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Breaking the Rules to Improve Care and Increase Joy in Work and Well-Being

Why It Matters

Sometimes "rules" get in the way of providing optimal care and system redesign.

Rules and regulations are an important part of health care. They are meant to standardize operating procedures, protect patient safety, ensure quality, and prevent fraud and abuse. But sometimes health care leaders inadvertently put processes or policies in place that have an unintended impact on the people we serve and support. Sometimes rules get in the way or even stymie optimal care and the best patient experience.

For these reasons, the Institute for Healthcare Improvement (IHI) Leadership Alliance started the Breaking the Rules for Better Care initiative in 2016 to identify and eliminate health care “rules” that may have been created with good intentions but, upon reflection, do not benefit patients, families, or staff. IHI encouraged participating organizations to ask their patients and staff a simple question: “If you could break or change any rule in service of a better care experience for patients or staff, what would it be?” Dozens of organizations identified hundreds of rules deemed to provide little or no value to patients and staff.

In 2017, IHI’s Health Improvement Alliance Europe (HIAE) introduced the Breaking the Rules for Better Care idea to European health care settings. Member organizations received over 500 rule submissions from patients, families, and staff through suggestions boxes in cafeterias, postcards, comment boards, and staff brainstorming sessions.

In February 2023, IHI’s Strategic Networks once again hosted a Breaking the Rules for Better Care effort and saw participation from nine organizations across the globe who collectively submitted over 1,200 rules. For one week, leaders asked providers, staff, and patients to submit rules that got in the way of effective and high-quality health care.

Once again, IHI saw an enthusiastic response to the idea of removing unnecessary barriers to reimagining and redesigning our health care systems. As was the case during other Breaking the Rules for Better Care campaigns, participants found that some “rules” were myths, habits, or requirements that had outlived their usefulness. Participants often referred to these as “stupid rules.” This year, eliminating “stupid rules” like those governing the color of scrubs, re-opening staff entrances that had closed due to COVID-19, and expanding visiting hours provided quick wins.

Questioning administrative systems or policies that impede patient care and workforce well-being was also a common theme. For example, people across organizations took issue with typical appointment scheduling practices, with providers and staff seeking simpler, on-demand scheduling systems to increase patient access to care. In response, IHI heard from multiple organizations working to implement patient self-scheduling.

Sometimes rules that need policy reform or advocacy emerged. Frustrations over prior authorization practices, for example, came up in discussions more than once. This highlighted the reality that some forms of system redesign require collaboration with health care leaders and policymakers.

Breaking the Rules to Empower an Overburdened Workforce

Beyond system redesign, the Breaking the Rules for Better Care initiative has offered a platform for feedback and engagement in improvement throughout organizations, from providers to patients to board members. Justin Klamerus, MD, MMM, Executive Vice President and Chief Medical Officer at McLaren Health Care (Grand Blanc, Michigan, USA), described the process as “almost a catharsis or therapeutic process for many of our staff who are feeling so overburdened.” He said that pausing to reflect upon important questions (e.g., “Are we doing things wisely and using resources smartly?”) helped his organization’s leadership demonstrate that they are listening to patients and staff and doing all they can to help staff do their jobs as efficiently, and productively as possible.

For Louise Rang, MD, FRCPC, Professional Sustainability & Wellness Lead at Kingston Health Sciences Centre (Kingston, Ontario, Canada), inviting the staff to Break the Rules for Better Care came at the right time for her organization’s staff. “It has been just what our department needed to help reengage a tired workforce and help build a culture of agency with our incredible numbers of new staff,” she said. Rang also noted that using the Breaking the Rules for Better Care Resource Guide (including a sample email/newsletter announcement and template for recording responses) made the process easy, and joining monthly calls with other Breaking the Rules participants provided tips, support, and inspiration. She noted that staff throughout the organization felt inspired to offer ideas for improvement now that they knew leadership was listening. “A cleaner said that he had filled the survey five times as he went through his day [because] he kept thinking of stuff and was so happy to have someone to tell,” Rang recounted.

What would Breaking the Rules for Better Care look like in your organization? Use the Breaking the Rules for Better Care Resource Guide for step-by-step planning and implementation guidance. You might be surprised by what you find.

Nikki Tennermann, LICSW, MBA, is an IHI Senior Project Director. To learn more, join IHI and teams from the University of Arkansas for Medical Sciences, Kingston Health Sciences Center, and Schneider Regional Medical Center for session D02: Breaking the Rules for Better Care (9:30 AM to 10:30 AM Eastern Time) on Friday, December 13, 2023, at the IHI Forum.

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