On the evening of July 9, 2016, I was nervous about the “sharing and learning session” I was to facilitate at Sitaram Bhartia the next day. This was going to be the first-of-its-kind session at the hospital where five teams were going to share their improvement stories with each other. Neither were they going to showcase their work to management nor to an audience outside the hospital.
I reached the hospital at 7:50 AM for the session that was scheduled to start at 9:00 AM. As I sat in the lobby looking at attendees walking in, I hoped that they would find today’s session worth spending their Sunday at the work place. I entered the auditorium at 8:30 AM and met attendees who had arrived a bit early. One of them was so nervous that she could not sleep past 3:00 AM. Some other attendees were in a similar state – feeling anxious as it was the first time that they would be standing up in front of an audience of thirty people to share their work. With all this happening it was soon 9:00 AM and the time to start!
The first team came up to present their work and the consultant lead introduced the team: for the first time we had three front line staff members presenting their work. They all looked nervous but spoke well. They did not have to look at notes or slides because it was their story… it was their work they were talking about. They told us how they tested and tried many things for reducing waiting time for patients visiting the busy OB/GYN clinic on Saturdays. They made it clear how brainstorming together and sharing the workload helped them succeed. In the Q&A session only consultants in the audience asked questions. When this happened I felt the session was not accomplishing the goal it was supposed to meet. It meant the front line staff was not feeling secure enough to open up and ask questions. But there was little I could think of doing and we moved on to the second presentation.
The second team presented their work on making care for paediatric patients visiting the emergency room more reliable by using a triage tool. The triage tool was a structured pathway that nurses and doctors could follow to reduce the chances of wrong clinical management. This time we had three nurses talking about their experience along with their consultant lead and quality officer. They talked openly how they struggled with their tool initially and how a new nurse didn’t like the tool. They talked about roadblocks and successes. The front line staff in the audience seemed more comfortable and asked a few questions.
The third team was from the laboratory and they presented their work on reducing wastage of controls for calibrating the auto-analysers. This was to be a rather technical presentation and I was not sure if the other teams were going to be interested. But the laboratory team made it very simple – they explained their project by bringing an actual control and showing how they prepared and used the controls. Suddenly a technical topic became interesting and there were many questions from the audience.
Next came a team that had started their improvement journey only three months ago. They talked mostly of the challenges they were facing in increasing breastfeeding in babies discharged from the neonatal intensive care unit. The audience seemed engaged and this time provided suggestions. The nurses, technicians and other front line staff looked more relaxed and displayed empathy towards the team facing challenges.
By now we were running half an hour late and though I wanted to cut down the presentations short I couldn’t – the teams were keen to share their experience and the audience was engaged and had several questions. I let it continue.
We came to the last presentation. The Operation Theatre team presented their four year long experience with reducing time to shift patients from the ward to the theatre. They had worked on this in 2012 and had succeeded in reducing the time up until the start of 2016 when the delays in shifting patients went up significantly. This team spent a lot of time discussing their failure – they shared that lack of transparency and communication between the different stakeholders allowed a new team member to come in and overturn the system without understanding the implications. They used their learning to create a new process with participation of all stakeholders.
I very much enjoyed all the presentations and learnt many new things. Team members that were mere names now became familiar faces. All in a few hours, anxiety turned to engagement, smiles, empathy, and respect. During the lunch that followed we played a game that allowed people who knew little about one another interact and establish rapport.
While I was seeing all this happening – front liners talking and engaged, and hierarchy between doctors, nurses, technicians and administrative staff being flattened – I felt we had arrived at an important milestone in our quality journey. I thought about my first year in quality – how we failed in the first two projects, how I doubted the methodology, the suitability of implementing quality improvement in our hospital, and whether I was the right person to be leading such efforts. But despite the doubts, we pushed on – much because there were so many problems that needed solutions. Our third project, reducing missed calls to the hospital’s telephone exchange was a resounding success. From that point onward we became much more effective in tackling challenging problems – we reduced complaints from admitted patients and improved patient satisfaction, reduced turn-around-time for laboratory tests, and increased breastfeeding rates. But these were projects in silos, others didn’t know about it. Today’s event had broken those silos – allowing teams to learn from each other and empathise with each other.
What happened today could not have happened five years ago because the journey of quality improvement is not like buying a fancy piece of equipment or bringing on board a new prolific consultant. It is about building a culture where improvement becomes a way of working. This needs support from the top and champions who are willing to persevere despite setbacks. The journey is not easy but the rewards are well worth the pains.