Arkansas system breaks rules

If you could break any rule at your health system, what would it be?

This is the question Little Rock-based UAMS Health asked its 6,000 clinicians as part of an initiative spearheaded by the Institute for Healthcare Improvement called "Breaking the Rules for Better Care."

After a week, the six-hospital system recorded 584 rules to break or change from about 400 responses. 

"I think we internally create rules that are obsolete, that create waste for our own employees," Thea Rosenbaum, MD, the system's chief quality and clinical transformation officer, told Becker's. "We simply forget because we've been doing the same thing for years."

Jill Duncan, RN, vice president at IHI, echoed Dr. Rosenbaum's thoughts, adding that most "silly" rules at hospitals are habitual and created through precedence. 

One policy that was often addressed at UAMS Health, and across the nation, surrounded drinking water. 

"'Can I have something to drink near my work station when I'm working on the unit?' That's a rule we've been talking about for 25 years," Ms. Duncan said. "There is good guidance from a number of bodies to give people permission; that, in fact, our workforces having access to water during their shift is an important part of sustainability."

UAMS' interdisciplinary task force for the project explained to survey respondents why sterile areas don't allow for drinks and clarified it's OK in some clinical areas. 

Other submitted rules included casual Fridays, compensation and penalties for tardiness. Half of the answers were related to HR, 30% about patient care, 8% about facility rules and 12% fell in the "other" category. 

A recurring theme was a dress code, with requests for jeans to be allowed on Fridays. The task force consulted its patient advisory committee, which said patients would perceive clinicians wearing jeans in a negative light. Instead of ignoring the suggestions, the system compromised by allowing clinicians to wear sweatshirts with the UAMS logo. 

"We sold out in the first week that we received thousands and thousands of these, and no one has ever mentioned jeans after that," said Dr. Rosenbaum, calling it a "win-win."

Before the survey was sent out, the system conducted three listening sessions, each with 50 employees and C-suite executives. From there, "champions" were selected to spread the message about the rule breaking initiative. 

After the survey, each respondent was contacted with updates on whether the rule was broken, modified or couldn't be changed. 

As of Feb. 16, UAMS has broken about 40 rules and was working on 17 others. Any of its 12,000 employees can access a webpage that tracks the progress and submit new rules to break.

The IHI piloted the initiative in 2015 among 24 members in its Leadership Alliance. In that cohort, 375 rules were collected, and 85% of them were either habits, myths or administrative policies. Three years later, 240 organizations across 21 countries took IHI's toolkit and launched their own version, capturing more than 500 rules. 

In 2023, 10 organizations in the Leadership Alliance found 1,200 rules — most of them related to burnout and other workforce burdens. 

Ms. Duncan and Dr. Rosenbaum recommended starting small, posing the question to one shift or department, and having courage to not only ask the question but also find solutions.

"A key takeaway from Breaking the Rules for Better Care are the opportunities for systems to engage staff at all levels of their organizations," Ms. Duncan said. "This is not just front-line providers. There has been tremendous success by organizations that have used this for everyone, from the valet at the front door to admissions people to environmental services, food safety and cafeteria staff."

Ms. Duncan said there's a festive energy among the system leaders about this initiative, which allows them to find weeds and tear them from the garden.

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