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The Case for Making Simple Changes

Analysis  |  By Megan Headley  
   July 09, 2018

By tackling small problems first, healthcare organizations can create a problem-solving culture that leads to continuous improvement.

A version of this article appeared in July on PSQH.

In an ideal world, healthcare providers would be constantly studying patient satisfaction scores for even the smallest suggestions that could help them improve the patient experience. They'd be regularly searching for even minor insights on how to improve surgical processes or strengthen communication among caregivers or with patients.

In a more realistic setting, though, healthcare providers are struggling to implement improvements and rarely have time for meaningful engagements with patients that could translate to even the smallest advances in patient care.

Yet there is room for improvement, even in the real world. And often it's the simplest changes that can have a big impact.

Change in Language Can Change Your Outlook

Jennifer Lenoci-Edwards, RN, MPH, CPPS, executive director of patient safety for the Institute for Healthcare Improvement, shares a story that IHI CEO Derek Feeley likes to tell: "There was an elderly woman who was always getting out of bed, even though she was a fall risk. It turns out that the reason she kept getting out of bed was because staff kept putting her rosary beads away in the drawer across the room. They had to figure out what mattered to her, which was having those rosary beads. Having those with her in bed minimized her risk of falls."

Introduced in 2012, IHI's "What Matters to You?" program is one example of how the smallest changes can have a huge impact on patient care.

"Our previous CEO Maureen Bisognano reframed the question 'What's the matter with you?' to instead ask 'What matters to you?' " Lenoci-Edwards explains. "It has a huge applicability from a patient standpoint in terms of really defining the critical aspects of care that a patient needs in order to be happy and healthy."

The question highlights the discrepancy between patients and caregivers that can crop up when creating an optimal care plan. "Think about when the patient comes in and you're talking to them about cholesterol medications, when the truth is all they really care about is whether they can ambulate to the door to talk to the mailman every day," Lenoci-Edwards points out.

Getting on the same page, by reframing the initial question, can help create a care plan to which the patient will adhere—and that's important. "We're spending a lot of time overmedicating patients when really at the heart there are adherence issues because that was never really something that mattered to the patient," Lenoci-Edwards adds.

Asking the Right First Question

Asking the right question is often the biggest impetus for change, as questions create clarity and inspire people to think in unpredictable ways. But to get value from this process, you have to be willing to act on the answers.

As Australian anesthesiologist Dr. Rob Hackett recently blogged, "Because Evidence Based Medicine places all of the emphasis on clinical trials, it forgets to ask the first, most basic question of all: does the idea make sense? Through this, EBM can be used inappropriately as a tool to maintain the status quo … Certainly, lack of evidence must not be used inappropriately to stoically defend the status quo—for in the end it is our patients who suffer."

Hackett would know. He rose to worldwide social media fame when the hashtag #TheatreCapChallenge highlighted his decision to write his name and position on his reusable cotton surgical cap.

The idea behind this was simple. The World Health Organization's Surgical Safety Checklist advises that all staff in the operating room introduce themselves by name and role prior to beginning surgery. This doesn't always happen. And while not performing introductions might seem like a simple oversight, Hackett had seen firsthand that working with a cast of ever-changing nameless colleagues was potentially putting patients in danger.

One of the more compelling parts of this story is that, when Hackett approached senior hospital staff about adopting his surgical cap strategy, he met with resistance—even though the simple step has since been found to reduce staff member mix-ups, facilitate patient handovers, and improve camaraderie during surgery.

As Hackett later wrote on his PatientSafe Network: "Perhaps administrators view a label on one's head as a message of imperfection. If we forget people's names what else might we forget? Unfortunately, this is how hospitals are invariably designed—on the premise that as doctors and nurses we shouldn't make mistakes … We need to develop systems which reduce mistakes and minimize them from causing harm when they inevitably occur. For this to happen, we need to let everyone know we're human."

Prioritize to not be overrun by data

Being human, healthcare staff often find it overwhelming to simply maintain the status quo, much less drive improvements in care. Even in healthcare organizations that are open to process changes, there's simply no time to identify and act on even the simplest improvements.

"If you think about patient data, staff satisfaction data, safety culture data—all of that information has these little nuggets of things that could be improved, ways to make a very small change in the acute care setting or in ambulatory care," Lenoci-Edwards points out. "But we don't necessarily have the ability to turn on a dime on prioritizing these nuggets or turning them into improvement. A really well-oiled machine has some type of structure that helps you to look at all these individual data pieces and triangulate on which one of these ideas could help address a particular problem and then actually using improvement teams to take action.

"But I think this is really hard. There's a lot of data, and it takes a lot of manpower to turn this into improvement," Lenoci-Edwards adds.

Commit to Simple Changes

Simple changes aren't always going to make a massive impact, but they can consistently drive performance forward—which is an improvement over refusing to change at all.

In fact, research from the Harvard Business School revealed that when healthcare organizations move the focus from "big bang" priorities to low-hanging fruit, their employee-suggestion programs are more likely to succeed. By acting on and fixing small problems first, organizations make strides in developing a problem-solving culture that ultimately can smooth the way for larger-scale solutions.


Patient-centered care improves patient outcomes.

Small changes can drive momentum toward larger-scale improvements.

A support structure should be in place to help facilitate change.

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