For better care, break the rules: 5 tips to get started

Patient safety experts from around the globe discussed the importance of breaking rules to improve clinical and administrative processes during a Dec. 13 session at the Institute for Healthcare Improvement's National Forum on Quality Improvement in Health Care in Orlando, Fla.

While exceptional clinical quality relies on clinicians following strict policies and procedures, some rules can cause excessive administrative burdens and unnecessary complexity at healthcare organizations, according to Saranya Loehrer, MD, IHI's head of the North America region. During the discussion, Dr. Loehrer outlined the history of Breaking Rules for Better Care, an IHI initiative aimed at improving care by eliminating superfluous rules.

IHI rolled out the first "Breaking Rules for Better Care Week" in January 2016 and called on 24 healthcare organizations from the IHI Leadership Alliance to solicit feedback on healthcare rules from staff and patients. The organizations asked, "If you could break or change any rule in service of a better care experience for patients or staff, what would it be?"

In total, IHI collected unique 342 rules to break, which generally fell into one of three categories:

  • Rules that needed clarity. Many "rules" were actually myths or habits staff members thought were official policies. For example, some staff members said they'd change their hospital's rule mandating patients may only receive one blanket, when the hospital had no such rule, according to Dr. Loehrer. These types of rules often required simple clarifications to yield improvements.

  • Rules that needed redesign. Other rules, such as visiting hours or limited patient access to medical records, were enacted by an organization's leadership and needed be internally removed or altered.

  • Rules that needed advocacy. Some rules required policy or regulatory changes, like CMS' three-day rule, which mandates three consecutive days of inpatient stay for Medicare to cover skilled nursing facility care. These rules are more difficult — but not impossible — to change.

IHI's Breaking the Rules program has since spread internationally, with health systems across Europe adopting the quality improvement initiative. Amelia Brooks, IHI's director of patient safety and the European region, and Dr. Amar Shah, associate medical director for quality at East London National Health Service Foundation Trust, joined Dr. Loehrer in the conference session to discuss the global initiative's progress and share how hospital leaders can implement their own breaking the rules program.

Here are five pieces of advice for healthcare leaders seeking to "break the rules" at their own organization.

  1. Be comfortable with discomfort. While some staff members can demonstrate an initial wariness about breaking rules, Ms. Brooks believes the program's message must be provocative. "This initiative has to feel uncomfortable," she said. "If we're not feeling uncomfortable, we won't achieve a significant enough change for us to notice something different in our system."

  1. Start small. Rather than rolling out the initiative across an entire organization, Ms. Brooks recommends starting in a specific unit or department to test the change process. "Just start somewhere, it doesn't matter how small it is," she said.

  1. Spark staff interest. Before formally introducing a break-the-rules initiative at his healthcare organization, Dr. Shah ran an underground teaser campaign to pique staff members' curiosity. Dr. Shah and his team gradually placed red tape across the organization's 100 sites over two weeks with no explanation. The team also hacked the CEO's monthly video blog to include images linked to break the rules. "We wanted to model breaking the rules in a way that breaks the rules," he said.

  1. Offer numerous methods for feedback. After two weeks, the hospital shared a video revealing the initiative and called on staff members to share what rules the organization should consider getting rid of. Dr. Shah gave staff members another two weeks to submit their rules via multiple communication routes, some of which were anonymous. Staff members could share their feedback by email, leave an audio message through a dedicated phone or place paper submissions in a mailbox. The organization's largest sites also contained pop-up video booths, in which staff members could put on masks of the executive team's faces to record a video message with their suggestions. "This was the most popular method," said Dr. Shah.

  1. Prioritize rules to break. The organization received 120 unique ideas after the two-week submission period, according to Dr. Shah. To promote transparency, the organization posted every rule online and asked staff members to vote on which should be the highest priority to address. A small group of staff members and patients also used a scoring system to analyze the ease of removing each rule, and how that removal would affect patient care and financial outcomes. This process helped the organization prioritize which rules to tackle first to achieve the most beneficial outcomes.

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