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Case study

A walk-through is an excellent method to use at the start of a quality improvement project because it is a simple and inexpensive but powerful way to provide clinicians and other staff with insights about the experience of care. Walk-throughs always yield ideas for improvement, many of which can be implemented quickly. Walk-throughs also build support and enthusiasm for redesigning care through the eyes of the patient much more rapidly than do data or directives from managers to “be nice to patients.”

As you do the walk-through, ask questions of staff you encounter. The following questions incorporate the staff’s perspective about their own work improvement opportunities into the process:

• What made you mad today?

• What took too long?

• What caused complaints today?

• What was misunderstood today?

• What cost too much?

• What was wasted?

• What was too complicated?

• What was just plain silly?

• What job involved too many people?

• What job involved too many actions?

Keep careful notes, and you will have a long list of things you can fix the next day.

Several years ago, the medical director and head nurse of a public com- munity hospital ED joined an Institute for Healthcare Improvement Service Excellence Collaborative to improve the care in their ED. At the start of the collaborative, they did a walk-through in which the doctor played a patient with asthma and the nurse played his family member. They encountered sev- eral surprises along the way, and their experience ultimately guided a redesign of the ED’s physical environment and processes of care. They came to one realization right at the beginning of the walk-through: The “patient” and the “family member,” both clinical leaders of the ED, had never entered the ED through the patient entrance.

When the patient called the hospital number (from his office) and told the operator he was having an acute asthma attack, the operator put him on hold without explanation for several minutes. Although the operator did transfer his call to the ED, his anxiety increased because he did not under- stand what was happening.

When he was finally connected to the ED, his family member took the phone to get directions to the entrance from an address in the neighbor- hood. The ED staff member was incapable of helping her and finally found someone else to give her directions. After this delay, as they followed the directions, they discovered they were incorrect. Also, as they drove up to the hospital, they realized that all of the signage to the ED entrance was covered with shrubs and plants. They had no idea where to park or what to do.

The ED entrance and waiting area were filthy and chaotic. The signage was menacing and told them what not to do rather than where they could find help. They felt like they had arrived at the county jail.

As the patient was gasping for air, they were told to wait and not to ask for how long. At this point in the walk-through, the doctor described his anxiety as so intense he thought he actually might need care.

The family member went to the restroom, but it was so dirty she had to leave; she realized that this simple but important condition made her lose all confidence in the clinical care at the ED. If staff could not keep the bathroom clean, how could it do a good job with more complicated clinical problems?

The most painful part of the walk-through occurred when the nurse told the patient to take his clothes off. He realized there was no hook, hanger, or place for them; he had to put them on the floor. For years he had judged his patients negatively because of the way they threw their clothes on the floor, only to discover that this behavior was, in essence, his fault.

The story could continue indefinitely. Many of the problems the medical director and head nurse experienced were relatively easy to fix quickly: standardized, written directions to the emergency department in different languages for staff to read; different signage in the waiting areas and out- side the hospital; and better housekeeping and other comfort issues such as clothes hooks in the examination areas. Other problems took longer to redress, but one simple walk-through helped refocus the hospital’s improvement aims and its perspective on the importance of the patient’s experience of care.

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