Positive feedback spurs process improvements

Time to first antibiotic for pneumonia drops

The traditional approach to process improvement — where errors are identified and then corrections sought — just doesn't work in the ED, argues John Whitcomb, MD, ED director at Aurora Sinai Medical Center in Milwaukee.

"When you ask what went wrong, the way you ask the question can lead you down the wrong path," Whitcomb asserts. "If you're giving your people a 'traffic ticket' — for example, asking why it took three hours to get an antibiotic to a patient — the message you're sending is, 'You failed. Your patient fell out.'"

That approach makes staff feel angry and hurt, and it also leads them to feel their manager is irrelevant, he says. "I recommend identifying the part of the bell curve that's two standard deviations above the mean (a standard deviation is sometimes referred to as the 'mean of the mean') — that defines excellence — and then reward it," Whitcomb recommends. "When I wash the dishes, for example, my wife gives me a kiss. That's pretty simple stuff, but it moves whole mountains."

Whitcomb and his staff clearly have moved mountains at Aurora Sinai. When they began a process improvement project in community-acquired pneumonia (CAP), it sometimes took patients as long as 12 hours to receive their first dose of antibiotics. The standard set by the Centers for Medicare & Medicaid Services [CMS] is four hours. "Our fastest time from door to antibiotic last month was 23 minutes," Whitcomb reports. "The month before, it was seven minutes."

The initiative coincided with a decision made in the ED to address pneumonia care. This initiative was part of a demonstration project being jointly sponsored by CMS and Premier, a Charlotte, NC-based health care performance improvement alliance owned by more than 200 not-for-profit hospitals and health care systems. "People were getting antibiotics at 12 hours — upstairs," Whitcomb recalls. "Once we started, we embarked on a relentless journey of looking monthly at every single pneumonia for the previous month."

As easy as 1, 2, 3

While the process was relentless, it was nevertheless always positive. Whitcomb employs a three-step process in his approach:

  • Step One: Identify excellence. "That was easy; CMS has done that for you," he says. "They give you a whole list of procedures for pneumonia, with all sorts of minute details." (See resource, at bottom of article, for more information on pneumonia procedures.)
  • Step Two: Make sure everyone in the department knows it's excellent. Whitcomb posts the processes on the department bulletin board. "Talk about it, get that pathway up there — make it easy and convenient," he recommends.
  • Step Three: Start a process for rewards. "We all want to be acknowledged," says Whitcomb. "Tell the world. Put my name on the bulletin board, and let everyone know I was perfect. But most of all let me know!"

Whitcomb created a "wall of fame" in the ED, says Ann Staroszczyk, RN, MS, director of quality at Aurora Sinai. That wall included the names of people who were top performers in following recommended procedures. "He gave a lot of positive feedback to staff who performed well," Staroszczyk says. She notes that Whitcomb also would commend those staffers in writing.

Process improvement in pneumonia was a regular topic at monthly departmental meetings. Once a month they would give something small, such as a package of 10 M&Ms, to top performers at the meeting, says Whitcomb. "I'd stand up and say, 'Dr. X got the best pneumonia this month, but it was not just him — it was Nurse Jones, Secretary Smith, and X-Ray Tech Lewindowsky.'"

All of those names would go up on the 'Wall of Fame,' and they'd all get packages of M&Ms. "You do this every month, and what starts happening? People start using their imaginations cohesively as a team so they can get the reward and be named 'the smartest people in the department' for that month," says Whitcomb.

Keep it light

It is important to inject a certain amount of humor into the program, adds Whitcomb. "The reward needs be of such 'serious' intent that you can laugh about it; you need to have a little bit of playfulness involved," he explains. "You also need to keep it under $10 so they don't have to pay taxes."

Even when he has to notify staff members that they've been less than perfect, he continues to emphasize the positive. "I craft a letter something like this: 'Dear Dr. Whitcomb: Thank you for the care you are providing your patients. It was perfect on the following five measures, and it would have been completely perfect if you had given antibiotics within four hours,'" he relates. "That's how you craft feedback notes."

This approach "has led to a dramatic paradigm shift in behavior," Whitcomb says. Now, when the radio goes off, and the emergency medical services staff report a high fever and shortness of breath, "the nurse says, 'I'll go hang the rocephin;' the doctor says, 'I'll call X-ray; the secretary says, 'I'll call registration,'" says Whitcomb. "When the patient is wheeled into the ED, the portable X-ray is already there."


For more information on improving performance in community-acquired pneumonia, contact:

  • Ann Staroszczyk, RN, MS, Director of Quality, Aurora Sinai Medical Center, 945 N. 12th St., Milwaukee, WI 53233. Phone: (414) 219-5517.
  • John Whitcomb, MD, Director, Emergency Department, Aurora Sinai Medical Center, 945 N. 12th St., Milwaukee, WI 53233. Phone: (414) 219-6666.

For more information on the Centers for Medicare & Medicaid Services (CMS)/Premier demonstration project and CMS guidelines for community-acquired pneumonia, go to the CMS web site, www.cms.hhs.gov. In the search box, type "pneumonia." When the next page opens, click on the following link: "Community-Acquires Pneumonia Premier Hospital Quality Incentive."