By Dorothy Brooks
With clinician burnout, a boarding crisis, moral distress, and other concerns making it tough for healthcare leaders to retain staff, it is nice to have an employee-pleasing strategy that can not only make healthcare workers feel as though they have an important voice but also boost operational efficiency.
That is the idea behind the “Breaking the Rules for Better Care” initiative spearheaded by the Boston-based Institute for Healthcare Improvement (IHI). The tactic involves asking staff for input on the following question: “If you could break or change any rule in service of a better care experience for patients or staff, what would it be?”
Approaches can differ on how and where healthcare organizations collect this input, but Louise Rang, MD, FRCP, RDMS, an emergency physician and the professional sustainability and wellness lead in the department of emergency medicine at Kingston (Ontario) Health Sciences Center, found that the initiative was surprisingly easy to implement within her emergency department (ED).
Rang tells ED Management that she first became interested in implementing the approach after attending a session about the initiative at IHI’s annual meeting in Orlando, FL, in December 2022. Rang immediately thought it would appeal to the people who work in emergency medicine.
“Generally, we are masters of being pragmatic and not always following the exact procedure that could be laid out. That’s how we make emergency medicine work,” Rang explains. “I think this kind of thing speaks to us because sometimes there are human rules that get in the way.”
Further, Rang notes the timing of such an intervention (in early 2023) made sense as well, given that while COVID-19-related concerns were receding, there were many stringent policies in place that did not always fit with what emergency staff needed to do their jobs optimally.
In addition, Rang notes that it was not uncommon to hear long-time staff explaining to new employees, “This is how things are done here,” but then being unable to articulate why or to even find a policy that dictated the approach. “It was just sort of accepted, but wasn’t always in the service of a great experience to either us as workers in the ED or our patients, either,” Rang observes.
Upon learning about the initiative, Rang sought input from a wellness leader within the hospital, and then quickly presented her plan to implement the approach at the next wellness meeting. It was determined that the intervention would first be rolled to the department of emergency medicine, which has two locations and receives about 90,000 patient visits annually.
Further, while some healthcare organizations have included patients in their “breaking the rules” interventions, Rang decided to start small, just including ED staff in the first rollout. “We just needed to make it manageable for our first couple of years, and so we didn’t include patients,” she says. “If you have structure in your department where you have a patient experience advisor or access to that aspect from the hospital, that would be tremendously useful, too.”
Implementing the approach did not require much in the way of up-front work, other than getting hospital leaders on board. Rang designed some posters to let ED staff know about the initiative and created a quick response (QR) code where staff could anonymously input their suggestions on rules or policies that should be changed or eliminated.
The posters went up in the department about a week before staff could begin submitting their ideas. In addition, the initiative was mentioned during morning huddles, and an email went out to all staff explaining the approach, observes Rang, noting that this nurtured a buzz for the initiative. It also did not hurt that the launch of this campaign was accompanied by big bowls of candy bars for staff to enjoy — a tactic that Rang encourages. “Everyone likes treats in the emergency department,” she says.
Within one week of enabling the QR code, 170 submissions had been collected, including some with multiple ideas for rule eliminations and/or changes. Among these, Rang identified 127 unique suggestions, some of which could be acted on quickly and easily.
For example, during the COVID-19 emergency, a rule had been implemented that prohibited staff from drinking water at their desks. The rule was quickly abolished, much to the approval of staff. “That was a nice, easy start,” Rang notes. Another easy win was the removal of what Rang refers to as an “egregiously located” bed in the hallway.
Similarly, there was a too-stringent “one-sandwich” rule that applied to patients and families stuck in the ED for a long period without access to meals. It was quickly revised, along with a reminder that it is important to ensure that patients and families are comfortable.
Another rule that was easily implemented or clarified included a policy to enable patients with asthma to be discharged with Ventolin inhalers. “When those are given, we cannot reuse them for anybody else, and so they may as well be going home with the patient,” Rang explains, noting that all this policy required was a reminder and clarification. “Many of these [suggestions] involved things that some people were doing, and others were not, so just tightening up our practice really helped.”
Other suggestions took a little more time to implement. For example, some of the nurses did not think they could place nasogastric (NG) tubes, so the task was always left to physicians to carry out. To address this issue, a nurse educator highlighted the issue and conducted some teaching sessions, Rang explains. The topic also was communicated during daily huddles along with education on how nurses can practice placing the NG tubes. Interestingly, the NG tubes policy was already in place; it just required reminders, reinforcement, and education to put into practice, Rang observes.
Some of the submitted ideas require more complex solutions that are still being worked out, but they are at least on the radar, Rang notes. Further, the intervention was a big success with staff who appreciated having their voices heard. “We have about 250 staff, so we were pretty happy with the 170 responses,” she says. “There was lots of buy-in and interest.”
Rang and her colleagues in the ED are planning another “breaking the rules” campaign this year, and she notes there are things she feels she can improve. “I wish I could have communicated a response to each [submitted idea] and what the status of that [idea] might or might not be,” she says. “That’s one of the things we’re going to do differently this year. We’ve got a bigger team in place, and so we will manage to communicate [results or progress] after the fact.”
Rang’s advice to emergency medicine clinicians interested in implementing a similar campaign is to ensure you have buy-in and involvement from both physician and nurse leaders in the department. That is crucial, she says. Also, when looking for colleagues to assist in the effort, individuals involved in wellness are a natural fit for such a project because it kindles a sense of agency, Rang observes. However, she also notes that quality improvement (QI) staff also are a good match. “You are asking how we can make a better experience for our patients with incremental change, and so that is very much in the QI zone,” she says.
In a final bit of advice, Rang encourages colleagues not to aim for perfection. “Don’t keep putting it off and keep thinking it can be a perfect campaign. Just do it,” she says. “If you are showing that you are acting on some things and making some changes, I think people will continue to engage.”
Rang returned to the IHI’s annual meeting in December 2023 and spoke about her experiences in launching a “breaking the rules” campaign in her ED. Also there to speak about the initiative was Donald Berwick, MD, MPP, FRCP, KBE, IHI president emeritus, senior fellow, and senior advisor to the IHI Leadership Alliance where the “breaking the rules” initiative was first created.
Berwick noted that while the intervention may sound like a cute idea, it can deliver a massive change. “There is an unleashing here that’s really powerful,” he said when speaking about the effect on employees when they see that their ideas are solicited and considered. “If you do this right … it provides oxygen in a stressed environment.”
Hospitals or EDs that are interested in spearheading “breaking the rules” campaigns in their settings do not need to start from scratch. The IHI has created a resource guide that includes sample scripting, tips, lessons learned, and other guidance that can help innovators get started down this path. The guidance is available at: https://www.ihi.org/networks/l....
With clinician burnout, a boarding crisis, moral distress, and other concerns making it tough for healthcare leaders to retain staff, it is nice to have an employee-pleasing strategy that can not only make healthcare workers feel as though they have an important voice but also boost operational efficiency. That is the idea behind the “Breaking the Rules for Better Care” initiative spearheaded by the Institute for Healthcare Improvement.
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