Authors: Ahmed Taher, Lucas Chartier, Shawn Mondoux
You are attending your monthly ED staff meeting where the main topic of discussion is the COVID-19 pandemic. Recent events around the world have compelled your hospital to make changes to better prepare for the expected increase in local respiratory cases. The ED staff meeting has a debrief about some changes that will be happening including personal protective equipment use changes, new COVID-19 swab testing, ED triage and flow changes and many other operational changes. You wonder to yourself how the front line staff will be able to accommodate all of these changes.
Welcome to a special post about QI in the time of the COVID pandemic. This post aims to be a high level discussion of the QI paradigm during large scale, highly dynamic changes that EDs are facing during this pandemic. We have introduced foundational topics in QI previously. The classical QI methodology entails: wide stakeholder engagement, detailed process mapping, forming a clear aim statement, and carrying out an implementation strategy while observing a family of measures, learning and implementing further changes. While the QI approach is pragmatic and meant for the clinical realm, pandemic planning and constant changes present certain nuances that can be beneficial for leaders to consider.
Preparation
An essential classical QI step is to compile a comprehensive list of stakeholders who will be affected by the changes. These may include frontline clinicians, porters, cleaning staff, security, patients, administrators, lab personnel, etc. Ensuring that each stakeholder group has representation will assist in helping delineate the current process and create changes that are sustainable. However, in the time of pandemic planning there may not be sufficient time to organize meetings of all relevant stakeholders to carry out lengthy discussions and full process mapping exercises. This is compounded by the constantly changing recommendations coming from public health units or ministries of health. Things need to move faster!
A practical and time efficient strategy is to gemba. This comes for the Lean paradigm and is a Japanese term that means “actual place”, i.e. the place where value is created.(1) In the healthcare context a leadership team might apply gemba to understand a given clinical care process. For example, a team might “walk the gemba” from the perspective of the patient (for whom we are creating value). This would involve following a patient through their ED visit while detailing the existing processes from triage, room preparation, patient movement, investigations, assessments and disposition planning. This is a nimble way to inform the process with relevant time stamps and decision points. In the pandemic-planning context, an important example would be to walk the gemba for a patient requiring protected resuscitation from patient arrival to disposition. Different stakeholders should be present for input during the gemba.
This process may be followed with every cycle or intervention to gain insight on current workflows. Workflow changes that are disruptive can result in front-line workers applying workarounds that may lead to unintended consequences. Updating policies without understanding the current process may result in further workarounds and unwanted variation and thereby decrease quality.
Implementation strategies
Given the highly complex nature of healthcare, changes in one part of the process may have consequences (intended or unintended) in other areas. Implementing changes to a process during the COVID preparations needs an efficient organized, sequential approach to study the effects of each intervention and make quick adjustments accordingly. Rapid PDSA cycles present a flexible, pragmatic and sustainable structure to organize implementation of changes to the ED.
Given the frequency of changes during pandemic preparations, an abundance of changes are happening in EDs without understanding their effects. Resource permitting, it is important to ensure process changes are measured to inform future interventions. Moreover, defining a family of measures may provide useful data about how these changes are impacting the ED. Pragmatism and efficiency may need to supersede a detailed family of measures during pandemic changes. However, an important takeaway from the family of measures concept, is to ensure the team considers unintended consequences of the interventions.
Interventions should be viewed through the hierarchy of effectiveness (Figure 1). Educating clinicians and running simulation for example is a great way to prepare for protected resuscitations. However, as we go up the ladder of effectiveness other interventions may include a door alarm on negative pressure rooms, removing aerosolizing equipment to prevent its use when unnecessary, and creating a dedicated intubation team. While the specific changes will vary based on a hospital’s overall strategy, centres should consider implementing the most appropriate “system-focussed” interventions for their setting. This may help cognitive offloading so that providers can focus on patient care activities.
Use of Checklists
Reducing variation is a core feature of delivering high quality care. Standardizing certain processes has been met with much success in the safety literature from other industries such as aviation and nuclear power, as well healthcare for example with preventing surgical complications as well as central line infections.(3,4,5,6) The power of the checklist has been to standardize core elements of a routine yet possible high risk process while allowing experts to communicate about nuances in the process when needed.(7) This can be helpful for example when running a protected resuscitation (Figure 2).
Derivation of simple checklists need strong stakeholder engagement and rapid cycle PDSAs with ample feedback collection to ensure their effectiveness and fit within the workflow. Checklists can also be utilized for non-patient care tasks, such as safe handling of samples in laboratories and environmental services COVID room cleaning procedures. Checklists integrated into electronic systems may also allow for process measures during the interventions.
Coordination
During pandemic planning there are a plethora of changes happening at all levels. It can be challenging to anticipate the unintended consequences of these interventions. This is especially true if changes are mandated by administrative teams that are removed from the front line by several degrees. Clinicians with QI expertise are necessary to fill in the gaps to ensure that the front-line processes and workflows are understood by leadership teams (i.e. a team that can gemba). This will help necessary changes be implemented in a coordinated fashion while minimizing disruption to pre-existing workflows. A coordinated approach to interventions is also important to ensure that various changes are supplementing one another and not competing for resources or undoing their effects. Many hospitals across Canada have already taken this approach with physician and nursing leadership contributing to pandemic planning decision making.
Summary
Pandemic preparation and response at the local and institutional levels will benefit from a QI/Patient safety lens given the dynamic and complex nature of the changes. Consider walking the gemba to understand front-line processes, using rapid PDSA cycle techniques with a broad family of measures, using checklists when possible, and ensuring central coordination. It is a trying time for the entire healthcare system, but the QI paradigm has flexible and robust approaches fit for the challenge.
Although hearing about all of the upcoming changes associated with the COVID-19 pandemic is overwhelming, you are relieved to hear about the QI strategies that can be implemented to help facilitate these changes to your hospital. You are hopeful that some of these changes will help improve the safety of both your patients and front line staff, and that a QI lens will help mitigate the challenges associated with implementing change in the times of the pandemic and beyond.
That's all for this special post on quality improvement in the times of the COVID-19 pandemic. The HiQuiPs team wishes to commend all healthcare services and ancillary workers both frontline and behind the scenes for their courage, dedication, and sacrifices. Thank you for all that you do.
Senior Editors: Ahmed Taher, Lucas Chartier, Shawn Mondoux
Junior Editor: Edward Mason
References
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Thomas E, Sherwood G, Helmreich R. Lessons from aviation: teamwork to improve patient safety. Nurs Econ. 2003;21(5):241-243. Available from: https://www.ncbi.nlm.nih.gov/pubmed/14618975.
Kapur N, Parand A, Soukup T, Reader T, Sevdalis N. Aviation and healthcare: a comparative review with implications for patient safety. JRSM Open. 2015;7(1):2054270415616548. doi:10.1177/2054270415616548
Haynes A, Weiser T, Berry W, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-499. doi:10.1056/NEJMsa0810119
Berenholtz S, Pronovost P, Lipsett P, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004;32(10):2014-2020. doi:10.1097/01.ccm.0000142399.70913.2f
Gawande A. The Checklist Manifesto. Henry Holt and Company; 2009.
Hicks C, Petrosoniak A. Protected Airway Checklist. St. Michael’s Hospital. Published March 23, 2020. Available from: https://twitter.com/HumanFact0rz/status/1242185601056739336.
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