Written by Dr. Louise Rang
I was lucky enough to attain funds from the "Quality Improvement Education Fund for SEAMO Physicians" to attend the Institute for Health Care Improvement (IHI) Annual Forum in December. One of the best presentations at the conference was on the "Break the Rules for Better Care" (BTRBC) Week initiative. The BTRBC program started after a hospital leader was inspired by a patient's note which included: “You broke the rules for us, and it made all the difference.” The nurse had simply allowed a visit between a family member and a new baby. It inspired a whole campaign that is now running in over 200 organizations in 21 countries around the world. This year, the Emergency Department (ED) and Urgent Care Centre (UCC)are trying it as a pilot project for Kingston Health Sciences Centre, and are one of a handful of groups participating in Canada.
During the week of February 13-17, all ED/UCC staff members will be invited to participate in an anonymous survey with a simple question: If you could break or change one rule in the service of a better care experience for patients or staff, what would it be, and why?
Having a slightly unconventional question gets people engaged and thinking in a way that asking "how could we do things better" doesn't (and yes, I know you are all thinking, those Emergency docs break the rules all the time, they will have a long list! But the truth is, this pragmatism is actually part of what makes us able to do our job, which is to navigate through uncertainty, together as a team).
Some examples of breaking rules:
- Allowing an extra family member in to see a sick loved one.
- Avoiding patients transferring from Hotel Dieu Hospital to Kingston General Hospital (KGH) via car having to stop at KGH triage again
- Allowing a personal care attendant to take an elderly long-stay patient to Tim Horton’s for an outing
- Sending a blanket home with a patient who is too lightly dressed for the journey home
- Drinking water at the desk
- Giving some extra antibiotics "to go" if a patient can't get to a pharmacy in time for the next dose
Generally, the responses fall into one of three buckets:
- Habits embedded in organizational behaviors, based on misinterpretations and with little to no actual foundation in legal, regulatory, or administrative requirements - sometimes they are good rules, but need to be clarified or refined
- Organization-specific requirements that local leaders could change without running afoul of any formal statute or regulation
- Actual statutory and regulatory requirements that need broader advocacy to solve
Interestingly, most groups who have done this found that about 70-80% of the "rules" identified were actually under the Department's own control to solve. As you all know, things are particularly hard right now in the ED/UCC. This survey activity is quite clever: it helps build camaraderie and engagement, while also identifying and quantifying some of the things that are getting in the way of us providing the care that we wish to.
Of course, the real work starts when the week is over: we will analyze the responses and see what we can clarify, refine or update. The key part will be communicating the results and our plan back to the whole Department so they know their input was useful - and with any luck, the response list next year will be slightly shorter!
A huge thank you to the SEAMO QI Committee for supporting my attendance at the conference, and to our ED physician & nursing leadership for allowing us a week to embrace our "inner rule breakers.”