Why It Matters
The best way to make space for health care redesign is to ask staff and patients to identify the rules, habits, policies, and procedures that get in the way of a better care experience, and then empower them to remove them.
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The Global Appeal of Breaking the Rules for Better Care

By Derek Feeley | Friday, September 29, 2017
Line of Sight

What is it about bending or breaking rules that appeals to so many of us?

Last year, when IHI facilitated a Breaking the Rules for Better Care Week, health care professionals all over North America and Europe identified hundreds of rules that were getting in the way of optimal patient care. Across a range of countries, settings, cultures, and health systems, people embraced the idea of “breaking the rules” in health care. Why?

I have a theory: People are overburdened. One of the big contributing factors to burnout is the fact that people feel over-regulated. There are too many rules that don’t exist for good reasons, so, when given the chance to break or eliminate them, people were glad to do so to provide the best possible care for patients.

Sometimes Rules Get in the Way

The idea of breaking the rules came from the IHI Leadership Alliance. We asked Leadership Alliance members to describe the elements of high-quality care. What must a health care system do to get unprecedented Triple Aim results?

One member told us we sometimes need to break the rules to get the best outcomes for patients. She told a story about a neonatal intensive care unit (NICU) where they were caring for a baby who wasn’t thriving. The mother was understandably very worried, and consequently, she wasn’t doing well either. The rules in the hospital, as is the case in many NICUs, preclude the mother from joining the baby inside the unit because of legitimate concerns about the threat of infections.

The care team eventually determined, however, that the baby and the mother weren’t going to do their best unless the two had some time together. The mother needed to take the baby in her arms to provide comfort and be comforted. So, that’s what the hospital arranged.

They later got a letter from the baby’s father that was glowing in its praise of the care the hospital provided. The main thing he stressed was his deep appreciation that they broke a rule for his family. He essentially said, “In order to give us the care that we needed and wanted, you broke the rules for us.”

New Rules, Not More Rules

Sometimes we get stuck in old ways of doing things. It’s human nature to do what’s comfortable and familiar, even if it’s not productive or helpful. But if health care professionals don’t have good reasons for conducting “business as usual” then we need to be open to change.

As we face tomorrow’s challenges in health care, we can’t do more of the same. Some of these challenges require new rules for radical redesign, but we can’t just layer new rules on top of the existing ones. You need to replace, not add.

People have a limited amount of energy and time. If all we do is ask them to do new things without removing the wasteful activity, we end up adding to people’s burden without securing any benefits.

Health care leaders need to create space for redesign. The best way to make that space is to ask both staff and patients to identify the rules, habits, policies, and procedures that get in the way of a better care experience, and then empower them to remove them.

This kind of inquiry motivates and enables people to reflect on what high-quality care should be. It also gives leaders a chance to do away with some of the frustrations staff feel at the point of care. What health care leaders learn from this exercise is often eye-opening.

Surprising Results

Once you start breaking the rules, you may find something surprising: many of the so-called “rules” aren’t rules at all. They’re customs and rituals. Often, what people assume are rules turn out to be just old habits.

For example, during Breaking the Rules for Better Care Week, our Strategic Partners at the Royal Free Hospital Trust in London identified a rule about their children’s playroom. It was only open Monday to Friday. Once they determined there was no good reason to close it on Saturday and Sunday, they opened it seven days a week. Staff are happier and the children are delighted.

We estimated that 80 percent of the hundreds of rules participants found during Breaking the Rules Week could be broken. This doesn’t necessarily mean that they should be broken, but the fact that they were not regulatory or legal requirements surprised us.

Too often we assume that meaningful change will take years and be painful. Sometimes that’s true. But, as the decision to break the rules showed us, important ways to improve care can come to light just by asking motivated and engaged caregivers to tell us what gets in the way of doing their jobs.

Fear of Breaking the Rules

If, as a leader, asking people to break the rules makes you uneasy, that’s understandable. Fortunately, this idea works well with some basics of improvement science.

Start small. Review the ideas in the IHI Breaking the Rules for Better Care resource guide. Ask an individual ward, unit, or team to think about the aspects of their work that offer no value or waste time or resources. Encourage them to think about what gets in the way of great patient care.

Or start with yourself. Ask yourself this question: If you could break or change one rule in service of a better care experience for patients or staff, what would it be and why?

Run some tests. Figure out what works and then scale it up.

Breaking the rules is not a chaotic free-for-all. We’re empowering people to pause and reflect on what works best for patients and staff. We’re often so busy doing what we do that we never take the time to study the impact of our actions. We forget to stop and ask ourselves, “Is what we’re doing really leading to an improvement?”

Editor’s note: Look for more from IHI President and CEO Derek Feeley (@derekfeeleyIHI) on leadership, innovation, and improvement in health care in the “Line of Sight” series on the IHI blog.

You may also be interested in:

Breaking the Rules for Better Care resource guide

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