September 17, 2019

When Theresa Brown heard about nurses hiding patients' drugs in the ceiling to work around their hospital's slow pharmacy, she "wasn't surprised." In a New York Times opinion piece, Brown, a clinical faculty member at the University of Pittsburgh School of Nursing, explains why these workarounds are all too common in the U.S. health system.

Report: 12 tactics for care standard prioritization, design, and rollout

How onerous policies lead to workarounds

Brown heard the anecdote about the drugs in the ceiling from Karen Feinstein, the president and CEO of the Jewish Healthcare Foundation. Nurses were hiding the drugs, Brown explains, "not because they were secreting away narcotics, but because the hospital pharmacy was slow, and they didn't want patients to have to wait."

It's just one example of health care providers embracing a "workaround"—a term that has a specific meaning in health care. According to ECRI, a nonprofit that researches medical practices, workarounds are "adaptive response[s] … to 'a real or perceived barrier or system flaw,'" Brown writes.

Workarounds often arise when caregivers perceive they must make a choice between adhering strictly to rules—which can sometimes be flawed—or putting the patient first, Brown writes.

Brown describes her own experience with her hospital's implementation of hand-held scanners for medication administration. The hospital required nurses to scan bar codes both on medications and on patient's hospital bracelets, aiming to ensure the drugs were administered correctly.

While the idea "sounds smart," the execution was riddled with problems, according to Brown.

"Some medications routinely came without bar codes, or had the wrong bar codes, and we nurses weren't given an easy way to report those errors," Brown writes. In other cases, "[p]atients' wrist bands could be difficult to scan and the process disturbed them, especially if they were asleep. The lists of medications on the computer screen were also surprisingly hard to read, which slowed everything down," according to Brown.

But the biggest obstacle was that the scanning software was incompatible with the hospital's EHR system—meaning that each medication administered had to be separately registered in each system. As a result, "what was already a lengthy process suddenly took twice as long," Brown writes.

In response, some nurses came up with workarounds, such as attaching copies of patient's bar codes to their medication carts or avoiding the system altogether. "I tried to adhere to the rules," Brown writes, "but if I was especially busy or couldn't get a medication to scan, I would chuck the whole process."

In response, hospital officials put in place a tracking system that publicly disclosed each nurse's adherence to the scanning rules. While that approach improved compliance, it also left nurses feeling angry and distrusted: "No one among the managerial class seemed to understand that nurses care a lot about patient safety," Brown writes.

Why workarounds reveal a bigger problem

The bar code story is not unique, according to Brown.

"[T]he entire health care system is built on workarounds—many of which we don't always recognize as such," Brown writes.

For instance, according to Brown, medical scribes are a common workaround to the "design flaws" of EHRs. "I have heard doctors say they need a scribe to keep up with [EHRs], the mounting demand of which is driving a burnout epidemic among physicians," she writes.

And while doctors who use scribes do see an increase in productivity and work satisfaction, the "trade-off is still there: Scribes demonstrate the extent to which paperwork has become more important than patients in American health care," Brown writes.

Brown writes that the Affordable Care Act, which she supports, "is also an enormous workaround," one that "works around our failure to provide health care to all our citizens."

"In its own way," she writes, "the Affordable Care Act is as jury-rigged as using ceiling tiles to stash medications" (Brown, New York Times, 9/5).

Create care standards your front line will embrace

To successfully scale efforts to reduce care variation, leaders should follow the approach shown here. Leaders first need to ensure their organization has adequate performance across the four foundational elements of care variation reduction. Once these elements are in place, leaders can begin spinning the care variation reduction flywheel.

This report contains tactics that will help leaders implement care standards that will be easier—not harder—for frontline nurses to implement, and yield cost savings.

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