June 19, 2019
This is the third Trust Practice Challenge to be featured in this letter. It was one of eight outstanding submissions we are showcasing at the annual Foundation Forum in August.
“Getting Rid of Stupid Stuff” is a fairly simple and straightforward program created by Hawai’i Pacific Health, one of the state’s largest health care providers with four medical centers and more than 70 clinic locations statewide. According to its submission, the program “is an invitation to clinical staff who use the EHR to identify documentation and other practice requirements that should be eliminated, changed and modified.” This practice was featured as an approach that could build trust in a November 2018 Perspective article in The New England Journal of Medicine.
Once staff members nominate problematic requirements, the IT staff studies the issue and explores potential improvements. From there, autonomous working groups decide if change is possible and prioritize the needed changes.
This practice originated from recently graduated RNs who studied the documentation of hourly rounds and found that the most common choice for rounding activity was AIDET (Acknowledge, Introduction, Duration, Explanation and Thank you), which happened to be the first choice on the list. But most nurses were not able to describe what AIDET meant – they just selected it to say “I was here.”
“Our executive team agreed that it was pretty stupid to require meaningless documentation, and our ‘Getting Rid of Stupid Stuff’ program was endorsed,” according to the submission. “Although the practice was initially directed at EHRs, it has been applied to other items.”
Rather than point out the lessons learned, as I have done in previous letters, I’d like to engage in a thought experiment. How could one totally ruin this perfectly crafted trust practice? Here are 10 ways:
- Centralize this activity in the C-suite or with other top administrative leaders: this would include the identification of problems, solutions and prioritization.
- Don’t reliably inform staff of your actions and don’t explain your rationale for agreeing to or rejecting changes.
- Don’t have leadership talk about this program on a regular basis to clinical staff.
- Develop more processes to ensure the program is complicated and less scalable
- Don’t trust your clinical staff to come up with stupid stuff and instead require studies to prove that particular practices are in fact stupid
- Develop a new rule: do not complain about the EHR because it does many good things.
- Reverse changes that are made after seeing that good documentation has been lost.
- Make sure the legal team reviews all decisions even after the staff assures you that they meet regulatory requirements.
- Assure that the process for submitting suggestions is arduous and changes take a long time to complete.
- Never recognize anyone for submitting a suggestion or celebrate the program’s accomplishments.
Daniel B. Wolfson
EVP & COO, ABIM Foundation