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A cure for ‘initiative fatigue’?

Frontline caregivers across the United States—and in many other countries, no doubt—are bombarded by multiple quality improvement (QI) projects. A clinical unit might simultaneously be engaged in efforts to reduce readmissions, eliminate hospital-acquired infections and other complications, increase hand-hygiene compliance, improve performance on core measures, and enhance the patient experience. The demands brought by participating in all of these efforts risk overwhelming health care professionals, who are already stretched thin in an environment of reduced reimbursements and health care reform.

So what are the ingredients that help some quality improvement projects succeed in this atmosphere? How do we avoid “initiative fatigue”?

These were among the questions that sociologists from the University of Pennsylvania and Harvard University sought to answer as they interviewed 150 hospital workers across six states who were involved in two large-scale quality improvement projects. Targeting surgical site infections and ventilator-associated pneumonia, respectively, the projects were funded by the Agency for Healthcare Research and Quality and led by Johns Hopkins’ Armstrong Institute for Patient Safety and Quality, with the sociologists as key members of our project teams.

They summarized what they have learned in a March 7 Health Affairs blog post. I encourage you to read the piece. Here are a few of its key points:

  • Safety must be embedded into daily work. Participating in QI efforts should not be treated as “an additional administrative burden,” as the blog authors write. Certain steps, such as giving staff protected time to participate in these projects “shows a commitment of hospital administration to QI, as opposed to viewing it as another activity that staff must add to their already stressed days.”
  • Small wins go a long way. Frontline staff can usually identify simple, inexpensive changes that can reduce the hazards that they have identified. These quick, early wins can show frontline providers that their team is capable of improving safety, and help to generate momentum.
  • Do it with feeling. It’s not enough for a care team to simply use a tool, such as a checklist. Observing teams in their use of a pre-surgical timeout, the sociologists found that some care teams used it only “symbolically”—often without any eye contact between providers, while other care processes were going on. For others, it was a “genuine safety practice,” as clinicians used the tool to identify potential risks. They revised the tool continually to meet their needs.

These lessons support what we have seen at Johns Hopkins, across the U.S. and internationally: When the work of patient safety does not feel like something extra, but is part of how we do things here, it has greater staying power. One way we have ingrained safe practices into daily work is through adoption of the Comprehensive Unit-based Safety Program (CUSP), a structured approach for improving patient safety culture while engaging frontline clinicians to tackle the hazards in their work areas. When CUSP teams are successful, they can absorb many of the quality and safety demands that staff face without it feeling like so much extra work.

In an article for an e-newsletter published by the Armstrong Institute several months back, one nurse leader from a Portland, Ore. hospital talked about how the CUSP framework helped her staff to avoid initiative burnout. Kris Farrimond says that the approach has appealed to nurses wary of  being overloaded. “It isn’t about doing one more thing,” she says.

“If you are using CUSP, you keep in mind that every patient has different risk factors, and you focus on reducing those risks, she said. “You think about what you are going to do for this patient, on this day, right now.”

Whether your organization uses CUSP or another quality improvement process, I think you’ll agree that that’s a great way to think of it. If we can participate in these important initiatives, while at the same time keeping the safety of our patients foremost in our minds, caregivers and patients alike will benefit.


Peter Pronovost

One of the world’s leading authorities on patient safety, Peter Pronovost served a the director of the Armstrong Institute, as well as senior vice president for patient safety and quality, at Johns Hopkins Medicine from 2011 until January 2018.

3 thoughts on “A cure for ‘initiative fatigue’?”

  1. Laura BerquoLaura Berquo

    It's exactly the perception I have as a Patient Safety Coordinator in a Private Health Care System in Southest Brazil.
    People in our 3 Hospital Net Services are so tired of Quality Improvement and Certification demands that seems to "forget" the basics on patient safety stuff.... Doing things "just the right way".

  2. Human caregivers are increasingly burdened with passive, data entry, non-interactive technology in ICU settings. FEAR of making errors supersedes confidence confidence in not making errors. We need technology that can think and communicate with human caretakers. If airline pilots were required to enter countless data into EHR systems, they would have very little time to fly their planes. However, this is our current state in healthcare.....and it is no wonder that reducing medical errors while reducing human burn-out is not happening as we would like it to happen. The technology is on the drawing board with Auto Pilot Medical and Healthcare Automated Lifesystems.

  3. The real issue is in terms of basics i.e. putting in place, nurturing and developing a patient safety culture. This comes out in this as well as scores of other learnings. Vertical programs or "branded hobby horses" without the culture are not only short term, are resisted, unsustainable and burdensome. The data needs to follow. If the initial purpose of data is to show that safety issues are all pervading then it is well known and accepted. I have yet to come across a setting which denies it as long as it is not seen as an attack which evokes defense. No meaningful reporting occurs without culture. Wrong data is worse than no data as is well known.

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