Learn from Variation in the Process

Monitoring and Learning from Variation in the Process

AFTER THE LAUNCH OF YOUR ORDER SETS AND PROTOCOLS: JUST THE BEGINNING!
At this point you should have launched your protocols/order sets at your center. What you do after this point is at least as important as what you did before you launched your order set. The team needs to devise a way to track deviation from your protocol and learn why it occurs. Practice that varies from your protocol may occur for any of several reasons:

• The protocol does not adequately address the special needs of a given patient.
• Old physician habits/ignorance/unwillingness to change.
• The order set/protocol is too hard to use.
  
• More familiar, well-known, or simpler routes to order insulin are available.

Your goal should be to continually modify the protocol to address valid issues on ease of use and individual patient needs. Look and listen for this feedback. Solicit it. You should give your own feedback and apply peer pressure to reduce undesirable variability that stems from physician style.

See the Clinical Tools section for examples of tools you can use to survey your patients, nurses, and staff on your protocols and order sets.

TASK
Devise methods to track deviation from your protocol. Revise your protocol on the basis of feedback from users and patient needs.

Download the Task Sheet