Start small to solve big problems
Trying to improve care in human services can be overwhelming. We start out with great aspirations to fix a care quality issue. But as we get closer to the problem it appears to loom ever larger, and we wonder what we’ve got ourselves into. Most care quality issues are entrenched and multifaceted and can’t be solved by a single solution or big-bang change. Often our initial enthusiasm wanes and we default to revising the procedure and running training because everything else seems too hard. Essentially, we’ve wasted time and effort on maintaining the problem, rather than finding the solution.
This case study reminds us that big problems can be solved – if we use the right method and start small. It tells the story of an IHI team working with a hospital that routinely used physical restraints on patients in their intensive care unit (ICU). Staff knew they should stop this practice, but were understandably nervous about the change. The IHI team cited evidence that the use of restraints can be harmful. They discussed their own experience in testing the removal of restraints. They talked about the successes they achieved and the failures from which they learned. But for the staff, change was difficult. Using restraints was common, and they were worried about the consequences of stopping.
The team worked with staff to apply improvement science to reduce and stop the use of restraint. A key element of the approach was starting small. Seeking a “big bang change, in the hope that transformative improvement will happen quickly, can lead to frustration and burnout. By contrast, an improvement approach entails breaking up the challenge into manageable portions, iteratively testing, learning what works and what does not, and building confidence. Using improvement methods creates staff agency allowing them the power and intention to act.
Starting small meant starting with one patient and learning what works and what doesn’t. The next week they moved on to three patients. A week later, they scaled up to one side of the hallway, and then to the next side of the hallway. They built their confidence that it was possible, and they built their confidence that they were doing the right thing. The staff’s fear of change and fear of the unknown gradually dissipated.
Improvement work can be a cause of burnout, but as with change more broadly, this usually happens when done badly. Some staff members fear that improvement work will merely add to their burdens, potentially exacerbating burnout. But it can be argued that the opposite is the case. If staff can effectively drive sustainable change — which improvement science methods enable them to do — the result can be energising rather than enervating. Particularly when big problems can be solved via small, but focused, steps.
All accessed 21/3/24:
IHI. From Hospitals to Everyday Life: Using Quality Improvement Skills to Tackle Problems. Institute for Healthcare Improvement, Feb, 2024. https://www.ihi.org/insights/hospitals-everyday-life-using-quality-improvement-skills-tackle-problems