By Dr. Cole Stanley

Starting with subtraction to simplify and embed QI in our fragile overstretched systems

Getting Rid Of Stupid Stuff (GROSS) so that you can focus on high value work

It’s nearing the end of another busy clinic day. With one colleague sick and another on vacation, you’ve barely been able to fit in the patients you need to see as you cover three panels for the day. Slouched in your office chair, you’re fumbling to open a small mountain range of snail mail that’s piled up. If only I had time to read that New England Journal of Medicine newsletter. If only I had time to catch up on this cancer screening reminder list. A heavy official-looking manila envelope falls from the pile. Apprehensively you tear it open and read – “As part of your College requirements, you must complete a Quality Improvement project and submit a report by this date.” It’s what you’ve dreaded, one more thing to steal your time away.

I suspect this is the gut reaction I sometimes evoke when I talk about embedding QI in our regular work day. Not one more thing! Some provinces have indeed made QI projects mandatory, which risks relegating them to annual one-off side projects driven by extrinsic motivation – just another thing to check off the list. This is a mistake. Luckily in BC we haven’t yet taken this path. Instead, teams are starting to voluntarily make QI part of their day. But there’s a problem. The high-volume, quick visit, understaffed setup we often work in leaves little room for anything new. We are unable to keep up with excessive expectations from the myriad guidelines for acute, chronic, and preventative care, as my colleague highlighted in this recent article. This is a fragility that we’d surely want to do away with, but how can we without more providers or less patients on our panels? This conundrum is a common refrain, and I suspect a major reason why there is slow uptake of embedding QI.

#embedQI – What do I mean by embedded QI? You and your team have regular funded time in your work (daily or weekly) to review quality of care and follow an iterative process to continually assess and improve. This goes beyond side-of-desk projects that require your efforts outside of regular work hours or one-off project-based funding from external sources. My working hypothesis is that we need to embed QI in order to shift our systems from their current fragile state, so that they are robust or even antifragile in the long-term (see my previous MD corner article for more on this).

Part of the human condition is that we more easily solve problems by adding (processes, new tools, guidelines, policies, rules, etc.). At the same time, we overlook solutions that simplify or subtract to lead to improvement. We see this in medicine – plenty of projects focus solely on additional things we must do (think checklists, education sessions, chart reviews). How many times have you heard the proposed solution to a problem being “they just need more education”? If we only do just one more thing.

Though sometimes effective, these “add-ons” are incredibly difficult to sustain in our time-scarce fragile systems, and unsustainable QI efforts risk building resistance in teams when further QI efforts are proposed (Chris Hayes’ work on highly adoptable QI). Even worse, our attachment to and overvaluing of the new things we create can make us escalate our commitment to what isn’t working, and we can get trapped in the sunk cost fallacy (Quit). What’s the result? We get a system that is overpacked with add-on features, complex processes, and outdated waste. But it doesn’t have to be this way. Natural systems often have elegant ways of improving by removing waste. At the cellular level, outdated or defective proteins are systematically discarded. Hypotheses on why we sleep include waste removal and time for learning and memory consolidation. These processes require significant resources, but evolutionary theory suggests they are vital to our long-term success (survival). Similarly, embedding QI in our clinical systems requires significant investment, but can become our mechanism for long-term success.

If this is to work as intended, it may be best to focus on QI efforts that reduce workload. In our complex systems, there are likely low-hanging fruit that your own team could identify to target first. In our BOOST Collaborative to improve retention on opioid agonist therapy (OAT), this was our opioid use disorder (OUD) form. We looked at the wasteful tedious process of preparing printed duplicate prescriptions for OAT, including all of the many mouse clicks, double documentation, math errors, illegible handwriting, pharmacy clarification faxes, and consequent prescriber grimaces (with the occasional wayward expletive). The solution – an electronic form that removed many of the chances for error, allowed easy printing of prescriptions, and added features of faster documentation of clinical parameters. Simply put – quality was improved while workload was reduced. I suspect this is why we saw OUD form usage go from 0% to near above 90% within a few months of launching it on our VCH Community EMR.

Doctors of BC has embarked on some subtraction work to reduce physician burdens. The American Medical Association (AMA) is also working on this, and has my new favourite acronym. Their “Getting rid of stupid stuff” (GROSS) modules offer a stepwise approach. With this, they also offer a “de-implementation checklist” for clinicians and health system leaders. When I saw them present on this recently, AMA leaders were keen to highlight that removing the low value tedious work is also protective against physician burnout. One promising approach may be to target tasks that are done frequently and require a lot of mouse clicks. A single mouse click seems like no time at all, but for frequent actions, these can add up to hours of your life wasted (see the “death by 1000 clicks” literature). The Subtract exercise described below may give you some initial targets for click reduction, as it did for our clinical team.

So what are some low-hanging fruit in your clinical setting? Here’s a team exercise I prepared based on Klotz’s book that you can run for idea generation:

Subtract, a QI team exercise – Use sticky notes to share your ideas for things we can subtract (from our digital or physical workspaces or processes). “When humans solve problems, we overlook an incredibly powerful option: we don’t subtract. We pile on ‘to-dos’ but don’t consider ‘stop-doings.’ We create incentives for high performance, but don’t get rid of obstacles to our goals. Whether considering a stack of Legos, preparing a grilled cheese sandwich, or writing an essay, Leidy Klotz shows that we consistently overlook the principle of subtraction as a way to improve. Our mental preference for addition–for adding to what’s already there rather than thinking of taking away–is so wide-spread and strong that we would prefer to accommodate wrong ideas than simply remove them” summary of Subtract, by Leidy Klotz.

So we can make a bit of time to do QI to then free up some of our time, but will this be sufficient? Parkinson’s Law would say otherwise. This is the phenomenon in which the work seems to fill the time allotted. It makes it incredibly difficult to do any sort of proactive non-urgent work (read QI), especially near the end of a busy work day. This is why we need to protect time for QI and embed it. My experience says this is best done when the team can come together with minimum interruptions and fresh minds – which is often the start of the day. And this is why some of the time freed up by QI efforts should be protected specifically for continued QI efforts.

Suggested actions

  • Subtract – team QI exercise
  • PSP Facilitation cycle – think of highly adoptable changes that focus on reducing workload
  • Protect time saved with QI efforts for continuous embedded QI
    • Beware the efficiency trap of filling all of the saved time with more patient volume, which fragilizes the system
  • Review Doctors of BC Physician burdens info, AMA resources including GROSS
  • Get QI into your team’s daily/weekly schedule
  • Start small, think big
  • Reach out to us at HDC, PQI, PSP for support

In my next article I’ll discuss how embedded QI builds team resilience, and can act as an antidote to provider burnout. It turns out if teams get time to discuss and work towards a shared purpose and are afforded the time to creatively problem solve and track their efforts over time, they feel more engaged and rewarded in their work. This alone can boost productivity and reduce staff turnover, thus helping shift our system from fragility to something more resilient to the challenges that are surely ahead.