As you would expect, hospitals are places where many procedures are performed daily by highly skilled professionals. In fact there are so many different procedures done by so many different people in hospitals, that the hospitals even have policies, procedures and committees on how best to update and improve these procedures. Despite all the energy spent identifying best practices and consolidating this knowledge into policies and procedures, there is still great variation among outcomes. Yes outcomes do vary, even when performing the same procedure.
Variations in outcomes can translate to decreases in quality and increases in costs. Today hospital administrators are constantly looking for consistency and predictable, replicable outcomes. The variable element we will consider here is ourselves, the human variable.
I began my work in healthcare as a researcher, and part of my job entailed obtaining bacterial DNA for further testing. The procedure was simple enough and yet the team leader always commented that each specimen always had different levels of contamination depending on the researcher providing the DNA yield. Even with ongoing in-service, newer equipment, tools, and cleaning agents the variance between research assistants remained. My own personal contamination levels were as disappointing as they were unpredictable. I asked if I could observe the researcher with the lowest contamination levels in an attempt to learn something from watching someone else perform the procedure. I watched a researcher who happened to be proficient and quick; she would hold a specimen test tube with one hand, remove and hold the test tube stopper with two fingers from her opposite hand, remove the specimen while never allowing the stopper to touch anything, then flame the test tube opening before reapplying the stopper again. Her movements were as graceful as they were simple; she consolidated all the necessary steps into a single fluid motion. This technique was not outlined anywhere in the procedure manual but was something she had learned during her years of experience. I began to practice the same technique and within a few days, my contamination rates fell dramatically.
We sometimes accept that different people have their own way of doing things, but these variations can impact the overall outcome of any procedure. There are many examples of this principle: Why can Team-A turn around an OR room after procedure X in 30 minutes, when it takes Team-B forty minutes after the same procedure? Why is there such a variance in time for different medical record coders to close out a medical record chart of a patient with the same diagnosis code? Why does one housekeeping team finish their tasks on time every time while the second team is consistently tardy?
But, how do we begin to understand the differences between trained professionals? One must identify the differences in every step performed before, during and after each process as it is performed by various individuals. This process is not as difficult as you may imagine, and it’s done with simple boxes and lots of colors.
Let’s see an actual example of a Variations’ Grid for drawing blood from a central line that resulted in a 90% CLAB infection reduction within 30 days. The first step is to write down every step done to perform a blood draw from a central line by each person doing the procedure.
After observing the participants and recording how they each perform the same procedure, one must then place each step in a block and assign it a color (ie. use of glove is light blue); finally organize these steps from left to right, stacking them one on top of the other.
Please see the example below:
It soon becomes very clear that these individuals have a variety of different ways of performing the same procedure, although they have the same goal, the order of their actions varies greatly. If every individual did this procedure exactly the same way the colors would align top to bottom, perfectly. After identifying which person has the best outcome, one can easily identify how their results were achieved. This behavioral process can now be taught to others to improve their outcome as well.
This is a very simple and easily executed program that reduces the variability of any existing process, leading to more consistent results.