A couple of years ago having worked as a medical intern for only a couple of months, I had already accumulated a list of practices I’ve noticed around the hospital that were making it difficult to work efficiently. Such hindrances ranged from disorganised medical stock rooms to impossible to find ICU discharge summaries to paper based on-call rosters that were usually only accessible through switch. So one night shift, during a brief reprieve from the barrage of cannulas and unnecessary night time fluid orders, I found myself offloading these frustrations onto the night registrar as part of an age-old bonding ritual between medical colleagues. Once I had finished my diatribe, instead of following protocol in this ritual by commiserating, he turned around and asked – ‘why don’t we fix it?”
His reply took me by surprise as the following thoughts immediately came to mind:
Such thoughts are pervasive amongst junior doctors and actually represent the main barriers preventing them from instigating positive changes within their hospitals. Let’s take a closer look at what these thoughts imply:
“I wouldn’t know the first person to talk to…”
Hospitals are organisationally complex and employ several thousand staff that operate within distinct functional, professional and even geographical units. Further adding to the complexity, these units generally have a hierarchical structure with a division of roles that can be vastly different from each other. It is no surprise then that interns whose entire medical training up to that point has been concerned with the genetic mutation underlying condition X and the differential diagnoses of symptoms Y find hospitals confronting and foreign. Most junior doctors (and even nursing staff) don’t even know who to approach when a computer is not working on a ward!
“I’m just an intern, no-one will listen to me,”
Unfortunately, it is the organisational complexity and hierarchy within hospitals mentioned above that leads to a sense of disenfranchisement and silently discourages junior staff from taking ownership and fixing deficiencies encountered in their work environment.
“What’s the point? I’ll be finishing this term soon anyway.”
This point touches on the fact that the high turnover of junior staff (who often only spend at most 11 weeks or so in any given rotation) reduces the incentive to invest energy and time to addressing local problems encountered during that rotation. Unfortunately this deferment of responsibility leads to an unacceptably high level of tolerance for system faults and errors.
“It’s been like this for years – things will never change.”
Finally, the most common logical fallacy in healthcare. Just because things have been this way for years leads some to believe that any attempts for change are futile. Often this conservative attitude is cited as the main cultural barrier to change within hospitals. However as we get away from the old doctor centred paternalist view of healthcare provision we are seeing more and more opportunities for cultural change in a new and progressive generations of doctors and administrators who have been trained in a healthcare model centred on patient autonomy.
So having recognised the above thoughts as barriers to change – the next question is ‘how do we ad-dress them?’ Fortunately that night happened to be peculiarly quiet for both myself and my registrar. Fighting off the inexorable urge to sleep, we brainstormed and eventually the ‘Innovations Group’ evolved from that discussion.
The Innovations Group is a multidisciplinary committee comprising of consultants, junior medical staff, nursing staff, managerial staff, hospital IT representatives and allied health. The catch – it is led by junior medical staff, namely residents and registrars. The initial aim of the group was to encourage junior doctors to develop innovative solutions to local or system-wide problems and facilitate their implementation by providing intellectual, logistic and executive support.
So how does it work? Every 2-3 months we would hold an ‘Innovations forum’ session which would generally occur over lunch where all junior doctors are invited to come and present any ideas that may improve their work environment or make things more efficient for patient care. From this session, two junior doctors would be invited once a month to formally present their ideas to the Innovations group. The ideas would then be discussed amongst the committee with emphasis on its feasibility, strategy for implementation, goals and timeframe as well as the potential contacts and stakeholders that would need to be contacted for this idea. The junior doctor would then be given the opportunity to lead this quality improvement / redesign project and to update the group regarding its progress at subsequent sessions.
Here’s an example of the process in action for a project currently underway:
Nursing staff photo directory
One junior doctor had the idea that there should be a ward based photo directory for nursing staff to aid communication between junior doctors and nursing staff on the ward. The idea was raised initially at the Innovations Forum and then selected to be presented formally to the committee. The doctor prepared a brief presentation identifying the rationale, details and costings of the project and these were then discussed at the monthly group meeting. Relevant stakeholders were identified and a meeting was arranged with the Director of Nursing at the hospital with the junior doctor and another committee member in attendance. From this meeting, a trial ward was selected and a pre-implementation survey was carried out which had a > 94% positive response rate. Following this result, the junior doctor was given approval to carry out a trial project on the ward which is currently in process.
The Innovations Group has been up and running now for the last 12 months, and since then a number of projects have been presented that are in various stages of completion. Examples of completed projects include the availability of an online specialty on-call roster and the creation of electronically available ICU discharge summaries. Projects in the development phase include such ideas as the construction of a visual language resource for patients from non-English speaking backgrounds and the instalment of a phlebitis score rating for intravenous cannulation on the wards.
Being part of the Innovations Group has been an excellent experience for myself and other junior doctors and goes some way to addressing the barriers to innovation and change presented above. Apart from the individual project endpoints themselves, participating in and leading a clinical redesign project gives junior doctors the opportunity to learn about the governance structure of the hospitals. By deconstructing the hierarchy, junior doctors are given the confidence to engage with various levels of hospital administration and carry out improvements from small to large. Undoubtedly, the leadership skills, confidence and knowledge of the healthcare system learnt from such a process will remain with junior doctors as they continue to seek out opportunities for redesign throughout their medical careers.
Junior doctors are at the frontline of our healthcare system and are generally motivated, optimistic and clever individuals. At a time when our healthcare system is suffering under significant social and financial pressures we need to create a culture of accountability that challenges traditional roles of junior doctors and sees them as drivers of change within the healthcare system. Through interventions such as the Innovations group we can capitalise on the enormous latent potential within this cohort to make tangible improvements to our work environment.
So next time you see something not working in the hospital – instead of submitting to the futility of it all – ask yourself ‘how can we fix this?’. See inefficiencies as a potential opportunity for change. Whether it is by starting your own Innovations Group at your local hospital, or even something small like picking up the phone and asking around to see who can fix that computer on the ward that hasn’t been working for months – you can make a difference.