Quality Dis-Provement (13 mins)

Does healthcare improvement sometimes feel like an impossible task? This episode looks at ways to refresh more than the data, but also our outlook and understanding, through an analytical approach.
Key Points:
-Time to give up?
-Human rights applications
-Breaking it down

References:
-World Vision International. (Feb. 9th, 2018). A Stolen Trombone, Barrier Analysis and Isaiah 65 – A chat with Tom Davis – World Vision’s New Global Lead for Sustainable Health. Retrieved September 8th, 2022, from https://www.wvi.org/article/stolen-trombone-barrier-analysis-and-isaiah-65-chat-tom-davis-world-visions-new-global-lead.
-Porter, G (2023). Simple Tools. Healthcare Quality for the Rest of Us: A Friendly Guide to Healthcare Quality Management. Porter Creatives.

Transcript

Process Dis-Provement

We’ve all heard it, and recently it’s gotten louder – the nay sayers who say we should just roll over and quit trying to improve healthcare.

Perhaps they don’t believe they’ll ever need health services, so it doesn’t matter to them. Or perhaps they are burned out after hearing the same message because they believed it rather than questioning its validity.

I know I’ve heard it: “No one will ever agree to that.” “Good luck pulling that one off.” “That’s going to be a losing battle.” “You should just give up.”

I’m one of those people who tends to bristle and question absolute statements, and at my core, I really don’t like being told what to do – unless someone is willing to explain why their way is better.

And one of my favorite tools to break out when I have an office full of naysayers is the tried-and-true Barrier Analysis. 

The Barrier Analysis was created for those “that will never work” situations, where a good solution is available, but people can’t or won’t adopt or comply, or the process keeps breaking before we reach the finish line. Too often it’s just like when you call tech support, and the first thing you hear is “have you tried restarting your computer.” And that bottom wrung of IT will keep you spinning in useless updates and password changes until you’re half insane. It almost feels like they are insinuating that the problem is you, not your technology. Sometimes it’s hard to tell if your broken computer is the barrier or IT is. But if you persevere, you’ll eventually get moved up the chain to a tech support guru who will take the time to listen to what is going wrong. They’ll ask more questions about your specific problem, figure out what is preventing your computer from doing the work it needs to do, and then figure out how to fix it. In other words, a good IT person does a barrier analysis to see what is preventing work from getting done. 

The original Barrier Analysis was part of a behavioral change methodology used in public health. It was originally created by Tom Davis to study barriers to water sanitation among Haitian workers in the Dominican Republic.[1] The Dominican Republic shares an island with Haiti, and for the most part Haitians are a marginalized group in the Dominican Republic. Davis noted that Haitian sugar cane cutters (known locally as braceros) were not utilizing best practices when it came to water sanitation even after his team had taught them how to clean their water for drinking, and when he asked their Dominican supervisors why the braceroswere not cleaning their water, he got answers like “they’re lazy, they can’t understand the message,” and other answers that referred to presumed human flaws. Does that sound familiar to anyone?

Well, Davis knew there had to be more to the story, so he developed a survey to analyze the situation that eventually became known as the Barrier Analysis. It turned out that the braceros wanted to clean their water and knew how, but they could not afford the bleach at the company store. Braceros were brought into the Dominican Republic to cut sugar cane, but their importation left them indebted to the companies that employed them, and the interest on that debt was structured in a way that it could never be repaid, much like American coal miners in historical Appalachia. Every bit of income they had went back to the company for food and shelter, and there was not enough left over for bleach or gallon-sized containers for cleaning water. The barrier did turn out to be a cultural one, but it was a culture of racism and human abuse, which took years to rectify.

While there will hopefully never be a human-rights atrocity at the root of issues affecting your work, the Barrier Analysis is a very useful tool for uncovering unseen causes of those issues. It helps get us away from emotional blaming to the real cause. This issue will almost certainly not be the stereotypical reasons that spring to mind without investigating and analyzing data about the situation, and it works great on those stubborn problems that repeatedly fail despite “flawless planning.” While I’ve never worked in water sanitation in the Caribbean, I think the barrier analysis is useful because we are all really good at offering excuses for why we cannot or will not change.

So then how do I know which excuses are legitimate and which ones are just me being unreasonable, cranky, or feeling discouraged? That’s where a personal Barrier Analysis can be helpful. So while the true barrier analysis tool is more in-depth and focused on public health behavior change, I like using a super-simple version to assess the work tasks that have stalled, because I can exercise all my skills at making great excuses and still come up with a solution. 

Task management is a huge deal in healthcare, and sometimes when the projects stack up, the workload can feel overwhelming. Everything on the list affects patient care, and anything I missed could potentially result in lower quality care for a real person in my community. That can be a lot of pressure. So, rather than feel anxious about the volume of work, I used the Barrier Analysis tool to divide and conquer and set some fresh priorities. 

So how does the Barrier Analysis work when I want to use it for an emotional recharge? When I do a barrier analysis this way, my first version is a list in very clear language that make sense to me and I don’t filter. Instead, I use the words you’re never supposed to use because they are emotionally-laden – all the honest, discouraged, totally frank assessments of why it’s completely impossible for me to do my job well. Essentially, I list all the tasks at work that have great excuses. Then I use that list as a starting point for a more developed analysis.

In a spreadsheet or table, I put the list of impossible tasks in one column. Then, I would add a new column to list every barrier that prevented me from meeting each goal, one-by-one – this is where I can creatively exercise my ability to make great excuses. 

In reality, this stage requires some time to really think about what it would take to complete the project. Does it take time, or does it cost money, or does it require working with a group of people that are impossible? Is it difficult to rally support among key players? Write down all the excuses that make each task difficult or even impossible.

The next step is to prioritize each barrier by how important the goal is, and how difficult it would be to accomplish. At this point, I often chose to score the priority level and color-code the difficulty of my barriers: green is simple, yellow is moderate, red is difficult, and purple requires a miracle. Feel free to customize your own analysis according to preference. In the end, there should be a simple list with a score for difficulty, a score for importance, and room to assign a priority number when finished.[2]

The final step is to find the highest priority task. Normally, I like to identify the tasks that are easy and important (also known as “low-hanging fruit”) because they can be done quickly and provide a good return. But for this purpose, I have a different approach: Start with the worst thing first and everything will seem easier after that.

Once you find the very worst, ugliest, toughest task, ask what the first step is. Then pull that out to stand on its own and keep imagining all the steps to the finished project. When that is complete, look at those smallersteps and ask again: Which one is the most challenging and why? Often, the toughest steps on the barrier list are either items that still need to be broken down into even smaller steps, or problems that are misattributed to people when there is really a legitimate process reason of why they cannot do what I’m asking them to do. 

Ultimately you’ll likely find that the toughest steps to complete are the ones that depend on other people. Sometimes, that’s our own issue because we bottleneck our processes on one poor, overwhelmed individual – often a highly capable worker who is overwhelmed by requests – and we get irritated when they ghost us because they are simply incapable of managing all the requests that come to them. But if we analyze that problem, there are certainly going to be better solutions than dumping all of those tasks on that one, poor soul. Someone could cross-train, an automation could be built, expectations can be adjusted. But if I don’t ask, I never learn, and if I don’t listen, it won’t get better.

So analyze each step that presents a barrier. Has anyone else ever gotten around this type of barrier? Probably. Well, then how? Is there a workaround? Is this process regulated and unchangeable, or are there alternatives to consider?

For example, we had an issue with education delivery in our quality department. Management said we needed to minimize staff hours for education because it was costly and difficult to schedule so that everyone affected could attend, but we also were asked to update more frequently about clinical updates and process or policy changes. It sounded impossible. Do more with less?

Well, after a barrier analysis, it was clear that I needed to break down the difficult and important tasks into smaller steps to make them more achievable. That way, I could make steady progress toward the final goal. 

I knew that we had previously worked toward a similar goal as part of a community education project. It seemed impossible, but instead of trying to do everything at once, I took the goal of educating the community about antibiotic stewardship, and broke it down into four steps:

1)    develop community education in laymen’s terms for non-clinical students

2)    identify opportunities to teach with the public relations and marketing department

3)    set a specific and achievable goal for the number of teaching sites to visit

4)    measure comprehension at each site with a post-class survey

Building on a previous success, we decided we could make better posters inspired by the idea of memes and emojies with more visual content that could be rapidly understood by staff and that would reduce time to explain and remind. We also discussed the option of sending short videos with policy changes and clinical updates, and we went to the bedside when patients that met criteria were being treated so that we could help answer questions and teach in live time. 

When we looked into this impossible task to do more with less, we discovered that the request was not a permanent “no”, it was just an opportunity to ask “how.”

As we asked better questions we got better answers.

[1] World Vision International. (Feb. 9th, 2018). A Stolen Trombone, Barrier Analysis and Isaiah 65 – A chat with Tom Davis – World Vision’s New Global Lead for Sustainable Health. Retrieved September 8th, 2022, from https://www.wvi.org/article/stolen-trombone-barrier-analysis-and-isaiah-65-chat-tom-davis-world-visions-new-global-lead.
[2] Porter, G (2023). Simple Tools. Healthcare Quality for the Rest of Us: A Friendly Guide to Healthcare Quality Management. Porter Creatives.