Improvement Across Departments Requires “Boundary Spanners”

The GBMC HealthCare System is making great progress in improving care. Every morning on Lean Daily Management rounds I hear of tests of change that have led to better outcomes under our four aims. We are making performance improvement the way we run our organization.

Dr. Deming taught us the importance of deep process knowledge. Without knowing how the work is actually happening, we have no hope of generating better designs. We must go to the workplace, or as the Japanese call it the “gemba” and observe the process to find the opportunities to make it better.  It is clear to me that when the work is totally within the control of a given unit or department, we make progress quickly. There are many examples of this at in our system of care, but one that I spoke about in this blog is the work of Charlene Mahoney, RN, Lewis Hogge, MD, and their team in the GOR PACU. They quickly identified a design change and got to 100% completion of the final check by the Anesthesiologist before the patient leaves the PACU.

In a complex system, like a hospital, it is much more difficult to improve performance when the process involves more than one unit or group. This is because no one “sees” the whole process. People know the part of the process that they are involved in and are quick to assume what is happening in the rest of the process. An example of this is in our process for medication delivery from the pharmacy to inpatient units. I remember in April 2013, at the Unit 38 LDM board, it was reported that there had been over 30 missing doses of medication the day before. This means that when a nurse went to give a patient a prescribed medication, it was not there at the time it was due. Through the hard work of our nurses, technicians and pharmacists, the rate of missing medications is much lower but we are still not at perfection. It is hard to fix the remaining defects because it requires direct study of each defect across the departments and units involved.

In this blog, I have been talking about mindfulness and the tenets of high reliability and referring to the work of Drs. Karl Weick and Kathleen Sutcliffe. Last week, I commented on the commitment to resilience, or the enhanced ability of high reliability organizations to deal with and overcome the unexpected. Another tenet of mindfulness is the reluctance to simplify.  Weick and Sutcliffe point out that high reliability organizations do not jump to conclusions and they do not allow people who haven’t seen and studied the entire process to suggest changes to the process. They suggest that organizations have “boundary spanners” or people that go from one department to see the part of the process that they don’t know in another department. This is the same concept as going to the “gemba” in Lean terms.

Boundary spanning is hard because we generally don’t have people who have created time in their schedule to do it. Instead, they are put in the position of spending their time fixing the same problem every day like in the movie Groundhog Day. In the medication delivery example, we need to do the hard work of studying the few remaining missing doses to come up with the improvements required to eliminate them. We need boundary spanning and we need to be reluctant to simplify and assume why things are not going well to avoid making the situation worse.

Do you have an example of boundary spanning or going to see the work in another department that has resulted in better care?