Editor’s Note: Colleen McCormick, a fourth-year medical student from Wright State University in Ohio, is using the IHI Open School Quality Improvement Practicum to conduct her first quality improvement project.
Every Wednesday during February and March, Colleen will write a blog post about her progress as a student trying to make a change in the health care system. You can catch up on her previous posts here.
By Colleen McCormick, fourth-year medical student, Wright State University
At the start of our improvement project, we made sure to identify some balancing measures. (For those of you who may be new to quality improvement, that means we wanted to make sure a change we were making to the system wouldn’t have negative effects on others parts of the system.)
For us, that meant it was a priority to ensure staff satisfaction. While our development team included representatives from all the key stakeholder groups, we also wanted to give each member of the patient care team an opportunity to provide feedback.
You may recall that we previously designed a palliative care screening tool to facilitate the consult process. To ensure ICU staff would find value in the tool, we shared it with them — both nurses and physicians — to gather feedback and make improvements. Many of the staff had helpful comments and suggestions. After a few more iterations, we had a simple screening tool that the staff were excited to use!
But we knew that small victory didn’t necessarily mean staff would be on board with the changes we are hoping to make. (After all, they are all very busy and it’s going to be a challenge to ask them to squeeze another thing into their work.) We knew the educational sessions — which started last week with the ICU nursing staff — would be another test.
The session planning team included an ICU nurse, a palliative care nurse, a palliative care physician, my faculty advisor Dr. W, and me. We developed a presentation that described the differences between palliative care and hospice care, and explained the benefits of palliative care in an ICU setting. We included the data analysis of our hospital’s palliative care utilization to show the staff our baseline compared to national measures
Finally, we handed out the updated palliative care screening tool and shared our aim: to increase palliative care utilization from 3% to 9% by April 2013.
Nearly 50% of the ICU nursing staff attended one of our educational sessions, and they really liked our goal of increasing palliative care! We solicited feedback about both the sessions and the content. The nurses agreed that the sessions were helpful, and they felt they would be able to apply the screening tool to all of their patients. The process, they said, wouldn’t be too time-intensive, and they thought the tool would encourage the ICU team to include palliative care in the care of the sickest patients.
However, the nurses were skeptical that ICU physicians would want to use the tool. They also feared that some of the physicians would not order a consult even if the tool recommended a consult for the patient. After all, the screening tool will be a disruption to the current process of consulting, and in many cases, it will ask physicians to change their behaviors.
Our planning team valued this feedback, as it will help us educate staff in the future. In addition, we were very grateful for the feedback the nurses provided regarding physician behaviors. (We agree it will be difficult to change these ingrained behaviors.) We are hopeful that by empowering nurses to complete the screening tool on each patient and bringing the results to the attention of the medical team, physicians may be more likely to consult palliative care. Also, the subset of physicians with whom we have spoken are enthusiastic about the changes to come. We hope that our physician champions will lead by example, encouraging their colleagues to consult palliative care. This may not be enough, though, especially for the physicians who still do not understand the benefits of palliative care.
Have you faced similar barriers in trying to change behaviors to improve patient care? I would love to hear how you approached and solved these barriers.
Finally, this week, the medical ICU teams will start using tool! We will continue to monitor staff and physician satisfaction as we move forward with the improvement project.