.

Outside pundits marvel that health care has been slow to adopt business process improvement. Stepping inside our maze, we gain the view that the healthcare system may not always be best defined as a sequence of events. Dr. Doshi provides us with two means to accomplish a heroic quest. Whichever of these two methods we utilize, Process Mapping is our string, laid down as a guide for clear analysis of our system for providing medical care. Able to navigate our Labyrinth, we can seek its challenges.

Process Maps (Monday)

To quickly recap, there are two types of process maps:

1. Sequential flow
2. Hierarchical task analysis

The sequential flow diagram organizes tasks with arrows indicating order of completion. The hierarchical task analysis diagram organizes tasks with arrows associating relevance to an outcome.

There appears to be uncertainty over which approach is more appropriate for healthcare quality improvement projects. I suspect it depends on the nature of the project, and ultimately the process in question. For complicated, multi-faceted processes with many outcomes of interest, it seems likely that the hierarchical task analysis diagram would provide a clear representation. But for single-track processes with minimal stratification, the sequential flow diagram seems a simpler, faster option.


What are some examples of healthcare processes conducive to mapping?

1. Single-track processes, for example, could include things like documenting patient encounters, performing physical exams, or even USMLE preparation (medical students, meet quality improvement).

2. Complex processes, on the other hand, could include rehabilitation regimes, cancer therapy, or new patient intake.


What are some practical implications of using process maps?

1. Construction: the marker-and-whiteboard method was demonstrated today, but technology is more advanced than that. What software exists to ease construction of process maps? Hey, Apple...is there an app for that?

2. Convention: complicated chemistry has rules for diagrams (bonds, elements, reactions, etc.); process maps need rules too. Dashed lines, dashed boxes, block arrows, solid arrows--the graphics need definitions. Do process maps already have standards? Or should healthcare users attempt to establish them as the tool becomes more widespread?

3. What else?



-Brian Blaugrund