Can Quality Improvement Be Improved

1. Can Quality Improvement Be Improved? Effective Diagnosis of Performance Gaps March 12, 2004 Kevin Kennedy, MHS Donna Thorson, MS Good morning, I�m Kevin and I�m an analyst at HealthInsight in Las Vegas. We are going to discuss diagnosing performance gaps in order to design interventions w/highest probability of success. Good morning, I�m Kevin and I�m an analyst at HealthInsight in Las Vegas. We are going to discuss diagnosing performance gaps in order to design interventions w/highest probability of success.

2. Presentation Objectives Define error; understand the �Big 3� categories of performance gaps Compare & contrast the �Big 3� Understand how the �Big 3� affect performance gap

3. In the Beginning� All of us have used quality improvement (QI) techniques How can we go one step further? Can QI activities be improved? Can Human Factors help? Can we improve quality improvement?? Can we design better systems for quality?Can we improve quality improvement?? Can we design better systems for quality?

4. What Is Human Factors? The science of designing tools, tasks, information, and work systems to be compatible with abilities of human users; both physical & mental.

5. Human Factors Includes the study of human error Airline accidents, car accidents, Columbia So, what is an error? Often hear about �pilot error� or �driver error� after accidents. How do we define error?Often hear about �pilot error� or �driver error� after accidents. How do we define error?

6. Definition of Error Planned sequence of mental/physical activities fails to achieve desired outcome An important question to ask is why was the desired outcome not achieved?? What factors may have contributed to the �error�??An important question to ask is why was the desired outcome not achieved?? What factors may have contributed to the �error�??

7. Personal Example

8. Why an Error? Sequence of actions did not achieve desired outcome � filling up my tank and leaving safely with car/gas pump in one piece I forgot to remove the nozzle prior to leaving What factors contributed to this?

9. Friends vs. Human Factors Friends � How could someone do this? HF � What were conditions & situation like when getting gas? What are characteristics of the task?

10. Diagnosis of Error Filled up my car thousands of times before without any problems � routine task Forgot to execute one step in the process Distractions contributed to forgetting to remove the nozzle

11. So What? When a gap exists, helpful to assess why prior to developing interventions If we do not understand reasons, interventions may not be effective Go beyond trial & error When a performance gap exists, trying interventions w/o doing some work on understanding why the gap exists may not be most effective model.When a performance gap exists, trying interventions w/o doing some work on understanding why the gap exists may not be most effective model.

12. A �friend� sent me this to show me I�m not the only one � I have since started a support group for those driving away with a gas nozzle still in their car!A �friend� sent me this to show me I�m not the only one � I have since started a support group for those driving away with a gas nozzle still in their car!

13. Things to Consider Are there different types of errors? What are violations? How are violations different from errors? Who cares? Is this human factors stuff just jargon?? Does it matter? No, being able to link performance gaps with different types of errors or violations can lead us to developing interventions with highest likelihood of success.Is this human factors stuff just jargon?? Does it matter? No, being able to link performance gaps with different types of errors or violations can lead us to developing interventions with highest likelihood of success.

14. The �Big 3� Categories of Performance Gaps? Plan is not executed properly (execution errors) The plan itself was inadequate to achieve desired outcome (planning errors) Deliberate departure from �safe� practice (violations)

15. What Is a plan? Means (includes mental/physical activities) to achieve an objective Peanut butter & jelly example Not having a plan is a plan

16. The �Big 3� Categories of Performance Gaps 1. Plan was not executed properly (execution errors) My gas station story Injecting the entire vial of medicine when distracted Patient not assessed for pain due to interruptions Immunization order given upon admission to be given at discharge, forgotten in the interim

17. The �Big 3� Categories of Performance Gaps 2. The plan itself was inadequate to achieve desired outcome (planning errors) Decided to drive to my favorite station 5 miles away and ran out of gas Not giving immunizations to residents with a cold Foot exams given to all patients with diabetes who take off shoes & socks

18. The �Big 3� Categories of Performance Gaps 3. Violations: deliberate, not necessarily reprehensible, deviations from those practices deemed necessary (by managers, designers) to maintain safe operation

19. The �Big 3� Categories of Performance Gaps 3. Violations Knowing speed limit is 65 and driving 80, seat belts Cutting corners, skipping steps, do not read manual before using equipment Omit foot exam since patient wearing boots & it will take too much time to take them off Accept a verbal statement of weight vs. weighing to save time

20. Violations Act itself is deliberate Negative consequences are not intended Certain conditions more likely to produce violations

22. Summary - Violations Important to recognize that everyone commits violations at some point Need to understand why and not just blame individual Still a systems approach

23. Errors vs. Violations Errors � involve individual thought processes Unintentional Can be product of system design Violations � involve social context (procedures, rules) Intentional Can be product of system design

24. What are the �Big 3� Categories of Performance Gaps? Plan is not executed properly (execution errors) The plan itself was inadequate to achieve desired outcome (planning errors) Deliberate departure from �safe� practice (violations)

25. Why Care About the �WHY�? Different Problems Different Solutions So why did Kevin just explain the difference between execution errors, planning errors, and violations. Human factors science teaches us that different problems require different solutions. Let�s explore this a little more.So why did Kevin just explain the difference between execution errors, planning errors, and violations. Human factors science teaches us that different problems require different solutions. Let�s explore this a little more.

26. Execution Errors What May Not Work: 1. Punishment 2. Rewards 3. Training or Education of Skilled Operators Why? Intended to correctly complete task. We�ll start with Execution Errors�remember that execution errors are things like forgetting, getting distracted, something slips your mind. Now, before we talk about the solutions that ARE likely to work, let�s look at the solutions that are NOT likely to work�because these are often the ones we think of first. Human Factors science tells us that: Incentives Training when the operators are already skilled in the task. May not work for Execution Errors. This is because this type of error is an unintended act, and research shows that punishment does not change behavior when people don�t intend the behavior in the first place. Rewards won�t work for the same reason. I don�t need more intention, I need something to help me remember! I don�t need more training either. Research also shows that education will only work as a reminder for so long. We�ll start with Execution Errors�remember that execution errors are things like forgetting, getting distracted, something slips your mind. Now, before we talk about the solutions that ARE likely to work, let�s look at the solutions that are NOT likely to work�because these are often the ones we think of first. Human Factors science tells us that: Incentives Training when the operators are already skilled in the task. May not work for Execution Errors. This is because this type of error is an unintended act, and research shows that punishment does not change behavior when people don�t intend the behavior in the first place. Rewards won�t work for the same reason. I don�t need more intention, I need something to help me remember! I don�t need more training either. Research also shows that education will only work as a reminder for so long.

27. Execution Errors What May Work: Prompts Reminders Memory Aids So if we aren�t going to use training or incentives, what might work? How about: Prompts Reminders Memory Aids Prompts are appropriate to use when people tend to lose their place in a process, when they are unlikely to remember what comes next, or when there are a number of potential options. An example is the alarm that only sounds when you don�t remember to put on your seat belt before starting the car, or the alarm that sounds when you leave your keys in the ignition. What are reminders? The word �remind� means literally �to bring to mind�, so reminders are something that bring to your remembrance the fact that something needs to be accomplished. Reminders are always present and should be used when: You are likely to forget something Your attention is likely going to be diverted to something else You are required to be vigilant An example of a reminder would be the sign on the visor that tells you to put on your seat belt. Or the post-it notes that I write and put on my day timer so I will remember to do something. And this is where Memory Aids come in. We have too many things to remember, and we need help! Memory Aids are something that we use when our short-term memory won�t be enough or when our long-term memory won�t be precise enough. EXAMPLE � Physician�s Desk Reference, algorithm for treatment of pneumonia. So if we aren�t going to use training or incentives, what might work? How about: Prompts Reminders Memory Aids Prompts are appropriate to use when people tend to lose their place in a process, when they are unlikely to remember what comes next, or when there are a number of potential options. An example is the alarm that only sounds when you don�t remember to put on your seat belt before starting the car, or the alarm that sounds when you leave your keys in the ignition. What are reminders? The word �remind� means literally �to bring to mind�, so reminders are something that bring to your remembrance the fact that something needs to be accomplished. Reminders are always present and should be used when: You are likely to forget something Your attention is likely going to be diverted to something else You are required to be vigilant An example of a reminder would be the sign on the visor that tells you to put on your seat belt. Or the post-it notes that I write and put on my day timer so I will remember to do something. And this is where Memory Aids come in. We have too many things to remember, and we need help! Memory Aids are something that we use when our short-term memory won�t be enough or when our long-term memory won�t be precise enough. EXAMPLE � Physician�s Desk Reference, algorithm for treatment of pneumonia.

28. Planning Errors What May Not Work: 1. Punishment 2. Rewards 3. Reminders Why? They believe they are acting correctly. The next type of error is planning errors. They occur when your plan is inadequate to achieve the desired results. First, what kinds of solutions are not likely to work? Science tells us that Incentives Reminders May not work. Why might these not work. Well, I have a great plan and I did exactly what I planned to do, I just didn�t achieve the desired outcome. In my mind, I did everything right. If you punish me, I won�t understand why I am being punished, and the punishment will seem arbitrary and certainly unfair. The same goes for rewards.The next type of error is planning errors. They occur when your plan is inadequate to achieve the desired results. First, what kinds of solutions are not likely to work? Science tells us that Incentives Reminders May not work. Why might these not work. Well, I have a great plan and I did exactly what I planned to do, I just didn�t achieve the desired outcome. In my mind, I did everything right. If you punish me, I won�t understand why I am being punished, and the punishment will seem arbitrary and certainly unfair. The same goes for rewards.

29. Planning Errors What May Work: Memory Aids Training or Education Creating a process Alright, so what might work for planning errors? Memory Aids Appropriate training or education Creating a process We�ve talked about memory aids as a solution to execution errors. How are they also a solution to planning errors? Well, a memory aid is a way of putting the correct plan in the world instead of only putting that correct plan in someone�s head. Putting the knowledge in the world� in a book, on a piece of paper, on a sign, anywhere but just keeping it in the head. We should use them when there is too much to remember or when we want everyone to have the same plan. EXAMPLE? Another possible solution to Planning Errors is Education, which puts a plan in somebody�s head. Education is the intervention most often used in health care. Unfortunately, it is often employed in the wrong circumstances� so it doesn�t result in the hoped for improvement. When IS it appropriate to use education? When people are making errors because they don�t know WHAT to do When people are making errors because they don�t know WHY they are supposed to do something When people used to do something differently (the science or practice has changed) Another possible solution to Planning Errors is�Creating a process (or altering a current process). It answers the question�how do we do this? And it�s appropriate when: There is no process now (meaning that everyone just does it their own way) The current process doesn�t address the needs of the users�, meaning it�s not a realistic process. Most likely, it wasn�t developed with the input of the users. The current process has unrealistic expectations (for instance, that people will perform perfectly, every time) Alright, so what might work for planning errors? Memory Aids Appropriate training or education Creating a process We�ve talked about memory aids as a solution to execution errors. How are they also a solution to planning errors? Well, a memory aid is a way of putting the correct plan in the world instead of only putting that correct plan in someone�s head. Putting the knowledge in the world� in a book, on a piece of paper, on a sign, anywhere but just keeping it in the head. We should use them when there is too much to remember or when we want everyone to have the same plan. EXAMPLE? Another possible solution to Planning Errors is Education, which puts a plan in somebody�s head. Education is the intervention most often used in health care. Unfortunately, it is often employed in the wrong circumstances� so it doesn�t result in the hoped for improvement. When IS it appropriate to use education? When people are making errors because they don�t know WHAT to do When people are making errors because they don�t know WHY they are supposed to do something When people used to do something differently (the science or practice has changed) Another possible solution to Planning Errors is�Creating a process (or altering a current process). It answers the question�how do we do this? And it�s appropriate when: There is no process now (meaning that everyone just does it their own way) The current process doesn�t address the needs of the users�, meaning it�s not a realistic process. Most likely, it wasn�t developed with the input of the users. The current process has unrealistic expectations (for instance, that people will perform perfectly, every time)

30. Violations What May Not Work: 1. Training and Education 2. Reminders 3. Prompts 4. Memory Aids 5. Punishment Why? Violations are a product of consequences and positive consequences are strongest. Here we are at the last of the �Big 3� categories for performance gaps: Violations. What do we do about them? Research tells us that the following interventions are not likely to work: Training Reminders Prompts Memory Aids Punishment The scientific reason here is that violations (knowingly not doing something you are supposed to do or knowingly doing something you aren�t supposed to do) are mostly a product of consequences�a product of what happens to you AFTER you violate, not what happens BEFORE you violate. Everything on that list, with the exception of punishment, is working on what happens BEFORE a violation, not after. Violations are a product of consequences. So what about punishment? According to research in human behavior, positive consequences are much stronger than negative ones. Here we are at the last of the �Big 3� categories for performance gaps: Violations. What do we do about them? Research tells us that the following interventions are not likely to work: Training Reminders Prompts Memory Aids Punishment The scientific reason here is that violations (knowingly not doing something you are supposed to do or knowingly doing something you aren�t supposed to do) are mostly a product of consequences�a product of what happens to you AFTER you violate, not what happens BEFORE you violate. Everything on that list, with the exception of punishment, is working on what happens BEFORE a violation, not after. Violations are a product of consequences. So what about punishment? According to research in human behavior, positive consequences are much stronger than negative ones.

31. Violations What May Work: Redesign work to eliminate frustrations Using policies and rules only when necessary Positive feedback for desired behavior Well, let�s look at what might work. How about Eliminating the frustrations that cause people to �work around� the rules Weeding out policies and rules that are unnecessary. Giving positive feedback for the desired behavior. Sometimes Redesign is what�s needed to stop violations. And if you hear people saying �I hate this!� Or �This is so frustrating� then, redesign might be appropriate. Use redesign when frustration leads people to do something in a different way than is �correct� or when tools and tasks are hard to use, cumbersome, difficult. Or when there are too many things to do at one time, resulting in goal conflicts. Research tells us that policies and procedures should ONLY be employed when other solutions WILL NOT work. They are a last resort. Why? Rules, policies are referred to in the science as the weakest level of hazard control. All of the other solutions we have been talking about have been shown to be significantly more effective than creating policies. Why are they so weak? Because they require people to be: Vigilant Remember They often require people to be perfect� so really the solution wasn�t �let�s create a policy� it was �let�s require people to be perfect� which doesn�t account for the true capacity of people. Policies can also create goal conflicts, and following them can result in problems elsewhere in the system. Another solution to violations is rewarding people for correct behavior and REMOVING the rewards for incorrect behavior. Note that we want to reward people for the correct BEHAVIOR, not LUCKY outcomes. What�s the difference? Let�s say that we have 2 nurses. The first one walks into a room to administer some medication and she doesn�t check the patient�s armband first. She knows him, she�s been taking care of him for 3 days. She administers the medication, and as usual, there is no adverse outcome to the patient. Our second nurse walks into another room to administer some medication, she also doesn�t check the armband, because she too knows her patient. Unfortunately, the patient is allergic to the medication she administers and has an anaphylactic response. The first nurse? Incorrect Behavior (didn�t check the armband), the outcome? Lucky, no harm to patient. The second nurse? The same Incorrect Behavior, but the outcome was bad. The behavior was the same in each case. And that�s where we want to focus�on the behavior, not on the outcome. A system that focuses on the OUTCOME will reward people who routinely violate but have no adverse events. The important thing to remember about violations is that people don�t intend the NEGATIVE consequences that sometimes result from violations (adverse events, medication errors) but they DO intend the POSTIVIE consequences (which most often is Time Saved). So, to address violations, you need to look at the positive consequences they receive from violating and see if you can eliminate or reduce those. You can reward the correct behavior. How do you do that? Well behavioral science tells us that the STRONGEST consequences, the consequences that are most likely to result in repeat performance of the correct behavior, are: Positive� Immediate� Certain� consequences. Well, let�s look at what might work. How about Eliminating the frustrations that cause people to �work around� the rules Weeding out policies and rules that are unnecessary. Giving positive feedback for the desired behavior. Sometimes Redesign is what�s needed to stop violations. And if you hear people saying �I hate this!� Or �This is so frustrating� then, redesign might be appropriate. Use redesign when frustration leads people to do something in a different way than is �correct� or when tools and tasks are hard to use, cumbersome, difficult. Or when there are too many things to do at one time, resulting in goal conflicts. Research tells us that policies and procedures should ONLY be employed when other solutions WILL NOT work. They are a last resort. Why? Rules, policies are referred to in the science as the weakest level of hazard control. All of the other solutions we have been talking about have been shown to be significantly more effective than creating policies. Why are they so weak? Because they require people to be: Vigilant Remember They often require people to be perfect� so really the solution wasn�t �let�s create a policy� it was �let�s require people to be perfect� which doesn�t account for the true capacity of people. Policies can also create goal conflicts, and following them can result in problems elsewhere in the system. Another solution to violations is rewarding people for correct behavior and REMOVING the rewards for incorrect behavior. Note that we want to reward people for the correct BEHAVIOR, not LUCKY outcomes. What�s the difference? Let�s say that we have 2 nurses. The first one walks into a room to administer some medication and she doesn�t check the patient�s armband first. She knows him, she�s been taking care of him for 3 days. She administers the medication, and as usual, there is no adverse outcome to the patient. Our second nurse walks into another room to administer some medication, she also doesn�t check the armband, because she too knows her patient. Unfortunately, the patient is allergic to the medication she administers and has an anaphylactic response. The first nurse? Incorrect Behavior (didn�t check the armband), the outcome? Lucky, no harm to patient. The second nurse? The same Incorrect Behavior, but the outcome was bad. The behavior was the same in each case. And that�s where we want to focus�on the behavior, not on the outcome. A system that focuses on the OUTCOME will reward people who routinely violate but have no adverse events. The important thing to remember about violations is that people don�t intend the NEGATIVE consequences that sometimes result from violations (adverse events, medication errors) but they DO intend the POSTIVIE consequences (which most often is Time Saved). So, to address violations, you need to look at the positive consequences they receive from violating and see if you can eliminate or reduce those. You can reward the correct behavior. How do you do that? Well behavioral science tells us that the STRONGEST consequences, the consequences that are most likely to result in repeat performance of the correct behavior, are: Positive� Immediate� Certain� consequences.

32. Possible Solutions Execution Errors Prompts Reminders Memory Aids Planning Errors Memory Aids Training/Education Process Changes Violations Redesign Work Using policies only when necessary Positive Feedback We�ve just learned about possible solutions for each of the �Big 3� categories. We�ve talked about prompts, reminders, and memory aids being possible solutions for execution errors; memory aids, training, and process changes being possible solutions for planning errors; and redesigning the work, using policies only when necessary, providing positive feedback for correct performance and removing the positive consequences of incorrect performance as possible solutions for violations. SLOW Now, I�m not suggesting that these are the only solutions. This is just a short list of possible solutions based on human factors concepts. Now we would like to give you an opportunity to apply what we have been talking about.We�ve just learned about possible solutions for each of the �Big 3� categories. We�ve talked about prompts, reminders, and memory aids being possible solutions for execution errors; memory aids, training, and process changes being possible solutions for planning errors; and redesigning the work, using policies only when necessary, providing positive feedback for correct performance and removing the positive consequences of incorrect performance as possible solutions for violations. SLOW Now, I�m not suggesting that these are the only solutions. This is just a short list of possible solutions based on human factors concepts. Now we would like to give you an opportunity to apply what we have been talking about.

33. Group Exercise Aim � apply the �Big 3� reasons for performance gaps to specific scenarios ID a scribe and a reporter Choose 1 of the 4 scenarios and list potential reasons for gaps in performance (10 minutes) We are going to take some time now, for you to practice what we have been talking about. You will need to identify a scribe to record what your group says and a person to report back to the large group. (USE HANDOUT TO EXPLAIN THE EXERCISE.) We would like you to choose one of the scenarios from the four we will present and list the potential reasons for the gap in performance. We will give you 10 minutes for the entire activity.We are going to take some time now, for you to practice what we have been talking about. You will need to identify a scribe to record what your group says and a person to report back to the large group. (USE HANDOUT TO EXPLAIN THE EXERCISE.) We would like you to choose one of the scenarios from the four we will present and list the potential reasons for the gap in performance. We will give you 10 minutes for the entire activity.

34. Group Exercise After making your list � categorize the reasons (plan not executed, wrong plan, violation) Each table will be asked to report two reasons for gap and then their classification from the Big 3 After you have made your list of reasons, we would like you to categorize the reasons for the gap as execution errors, planning errors, or violations. If time allows, each table will then get a chance to report on two reasons they believe the gap exists and their classification of the reason.After you have made your list of reasons, we would like you to categorize the reasons for the gap as execution errors, planning errors, or violations. If time allows, each table will then get a chance to report on two reasons they believe the gap exists and their classification of the reason.

35. Scenario #1 Patients with diabetes do not always get an annual foot exam in the outpatient setting. Why not?

36. Scenario #2 Patients in the hospital who are eligible for PPV do not always receive it. Why not?

37. Scenario #3 Pressure sores in nursing homes are not always treated based on available science. Why not?

38. Scenario #4 Care planning & patient teaching for post-op orthopedic patients do not include instruction for pain management during activity/exercise. Why not?

40. Discussion

41. Case Study 1 Operating Room Focused on retention of foreign objects Diagnosed reasons why not all objects were discovered before closing Interventions implemented focused on human factors concepts (planning, execution errors) Event: 2 situations in which retained objects were present in patients after surgery Diagnosis: Why? Interviewed staff and physicians and found: 1. High level of distractions took place during surgical procedures (physician pagers and cells ringing, nonessential personnel entering OR during procedures) 2. High-risk surgeries (for retained objects) were not previously identified Interventions to minimize execution errors: Physician cell phones and pagers not allowed in the OR Nonessential personnel were no longer permitted to enter the OR during procedures Medical equipment no longer permitted to move in and out of the OR during procedures � in place prior to surgery. Interventions to minimize violations: Letters sent to each surgeon stating the new protocol for automatic X-ray for high risk surgeries. Organizational expectation that ALL staff would follow new processes. Be a part of the solution.Event: 2 situations in which retained objects were present in patients after surgery Diagnosis: Why? Interviewed staff and physicians and found: 1. High level of distractions took place during surgical procedures (physician pagers and cells ringing, nonessential personnel entering OR during procedures) 2. High-risk surgeries (for retained objects) were not previously identified Interventions to minimize execution errors: Physician cell phones and pagers not allowed in the OR Nonessential personnel were no longer permitted to enter the OR during procedures Medical equipment no longer permitted to move in and out of the OR during procedures � in place prior to surgery. Interventions to minimize violations: Letters sent to each surgeon stating the new protocol for automatic X-ray for high risk surgeries. Organizational expectation that ALL staff would follow new processes. Be a part of the solution.

42. Case Study 2 Home health Improvement in Pain Interfering with Activity Diagnosis � MD not notified Solution � Scripted dialogue for communication Results - 24.8% relative improvement We have been able to use the human factors concepts in our work with the home health agencies. A member of our home health team designed a worksheet that incorporated the OBQI process with the use of these concepts we shared today. One agency shared this success story with us. The selected for their target outcome (focus), �Improvement in Pain Interfering with Activity�. During the process of care investigation (the diagnosis), they found that the nurses were not consistently calling the physicians when a patient reported pain greater than 3 on a 10 point scale. (5 point?) They developed their plan of action with identified interventions to change the clinicians� behaviors and, through monitoring activities, saw no change. I was contacted for assistance, and as we talked about the reasons why the nurses weren�t calling the physicians, she admitted to me the reason was because they hated getting yelled at for bothering the doctors. We talked about possible solutions after diagnosis this as a violation (since the nurses were choosing not to do something they knew they should do). The reason behind the violation was frustration. The agency looked at redesigning aspects of the work and provided the nursed with new tool � a scripted dialogue they could use to communicate their concerns to the doctors about a patient�s pain level. This has changed part of their frustration with the task because they know what to say and how to say it to the doctors. They even did role playing to practice. What the agency has found as a result of this change is that the nurses are consistent in calling the doctors now. And this has resulted in an increase in the number of patients who report an improvement (meaning pain interferes less with their activities). Baseline 64.5% (11/01-10/02) remeasurement 73.3% (11/02-10/03).We have been able to use the human factors concepts in our work with the home health agencies. A member of our home health team designed a worksheet that incorporated the OBQI process with the use of these concepts we shared today. One agency shared this success story with us. The selected for their target outcome (focus), �Improvement in Pain Interfering with Activity�. During the process of care investigation (the diagnosis), they found that the nurses were not consistently calling the physicians when a patient reported pain greater than 3 on a 10 point scale. (5 point?) They developed their plan of action with identified interventions to change the clinicians� behaviors and, through monitoring activities, saw no change. I was contacted for assistance, and as we talked about the reasons why the nurses weren�t calling the physicians, she admitted to me the reason was because they hated getting yelled at for bothering the doctors. We talked about possible solutions after diagnosis this as a violation (since the nurses were choosing not to do something they knew they should do). The reason behind the violation was frustration. The agency looked at redesigning aspects of the work and provided the nursed with new tool � a scripted dialogue they could use to communicate their concerns to the doctors about a patient�s pain level. This has changed part of their frustration with the task because they know what to say and how to say it to the doctors. They even did role playing to practice. What the agency has found as a result of this change is that the nurses are consistent in calling the doctors now. And this has resulted in an increase in the number of patients who report an improvement (meaning pain interferes less with their activities). Baseline 64.5% (11/01-10/02) remeasurement 73.3% (11/02-10/03).

43. Take Home Ideas The �Big 3� provide a useful model to understand why performance gaps exist � a gap may have multiple causes The �Big 3� are important to consider when choosing interventions Human Factors concepts supplement traditional QI activities