Reliable Interventions

DFI Order Sets/Protocols/Pathways

The development of protocols that help to standardize the care delivered is an essential part of improved care delivery. The best protocols provide standardization while preserving the ability of the clinician to customize care for special patient situations or circumstances. Unlike variation from the protocol that arises from provider behavior, variation that occurs because of special patient situations is always acceptable. The protocol should make that clear.

As always the details are the key to success or failure. An order set/protocol will usually fail unless the team pays attention to these details.

Principle 1
KEEP IT SIMPLE FOR THE END USER. There will inevitably be trade-offs between the depth of the detailed guidance you want to give providers and the simplicity of the forms and processes the end users have to go through. Minimize the number of unnecessary steps.

Principle 2
YOU CAN'T INTERRUPT THE WORKFLOW. The proposed intervention needs to fit with the flow of the care team and cannot worsen efficiency. Ideally, the intervention would improve efficiency and eliminate waste and rework. Involve frontline workers to make sure that your plans are feasible, your order sets/protocols are easy to use, and your implementation goes smoothly. Default orders that articulate the starting point for the care of most patients are a good place to begin to standardize care. Clinicians should want to use your order sets and tools if they are constructed properly.

Principle 3
DESIGN RELIABILITY INTO PROCESS. Human beings are incapable of doing anything reliably 100% of the time in the complicated health care setting. Part of your team’s job is to engineer higher reliability into the processes of care. You will be disappointed with the results if your protocol relies solely on these traditional methods:

• Common equipment and standardized order sets;
  
• Personal checklists;
  
• Working harder next time;
  
• Feedback of information on compliance;
  
• Awareness and training.

All these methods are helpful, and some are necessary, but they are not sufficient for achieving breakthrough improvement. You must design at least 1 of the following methods into your interventions in order to enhance the probability that each patient will receive the correct kind of therapy for his or her particular situation.

Examples of these methods as they apply to DFI:

1. Incorporate obtaining wound and blood cultures and then limiting antibiotic choices based on local antibiograms on the admission orders set.
2. Develop forced functions that require a specific action to be taken or the reason it is not to be documented — such as documentation about imaging to evaluate for osteomyelitis.
3. Integrate daily data review into processes for multiple members of the care team.

Examples of these and much more are presented in later sections, along with specific tips on how to integrate high-reliability design features.

Principle 4
PILOT YOUR PROTOCOL/ORDER SET on a small scale before attempting wide implementation. Inevitably there will be some glitches with your initial order set and/or algorithm. It’s best to “fail faster” by piloting on a small scale so you can get the glitches out of the way before you implement your protocol more broadly.

The pilot can be as simple as a paper algorithm you ask 3 or 4 individuals to use or trying the order set on 1 unit or for a set period.

Principle 5
MONITOR THE USE OF YOUR PROTOCOL AND ORDER SET. Expect variation from the protocol and learn from it. Over time reduce variation from your protocol.
Rolling out the protocol is really only a beginning. You need to learn from variations in your process. Why isn’t the order set being used in some areas? Can you integrate it into other heavily used order sets? Which service needs your focused educational efforts? Which patients just don’t “fit” with your protocol — can you change the protocol so that it fits more patients and situations? The idea is to squeeze variability out of the process while retaining variation based on tailoring to accommodate individual patients. 

Develop a Framework

The diagram below represents a generic view of various components of care delivery within a hospital. Each entry could be a potential target for intervention or a point to introduce a “forcing function” (one of the high reliability strategies described above). It will be imperative to identify how this framework describes your institution (probably only superficially) or even to develop you own locally relevant process map.

From the SHM QI_Primer PowerPoint by Jason Stein, MD (Emory University School of Medicine), editorial composition; Greg Maynard, MD, MSc (University of California, San Diego), editorial composition and review.

High-Reliability Strategies

1. Desired action is the default action (not doing the desired action requires opting out).
2. Desired action is prompted by a reminder or a decision aid.
3. Desired action is standardized into a process (take advantage of work habits or patterns of behavior so that deviation feels weird).
4. Desired action is scheduled to occur at known intervals.
5. Responsibilities for desired action are redundant.
6. Algorithms and reminders are incorporated into the order sets.