Improving Health Care Quality Through Signs or Systems?

To improve quality, the most effective hospitals and leaders focus on processes and systems, instead of just lecturing and cajoling their employees and physicians to do better. W. Edwards Deming famously stated that the problem with posters and exhortations was that “they take no account of the fact that most of the trouble comes from the system.” His words still ring true today.

Hospitals are places where quality and safety should be paramount, given the number of things that can go wrong and the harm that can occur to patients or staff. Dramatic, high-impact errors such as medication errors (for example, the heparin dosage error that harmed the newborn twins of actor Dennis Quaid) and wrong-site surgeries (estimated to occur 40 times per week in the United States) seem eminently preventable with better processes and improved communication.

There are more frequent, yet quieter, process defects that lead to awful pain, long recoveries, or even death, including hospital-acquired infections or what the Centers for Disease Control and Prevention call “healthcare-associated infections (HAI),” which are estimated to cause 100,000 deaths per year in the United States. When a hospital has five wrong-site surgeries in a span of two years, as occurred in Rhode Island, that gets a lot of attention, and people are rightfully outraged. But as Stalin said, “A single death is a tragedy; a million deaths is a statistic.” Sadly, because the public seems unaware of the amount of harm and death caused by infections and preventable medical errors, there seems to be little pressure to improve.

It has been known in health care for more than 150 years that poor hand hygiene spreads microbes and infections. In fact, it seems like common sense these days, even among the general public, that we should frequently wash our hands to prevent the spread of disease. In hospitals, patients aren’t just catching the common cold; they are being exposed to killers like MRSA and C. diff.

Inside most hospitals, you will find yourself bombarded with signs and posters that exhort, cajole, or remind people that washing hands saves lives, as if this is a recent medical discovery. There are dozens or hundreds signs posted in public hallways, patient rooms, cafeterias, and staff break rooms. Hospitals have been hanging signs about hand washing for decades, yet compliance rates are still dreadfully low (often hovering around 50 percent, in some studies).

Hospitals post a variety of boring, straightforward signs and posters that ask, remind, or use guilt to invoke staff members to wash their hands. There are signs that implore patients, families, and visitors to ask physicians and staff members if they have washed their hands. You’d think it was the hospital’s job to manage the system. I can’t think of any car dealer that would hang a sign exhorting you to “Ask your mechanic if he properly tightened your lugnuts!” or an airline that prints, “Ask your pilot if he performed his pre-flight checklist!” on a boarding pass.

There also seems to be a bit of a “cuteness competition,” where hospitals compete for people’s attention with a variety of signs that feature cute or charming photos. You see signs with comical but gross cartoon microbes, posters with kittens or puppies, and signs with babies (who wants to make a baby sick, after all?). Even more puzzling, a reader of my blog recently sent a picture of a sign showing a monkey (or maybe it’s a baboon) with the caption, “Stop & Think. Are you transmitting infection?” I’m not sure that comparing people to apes inspires them toward better quality and job performance.

Is there medical evidence that these signs help or the lack thereof would lead to more infections? If signs help, are more signs more helpful? Do the signs become visual noise that is easily ignored over time? Again, the evidence seems to point toward signs not working. If the plan-do-study-act (PDSA) cycle for improving hand washing included “hang lots of signs” as the plan and the do steps, it’s time to study the impact on infection rates, and adjust with some new strategies.

As an alternative approach, leading lean hospitals have increased hand hygiene compliance by improving the systems in which people work. They are freeing up time through the elimination of waste. For example, if you’re not running around as much looking for missing medications, you have more time to wash your hands properly. Even the most “unlean” hospitals have made great strides in hanging gel dispensers outside of most patient rooms, in hallways, at front entrances, and even inside elevators (since you have the time, gel up). On the other hand, one intensive care unit (ICU) I recently visited had two signs imploring visitors to clean their hands before entering, but there was no gel dispenser or sink anywhere near that entrance.

It’s not just hand hygiene. There are countless other hospital practices that are “managed” by hanging reminders and posters, with phrases such as:
• Caution
• Warning!
• Be careful
• Don’t forget
• Please remember

At a plant I visited, a sign was posted warning staff to not restart the pharmacy robot if anyone was inside the enclosed space. What factory would allow equipment that could not be properly “locked out?”

And I once saw an electronic inventory cabinet that had a sign saying, “Please, please, please push a button every time that you remove ANY item.” Are these signs effective? This hospital unit usually had inaccurate inventory counts because the buttons did not get pushed, leading to the undercharging of patients and the understocking of needed supplies. We need to ask why the buttons aren’t being pushed or look to see if the buttons don’t work properly, or don’t give proper feedback when pushed.

While posters urge employees to not forget daily tasks, simple checklists have proven effective in settings ranging from operating rooms to dentist offices. Proper system design recognizes our basic human nature that we are imperfect and we forget things. For example, it’s an important daily task for nurses to do “narcotics counts,” ensuring that medications have not been stolen or lost. Some hospitals merely hang signs that say, “Please remember the narcotics counts,” while others have check sheets and proper daily management oversight.

In hospitals, the odds are good that when you see a “Do not block electrical panel” sign, the panel is blocked by a cart or a bed (a violation that arguably never occurs in a highly disciplined lean factory). The signs don’t help when the hospital unit hasn’t been designed with the proper storage space for carts and beds. Staff members have no choice but to block the electrical panels. Calls for accountability and discipline (or more posters) will do no good if the system isn’t properly designed.

Clearly, we can do better. We can’t just rip down the posters and signs, and we especially shouldn’t tack up signs that say “No Poster Hanging!” or the classic “Post No Bills.” Instead, we need to make it easier for people to do the right thing, such as washing their hands and not blocking panels. Leaders need to make sure people have time in their day to do things the right way. When we see processes not being followed, such as narcotic counts not being done twice a day, managers need to ask why instead of being punitive.

It’s often said in the lean approach that “problems are a treasure.” Each sign and poster, every warning and exhortation, should be viewed as a visible symptom of a deeper system problem, rather than being a solution in and of itself. We need more of this mindset, not more posters.

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