thequalityproblem

[thequalityproblem]

Creating Home-grown Solutions

How to use your DATA to create solutions that will ACTUALLY work for your unit and not just Band-aid the problems...

Okay, I’m going to do it. I’m going to discuss CLABSIs and CAUTIs.

Let’s start with a quick description of what the hell I’m talking about…

CLABSI - Central Line-Associated Blood Stream Infection

CAUTI - Catheter-Associated Urinary Tract Infection

Basically, you stuck something into a patient and as a result, they now have an infection. The reason that we monitor this is pretty simple: we want to heal people. Giving them infections is usually frowned upon, as it compounds whatever other medical issue brought them to the hospital in the first place.

Nurses understand what CLABSIs and CAUTIs are. Nurses even understand their role in preventing such infections. But there is a whole lot of knowledge that is gained on the back-end, that never gets back to the floor nurse. 

Part of that is because the collected data is provided to the directors and managers at the various meetings they are required to attend, and it is really hard for them to remember all the stuff they are supposed to do, and wouldn’t you know, it doesn’t always get discussed with the floor staff. 

(Org Chart problems, amirite?)

The other part of the issue is that CAUTI and CLABSI rates are often tied to reimbursement, quality scores, you name it. The thing that everyone seems to agree on is that if the hospital gave the patient an infection, shame on them, we must dole out punishment. SO when the number of CAUTI & CLABSI rises, the big cheese FREAKS OUT and everyone else follows suit. They panic and throw a dozen solutions at the problem, without ever really knowing what, IF ANYTHING, worked. It is more important to find a quick solution than to take the time to really look at what the root cause is and spend time fixing it.

The best way to do that is to investigate EVERY INSTANCE OF CAUTI and CLABSI to see what (if anything) they have in common. To be fair, a lot of healthcare systems do this already. They have a process for investigating and reporting the results, the issue is that they believe the process in enough. But its not enough for just the administrators to know the data, it has to be communicated to front line staff - you know, the people who actually are going to be responsible for making a change.

Was the infection likely caused from insertion of the catheter or maintenance of the catheter? What was the type of bacteria? There are lots of tools out there that can be used to help facilitate successful investigations. At the end of the day though, all of the investigating is being done by other members of the healthcare team, not the frontline staff. 

My point is this: posting a graph in the hallway or at the nurses station that shows that the unit has had three CAUTIs this year is not helpful to anyone. If you ask your staff to “speak to the data” they will say, “yep. We had three.”

It is more important to be as transparent and open with staff as possible about the data and work to fix the actual problems that were identified in the investigations. 

Imagine the look on that Joint Commission surveyor’s face when they point to the graph and the staff say, “Ah, yes. We did have three CAUTIs this year. Interestingly, what we found was that all three events could have been attributed to other infection sources that we hadn’t considered or even known to culture (i.e. open wounds, oozing ostomies, etc.). SO - instead of implementing the newest, most expensive insertion kits that would have made no difference at all but were a quick solution, we spent the time working with providers and residents and the Epidemiology and Lab Departments to create a protocol for when to culture and when not to. Basically, we looked at our data and found a solution that was appropriate for our specific unit and not just a blanket fix-all that wouldn’t have really made an impact on our numbers but would have sounded good to talk about at board meetings. It’s great for me as the nurse, because I am no longer questioning why we are getting shamed at every staff meeting. I understand that it was a collective issue. None of us knew the specific CAUTI criteria and now that we have a better understanding of how a CAUTI is classified, we can work diligently to fix the issue.”

Mic drop. (Is that still a cool thing to say? If no, pretend I didn’t write that. If yes, laugh heartily for my topical humor is both refreshing and spot on.)

I will close out my post with this: 

My example of CAUTI and CLABSI is super general. Any issue, whether it’s an important safety event, or just trying to figure out why all the 0500 lab draws are consistently collected late can be figured out with some data collection and a deeper dive. 

It is much easier to jump to solutions than to take the time to do a thorough investigation because so many solutions exist out there. And some of them will work! You WILL get lucky some times if you just implement solution after solution hoping one of them sticks.

But that is how you get the “flavor of the month” mentality from staff. They see the constant change in protocol and get frustrated because they don’t understand the quick changes with little to no notice. Take the time to put in the hard work, get the RIGHT results, and include the staff in the conversations for creating a solution that is specific to your issue and will lead to better results. Continue to collect data and make changes based on what the DATA shows.

Norman out. (again, if this is not a hip thing to say, please disregard.)

[thequalityproblem]

Some tips & hints for engaging your nursing staff

Here are some important tips and hints to keep in mind the next time you are meeting with patient care staff. 

Remember, they are the life blood that fuels the hospital, so getting them interested and engaged in your message is crucial to seeing the results you are looking for. 

No pressure, though. 

Life. Blood.

1. Competition: I am not referring to the unit vs. unit competitions that ultimately end in a pizza party for one shift. I’m talking about that personal competition between yourself and your ability to do better.

Nurses are oddly competitive. I mean, its not like they’re sitting there timing how long it takes nurse Becky to pass her mid-shift meds and then trying to beat that time by a few minutes. Nurses are weirdly competitive in the way that, if you listed every nurse on the unit in order of med-scanning accuracy, and my name was at the bottom, I would take that as a personal loss and up my game.

Think I’m wrong? Name one of your nursing friends who doesn’t know the EXACT number of questions they completed on their NCLEX exam before it turned off. Its their badge of honor. Personal glory.

2. Food: If you are going to have a presentation, PowerPoint or otherwise, that everyone has to sit and watch you MUST provide them with food. Food will almost always get your staff where you need them to go. BUT, and this is a very important BUT, it can’t be food just for the sake of food. 

* The correct way to provide staff with food: 

ADMIN: “Hey folks, I know there have been a lot of questions about the Coronavirus, so we put together a presentation, you’ll be able to ask questions at the end, and also lunch will be provided.”

STAFF: “Huzzah! What a great day to learn about an emerging pandemic!” 

* How NOT to provide staff with food:

ADMIN: “Hey folks, we need you to take a mandatory staff survey so us executives have decided to take an hour out of our busy day to scoop half-melted ice cream for you. Come down to the cafeteria from 12pm - 1pm, when my schedule allows me to sling this sloppy sprinkled mess into a cup for you, remember to give the hospital 5 stars on your survey!”

STAFF: “This feels like bribery. Sugary bribery. I see right through this uncharacteristic display of nurse affection. However, I’m going to eat this ice cream. Because I love ice cream, even though I do not care about this stupid survey.”

3. Give them the story: As administrators, we become very good at using all the right words to tell the story in such a way that keeps it vague but also conveys the sense of urgency. This is a great skill when you’re presenting to the hospital board or to an outside facility. But nurses want the gory details. They want to know exactly what went down, how it happened and all the queasiness in between.

Example: We had a very unfortunate patient safety event that occurred at a hospital I used to work for. During a meeting with our Professional Nurses Council, I broke down and just laid out all the details. I couldn’t help myself. The story was so sad and I’d been coming to this meeting for almost a year. I knew these nurses and knew that they had huge hearts. They needed to know exactly what happened and how we (the hospital) failed to protect the patient. By the end of the meeting, a few of us were crying and sharing other stories of tragedy that have happened to us or family members, but we also came up with some amazing ways to prevent the event from occurring again. My point is that by being honest and transparent and really opening up with staff about the gaps we identified in the patient’s care, they became emotionally involved and instead of just “wanting to do better,” they demanded it.

4. Professional Growth: Offer and encourage certifications, CEUs and extra courses - it will mold your staff into well-rounded professionals (which benefits the hospital) and will provide them with the confidence and skills that will help them grow in their career.

PLUS

Many healthcare professionals have a licensing requirement to obtain continuing education credits. 

Nurses and physicians love to learn, and also love to not come in on their days off. When the hospital takes the time to work those credits into the material they provide, it is way more likely to get staff to sit through a presentation about patient safety than some dumb ice cream social (sorry, I really, really hate ice cream socials).

5. Offer up committee positions to unit staff: Allow ANY staff member to participate in committees that they WANT to be on. 

Instead of offering nursing governance or nursing-specific committees, ask if anyone would be interested in attending safety event review meetings or patient experience, or things that usually just take up all the time of the managers and directors. This could free up some people that you need on the unit (ahem, managers) and give the unit staff a chance to voice their concerns and better understand the processes that shape the hospital administration. 

Plus, wouldn’t you rather have someone attend a meeting who is choosing to be there instead of someone who is required and is sick and tired of going to meetings that they don’t care about? Take some of the burden off the managers. Show staff that you trust them and their experience to help run the hospital. 

6. ASK THEM WHAT THEY WANT! 

You have decided that the current draw sheets you are using are too expensive. So.... you let a group of staff members try them out and cast some votes! (Also, add some diversity to the trial group - don’t just use nursing; utilize your housekeeping staff, nurse aids, the people who will actually use the product) If they hate all the choices you give them, ask them their opinions on other ways to reduce cost - for example, are we stocking some stupid shit that no one ever uses? Get rid of it and keep the good draw sheets!

And then clearly COMMUNICATE the change to all the staff:

“Attention men and women who work so hard and we love you so much (seriously, we need you to give us 5 starts on that survey)... we asked 130 draw-sheet users to try out a new product and the results are in! The majority of our trial group picked this product so we are switching - BUT please let us know if they aren’t working out and we will revisit the draw sheet decision!”

 ...or we will distract you with an ice cream party

[thequalityproblem]

Ugh. The Understaffing Issue

“Understaffing” is a term often used in the hospital to describe a whole host of issues, including:

Not having enough nurses to staff the UNIT appropriately.

Basically, each nurse has to suck it up and take on more patients. 

Not having enough nurses to staff the HOSPITAL appropriately.

Some nurses will have to suck it up and work on a unit they are not familiar with

Having enough nurses but not having enough support.

Nurses are having to do their own job plus someone else’s (like being charge nurse or being a tech/nurse’s aide)

Having enough nurses and enough support, but the patients are high acuity.

The patients are sicker and/or require more resources which means more time is spent in the patient’s room, which means less time for the other patients.

Generally, understaffing is a topic that I try to avoid at all costs. It always feels like a lose-lose situation. 

From the point of view of the hospital administrator, its a barrier that I have no control over, but it constantly impedes all my genius (yep, I said it) ideas about how to meet the goals I was hired to meet.

From the nurse’s point of view, this is the hard stop. The most basic element to providing good patient care is to have an appropriate number of patients to care for, and if the hospital can’t do that for me, I’m not doing shit for them. 

Pardon me for a moment while I trail off into a weird discussion about Maslow’s hierarchy of needs. Remember this thing? We learned about it in school? Ringing any bells? 

Basically what good ol’ Mr. Maslow was getting at is that, as a human, we have basic, primal needs that must be met (like shelter, air, water) in order to achieve the next level of motivation. I’d like to point out that this just a theory and there are a lot people out there who are smarter than me who like to argue the validity of this pyramid, but understand that I am using this as a METAPHOR for this whole understaffing thing.

If you look at this from the perspective of the nurse, the most basic needs are the things that provide career stability. Patients to care for, supplies to do that, support departments to make sure everything runs smoothly.

Here’s the part that is going to be a bit hard to swallow if you’re a hospital administrator: all those quality initiatives and metrics that teams of people have been hired to implement and improve upon - as the RN, those are at that highest level of the pyramid. Not to say the RN doesn’t care, I don’t know very many nurses to want to INCREASE your CAUTI rate, the problem is that it’s not even on their radar because they constantly feel like they are trying to make it to the end of the shift alive.

The hardest need to satisfy for nursing is safety. Nurses need to feel safe taking care of patients. Literally, the hospital’s most elemental task is to keep people alive. So if the nurse isn’t confident he/she can do that, you need to find a way to fix it.

Okay, but how do I fix it?

Well, that’s a little bit difficult. In fact, its an elephant... and the only way to eat an elephant is to take it one bite at a time. (I’m actually not really a huge fan of this saying, but you get the point. I’d much rather compare this task to Bruce Bogtrotter having to eat the entire chocolate cake in Matilda - I was pretty emotionally invested in that scene - also disgusted and proud - just a swirl of emotions, really.)

The best way to start the understaffing conversation with staff is to be as honest and transparent as possible. And I don’t mean explaining budget constraints and quarterly projections... I mean something like this:

Establish a staffing grid

Determine what your “hard line” is and put together a risk assessment  and detailed plan for the different scenarios you will encounter.

Example: at what point do you pull nurses to other units? What about techs? What is the magic number for allowing a unit to stop taking admissions? At what point does the hospital go to an “all-hands-on-deck” approach where all licensed staff are required to assist?

This is the point where the conversation usually stops. The grids are developed, the numbers are put into a policy or an operating directive where they hide in the nursing office and the poor bastards who are in charge of staffing and supervising take the brunt of the resistance when staff are upset about the situation.

In order to make a meaningful impact on staffing issues, you HAVE to keep going. The conversation has to be loud and in people’s faces.

Share the staffing grid with all staff - with a thorough explanation of how those numbers were determined (evidence based? provide the articles. Show the staff that you have done your homework and aren’t just picking nurse/patient ratios based on cost, that you care about their safety.)

Post the grids EVERYWHERE - this is going to be hard, because this part requires total accountability and transparency with staff, administration, and patients.

Update the grids with ACTUAL DATA. Just like with every other quality metric that is tracked on each unit’s KPI boards, keep track of staffing. Daily. Show staff how the daily assignments are lining up with the established plan. Change the perception of understaffing by being able to point to the actual data that shows that the last time we were “truly” understaffed was over a month ago.

Then (and this is my favorite part because I am a total data nerd) track and trend the data!! 

Track on the boards how many times nurses and techs have been pulled to or from the unit. Which units are the biggest offenders? Which units are the least common offenders? Why?

How many all-hands-on-deck days have there been? Is it rare or do we need to re-assess the grid?

Are there days/weeks when staffing is worse? Why?

Look at open unit positions, and examine all the factors that may have contributed to the issue. Let the data drive the change.

And finally but most importantly: practice extreme consistency. If you are going to take on the issue, do it all the way. If the plan says that an all-hands-on-deck situation has just been triggered, you need to dedicate your day to putting ALL HANDS ON DECK. Not just those hands that can probably reschedule the meeting this afternoon or those who can maybe cut lunch a bit early to help with a few tasks. The only way this whole plan will work is if it is taken seriously EVERY SINGLE TIME. I’ve been in these situations, and let me tell you, if I am told to drop everything I am doing to help the ED nurses, I’d better see the entire C-suite down there with me, because the first time I realize I’m down there alone while everyone else gets to go back to their offices, I’m going to realize that I’m the sucker and go back to what I was doing. And what does that say to the staff? “We care about your really hard day, but only kinda. Like, I care enough to tell other people that they should help, but I really can’t because I’ve got like a hundred meetings this afternoon” By the third or fourth time that everyone in administration is having to drop everything they are doing to go into staff, changes will start to happen. People will start paying closer attention to the data in order to fix the problem because it becomes everyone’s problem, not just the over-worked, over-burdened nursing staff.

The problem will not get fixed over night. But just by having the conversations and STAYING CONSISTENT with the developed plans, staff will start to see that their concerns are being taken seriously. Just like the light in the parking garage. (Same basic approach, just on different scales).

In order to finish off Ms. Trunchbull’s big, disgusting chocolate cake, keep everyone in the loop. Talk about what the data showed. Explain future plans to fix the problem and how it is being managed in the meantime (example: “Today sucks. There are too many call-offs, not enough people to cover, we tried all of our established and agreed-upon plans for improving staffing levels for you today, but unfortunately it can’t be done. In the meantime, we are going to have lab cover all your draws today. OR, we called in extra transportation so you won’t have to do any yourself OR we’ve had pharmacy change up a few things so that they can accommodate your requests quicker to help you out today.”)

Bottom line: SHOW the staff that their concerns and the hospital’s concerns are the same. When staff feel heard and safe, then maybe you can come at them with the whole “update your whiteboard” conversation.

[thequalityproblem]

The One About Communication

You can talk all day long, but if what you’re saying doesn’t mean anything to the people listening, you’re just wasting your breath.

So change the conversation. Don’t just inform the staff about upcoming changes, talk to staff about WHY something is changing or isn’t changing. 

It may make perfect sense to you, but understand that most nurses, techs and providers know nothing about the hospital budget, safety events, or any of the dozens of meetings that have taken place to make these decisions. 

The staff works hard for the hospital every day and deserves honest transparency. And not just when it comes to bad news - its important to be transparent about good news too! Don’t just assume that people will realize that you’ve done something nice for them and that they will appreciate all your hard work. 

If you want to make a bigger impact on the staff, you need to change their PERCEPTION of the work you’ve done.

For example: 

Every year the hospital staff is required to complete a survey about safety in the workplace. This year, multiple surveys mentioned that a problem for them was the lighting in the parking garage. Needs to be brighter to make people feel more safe. To administration, this is a quick win. Of course we can put up a few lights. Done, check that off the list.

How we can do it better: In addition to putting up the new lights in the parking garage, send an email to all staff, post some signage in the parking garage that says, “We Heard You! On our most recent Safety Survey, YOU said you would feel safer with more lights, so look at all this lighting that we have provided to make YOU feel safer because we are an awesome hospital administration that CARES about our staff and wants to do things that will make YOUR life easier!” (or something to that effect, I’m no marketing whiz).

The message to your staff will be clear. 

I’d bet that by fixing the problem the first way, some people might notice the lights. They might even mention it to their coworkers. 

By responding to the issue the second way, staff can really connect the dots. Believe it or not, they have a lot on their plates and when they notice the extra lights, their first thought, isn’t, “oh wow, they must’ve done this because I brought it up,” its something like, “well it’s about time, someone in administration must’ve had to park over here and realized it was total crap.” 

The staff doesn’t think that the hospital administration is putting them first, because it doesn’t always feel like that. BUT if you package your message in a way that shows staff that they do have a voice, I can pretty much guarantee that they will continue to speak up and when that light goes out again, they will bring up the fact that it went out, because they know their administration cares enough to fix it.

This is an example on a small scale of course, but you know what? Small scale victories can have a big impact. By taking the time to make sure that the staff feels heard and cared for, you are going to set the tone for a culture that feels like employees, and not numbers, come first.

[thequalityproblem]

Let’s start with the Org Chart

In order to minimize the gap that exists between quality ideas and quality implementation, its important to look at the basic (cough* flawed *cough) structure of the system. Honestly, this is not a thing that will change, probably ever, but I do think it is important to take a look at what we are dealing with.

Most hospital systems follow a similar hierarchy, commonly known as the Org Chart. It usually looks something like this:

Big Cheese who gets paid lots of money

Smaller Cheese who also gets paid lots of money

Director of Cheese

Manager of the Cheese

Coordinator/Charge Nurse (depending on shift and unit)

The Registered Nurse

The Patient Care Tech

What happens with this type of structure is that often, when there is an immediate issue on the unit, nurses are instructed to escalate it to their Charge Nurse and/or Manager. Which is great for nursing, because you work your ass off and deserve to have that managerial back up when there is an issue on the unit. 

When an initiative comes down from the Big Cheese, the Smaller Cheese doles out the responsibility to the directors, who, in turn, look to the unit managers to handle the day-to-day implementation of whichever new initiative has been deemed the most important this month.

The manager is constantly being stuck in the middle of all of this, usually with little resources.

On top of having the day-to-day responsibilities on the units, they are responsible for scheduling and making sure staff get paid, reviewing safety events, dealing with patient families, patient satisfaction, quality data audits, etc. the list goes on and on.

This is no one’s fault. It’s done this way because it’s always been done this way, and no one has really found a better solution. 

Do you have any idea how many unit managers I have seen cry at work? It’s too much for one person to have all that responsibility. 

Sure, Charge Nurses and Coordinators can help take some of the load, but they are not the ones who the Director and the Cheeses are going to come down on if something isn’t done correctly.

One thing that I never fully understood when working in the Quality realm of the hospital was why we didn’t have more face time with the front line staff. 

Whenever there was an initiative or an investigation to be completed, the onus always fell on the manager and I was told that “the manager is the owner of their unit” and it was their responsibility to do the face-to-face part of the work.

But what if, hear me out, instead of making the manager the owner of everything, we shared that responsibility? 

New protocol? Have the owner of the protocol teach the staff directly. 

New products? Have Supply Chain send out a notice about WHY or go floor to floor to explain the changes.

Serious Safety Event? Risk Management and the Nursing Directors should be out there talking with EVERYONE about the event and why things are going to change in order to avoid another event.

I completely understand the push back that this would receive: No one has the time or the resources to get out there and spread the word. 

But, are we saying that improving communication, informing our nurses, techs and providers of changes, or even (gasp!) including them on some of the decisions isn’t worth taking the time or finding the resources?

I know, it sounds like a lot, but just imagine how much weight could be taken off the shoulders of the managers, how much time we could free up if all the ancillary departments rallied together to talk to the staff and help out a little bit.

[thequalityproblem]

The Quality Problem: a definition

As I briefly discussed in the last post, the “Quality Problem” is really just the space between what hospital administrators know and what they are trying to teach front line staff. This seems like there should be an obvious solution, right? Just find a way to teach the front line staff.

Yea, I’ve already tried that. Lots of people have, in fact. Some have had some really good outcomes and others have fallen flat. 

The problem with this approach is that the hospital administrators have become so far removed from the day-to-day grind of patient care, that they don’t quite understand HOW to connect with staff to teach them what they need to know.

Let’s start by taking a look at this from both sides:

The admin:

“Ugh. Those patient experience scores are starting to look pretty bleak. If we can’t figure out how to bump those numbers up, we are going to take a hit for this quarter and it will definitely be my neck on the line. I know!! I’ll do lots of research and collect lots of data and figure out exactly where our issues lie. Then, I can take the one that will make the biggest impact on the numbers and teach all the nurses. I remember when I was working on the floor, we definitely had time to do all the stuff that I’m going to insist we implement. That oughta fix the problem.”

The nurse:

“I can’t believe they are making us sit through another in-service about being nice to patients. Are you kidding me? I am basically killing myself for this job. I haven’t slept a normal schedule for years (thanks for making this a 10am meeting when I just got off at 7 this morning, by the way - who needs sleep?), we are CONSTANTLY understaffed, and my patients are sick as hell. But sure. I will make sure to write down everything on the white board as soon as my shift starts because you have decided - for some reason that no one has explained to me or asked my opinion about - that doing so will fix all of our problems. Bitches.”

I have actually been on both sides of this problem, and it is extremely frustrating. I have been the nurse who is pissed off about all the seemingly arbitrary changes and the admin who worked her ass off on a new initiative, only to be told by nursing that they won’t be doing that because they do not have the time or resources to listen to me. It hurts. But I get it. 

I think that there are ways to bridge this gap, it will just take a little finesse and some outside-the-box thinking to make it work.

[thequalityproblem]

Healthcare Quality. Woof.

Let’s start with what we know about healthcare:

Nursing is a very noble career path. 

In addition to being compassionate and empathetic, nurses also need to know their stuff (ya know, simple things like medicine and pathophysiology and pharmacology) and have the energy and strength to advocate for their patients all while simultaneously waiting on patients’ family members, cleaning up some pretty disgusting body fluids and walking the fine line between kiss-ass and tough-as-nails with some providers to get orders placed at four in the morning. 

I’m pretty sure everyone gets this.

No one out there really thinks that nursing is a pleasure cruise (or at least, no one is brave enough to say so out loud), but let me tell you, there is a whole lot more going on within the hospital that you aren’t even aware of.

In addition to all the back-breaking work required to keep patients alive, nurses (and, honestly, all providers including physicians, NPs, PAs, CNAs...) are also expected to not only understand the quality concerns within the hospital, but actively work to improve the issues.

I’ve been there. 

While working as a med-surg nurse, I can’t even tell you the number of times I was notified by management (usually via a bright sticky note in the break room) about an important process change - with no explanation as to why. Or found myself in the clean utility room only to find out that we changed brands or even actual products that we used daily - again, with no information provided to us about why or how this decision was made. And my absolute favorite was standing face-to-face with the Epidemiology Manager, dopey-ass look on my face while she grilled me about our unit’s CAUTI and CLABSI rates in front of my unit manager - I feigned some tummy trouble to get myself out of this conversation, so, ya know, real Nurse of the Year material over here. 

Most people don’t realize that in addition to patient care, hospital staff have to work just as hard to meet specific quality criteria. What this means is that hospitals receive a lot of their payments and reimbursements based on the quality care that they provide. “Quality care” can really be broken down into two categories:

OUTCOMES - basically, did the care the hospital provided make the patient better? 

PATIENT EXPERIENCE - but were they happy with the care you provided?

I’ll touch more on these later, but wanted to mention them now because it’s important to have an idea of what “quality care” means.

I transitioned from working the floor to working in the Quality Department after only a few years. The focus of the QUALITY DEPARTMENT is to help the hospital achieve that quality care. 

In that time, I’ve updated and created hospital policies, participated in intense investigations regarding patient safety concerns, worked to prepare an entire eight-hospital system for their impending Joint Commission surveys - and after all that, I have learned one extremely important lesson:

Hospital administrators can’t accomplish shit without the support and engagement of the nurses, techs, and providers who are doing the real hard work.

This does not mean that achieving quality care is impossible, it just means that in order to get there, we need to re-think some of the ways we’re doing it.