Friday, July 25, 2014

Searching for stuff: patient safety, DXerror and RCA info. Places to start

I had a colleague ask recently about finding information on root cause analysis in general and in getting started on diving into the diagnostic error evidence base. I recognize that this response is pretty quick and dirty and what I typically don't include on this blog -- but she liked it, so I thought others might as well.
....

I wrote ... This safety stuff is very messy to look for—as the language used to study, discuss and (ultimately) search for it varies due to the range of industries that touch it, where the materials reside and that the science of safety is evolving pretty rapidly.

As with any patient safety topic—I always suggest that folks start with AHRQ’s Patient Safety Network:
http://psnet.ahrq.gov/. Not because I help develop it – but it is a good entry way into primary safety topics,  the medical literature (to look for MESH subject headings) and non-pubmed indexed materials.

Check out the primers on both DxError, RCA and failure analysis – all three touch on your question:
http://psnet.ahrq.gov/primer.aspx?primerID=12
http://psnet.ahrq.gov/primer.aspx?primerID=10
http://psnet.ahrq.gov/primer.aspx?primerID=24

Another tidbit if you REALLY want to have a more complete search strategy approach to a patient safety topic -- is to again draw from AHRQ. The released a comprehensive review of patient safety strategies last year: http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html

There is one on DxError:
http://www.ahrq.gov/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetyIIchap35.pdf
And what is REALLY helpful (again, if you are aiming to be comprehensive) the authors share the search strategies used to support the reviews in each chapter. See c78 to c80 for the search strategy for the DxError chapter.
http://www.ahrq.gov/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetyIIapc.pdf

The other thing about DxError is how you client defines it. Delay, over- and under-diagnosis, decision making, cognition, biases (availability and otherwise) etc all could play into a search—depending on what the person is really looking for.

Lastly -- here is an article --  (wish it was free: the first author happens to be a contributor to my new Patient Safety book: http://tinyurl.com/lukj64e: )-- that also provides some thinking about search in patient safety: http://qualitysafety.bmj.com/content/19/5/452

Now – this may be more than you want or need – but what I think is useful is the strategies not only give someone like you (and other librarians) a robust place to start, but it illustrates the complexity of searching for materials in the world of patient safety!

Hope it helps.

Thursday, May 22, 2014

Middle managers as boundary spanners: a UK study of interest

I have long believed that middle managers serve as boundary spanners (or knowledge conduits) – helping to connect the dots between departments, teams and organizations. I am curious to hear how the results of this new study from the UK might inform how organizations could work with middle management --or structure their role -- to improve the reliability of this knowledge sharing role to support high quality, safe care.

Ward V, West R, Smith S, McDermott S, Keen J, Pawson R, et al.
The role of informal networks in creating knowledge among health-care managers: a prospective case study. Health Serv Deliv Res 2014;2(12).
Information and free full text
Summary

A quick thought after a first glance at the publication:

This report highlights the importance of the water cooler “method” of sharing knowledge. In the work reflected in my recent book there has been concern voiced by front line care providers that there is little time to just talk to one another and that this could be detrimental to the safety and quality of care provided. I suspect that a lack of time on the administrative or “blunt” end for informal conversation (ideally face-to-face) could be detrimental as well.

Will the findings inform a different EI&K service delivery model? And also how librarians—who may serve as middle management—see their roles differently as both boundary spanners and information, evidence and knowledge service providers?

I look forward to diving into the report more deeply to identify other items of interest. In the meantime, sharing your thoughts here would be welcome.



Monday, May 05, 2014

Dialogue: a tool to facilitate the exchange of knowledge

Today’s environment for sharing information, evidence and knowledge is complicated--perhaps even complex. (A whole other topic all together ... for another time!) A variety of tools, styles, formats and time elements affect our ability to communicate clearly and efficiently. With the plethora of models that can be customized for specific needs, styles and wants, one would think communication would be more often successful – but its often not.

One method relied upon to share information and knowledge (depending on how you define knowledge) is the written text – in whatever format it is delivered. I had a colleague once suggest to me that librarians needed to embrace "dialogue" as a tool to share knowledge rather than the provision of articles and other stagnate information and evidence artifacts.

This is an intriguing idea. It certainly builds on the KM concepts outlined by Nancy Dixon in her 2000 book Common Knowledge (ISBN: 0875849040). In that classic text she promotes team discussion and feedback as mechanisms for knowledge transfer  -- which highlighting that a structured process is what helps make it successful. So shouldn't others consider it too?

This idea of transferring knowledge in small groups rings true in patient safety circles as well with the emphasis and interest in debriefs, patient and family-centered rounds, daily huddles, walkarounds and regular team/unit meetings serving as knowledge transfer opportunities in the acute care environment. These communication mechanisms allow for knowledge and information to be shared as needed -- in a context that allows real-time impact of the knowledge and information shared to be acknowledged through action.

In response to my colleague, then, can and should information professionals facilitate and contribute to the use of dialogue as a knowledge sharing activity? Should management and clinician leaders enable that engagement? If so, what is the best marriage of the librarians skill set with the function of dialogue? I recognize that at the sharp end it may be more difficult, but the closer librarians are to the clinical team the more likely it is to happen. Certainly participating in front line information exchange activities from time to time will help inform any dialogue that might result in trying to invigorate evidence, information and knowledge (EIK) services that seek to contribute to improving the reliability of care processes. Also participating in committees, not only from a service perspective but as an EIK strategist will strengthen partnerships and boundary spanning opportunities.

Lastly -- dialogue is a key systems thinking tool. If info pros are to be realized as systems thinkers, shouldn't they be adept and comfortable demonstrating AND explaining the art of dialogue as a tool in THEIR information and knowledge sharing arsenal? I think so.

Monday, December 16, 2013

Listservs: knowledge or info sharing? Effective use helps with both - a holiday jingle


I recently began moderating a new email discussion list. Now -- one  may say they are "old school" but for some communities they still serve a very useful function -- if used appropriately ;-).

In the spirit of the holiday season, the following reminders fell into order to align with the familiar cadence of a traditional Christmas tune. You know how to fill in the blanks. Enjoy! And if you have a group that is in need of gentle reminders .... Feel free to redistribute (attribution is appreciated).

12 ways of listserv etiquette (sung to the tune of the 12 days of Christmas)
© Lorri Zipperer 2013
(thanks to Ruth Ryan and Susan Carr for their editorial comments)

My first day on the listserv, the moderator said to me…
A proof-read reply is preferred

My second day on the listserv, the moderator said to me…
Please sign your name ... 

My third day on the listserv, the moderator said to me…
No “me too’s” ... 

My fourth day on the listserv, the moderator said to me…
This isn’t Twitter! ... 

My fifth day on the listserv, the moderator said to me…
Remove banners from other posts! ... 

My sixth day on the listserv, the moderator said to me…
No published attachments ... 

My seventh day on the listserv, my moderator said to me:
Search archives for answers ... 

My eighth day on the listserv, my moderator said to me:
Change “subject” as needed ... 

My ninth day on the listserv, my moderator said to me:
Always be polite ... 

My tenth day on the listserv, my moderator said to me:
Address as appropriate ... 

My eleventh day on the listserv, my moderator said to me:
Curtail repetition ... 

My twelfth day on the listserv, my moderator said to me:

Talk off-line and recap ... Curtail repetition ... Address as appropriate ... Always be polite ... Change “subject” as needed ...Search archives for answers ... No published attachments ... Remove banners from other posts! ... This isn’t Twitter! ... No “me too’s” ... Please sign your name ... A proof-read reply is preferred.

Happy Holidays!

Wednesday, July 10, 2013

Knowledge gathering important to evidence application in the innovation process

This freely available article illustrates a nice transition of the need for expertise in how Evidence, information and Knowledge play a role in innovating in health care.

Incorporating evidence review into quality improvement: meeting the needs of innovators.
Danz MS, Hempel S, Lim YW, Shanman R, Motala A, Stockdale S, Shekelle P, Rubenstein L.
BMJ Qual Saf. 2013 Jul 5; [Epub ahead of print]
http://qualitysafety.bmj.com/content/early/2013/07/04/bmjqs-2012-001722.full.pdf

It includes some nice pointers for organizing a role for search experts (librarians or otherwise) to play a robust part in the innovation design process. The article highlights information (the sharing repackaged results), evidence review (identifying and qualifying what the science says works) and knowledge gathering (the contextual piece of WHY a proposed intervention MIGHT work in a particular environment and how it might be spread) as important parts of the overall innovation process.

I submit, however, that the suggestions for improvement (pg 7 of the preprint) illustrate the importance of knowledge sharing skills as being a concrete part of the innovation process. To fully capitalize on the information and evidence expertise on the team knowledge has to be infused into the process from the beginning (ie asking the questions about what evidence is needed), translating what is found into information and then applying it in a way that helps the innovation spread to improve care.

Can healthcare in general and patient safety specifically afford to not "rev-up" their efforts by strategically motivating improvement through building the knowledge piece into the innovation process from the 'get go?'

I think not.


Thursday, April 04, 2013

Failing in Order to Succeed. Part 3

Failing is never really fun. Admitting it is even less fun. Although there is a move afoot to see failure as an opportunity to learn, it’s easier said than done. This 3-part article seeks to provide a provocative perspective on how to think about learning from unintentional failure through the use of evidence, information and knowledge (EI&K).

Part 1
Part 2

Failing in order to succeed: Part 3

Reaping the wild wind of failure

By Lorri Zipperer

Lorri Zipperer
Zipperer Project Management
www.zpm1.com
Albuquerque, NM
Copyright 2013

 
The ability for organisations to reap the benefits of this unique skill concentration is, alas unrealized at this time. Librarians and other information experts must understand their organisation’s culture to apply this expertise to enrich its learning from failure. An appreciation of the depth of what really happened rather than taking a more superficial or cursory approach is required for EI&K to genuinely be used to realize system-oriented learning after a stumble.

 
The real loss is when failures replicate: both within the same organisation and amongst those who need to learn from the experiences of others. For example, when failures in medical care occur, an awareness of that incident is thought to help minimize its occurrence elsewhere. “It won’t happen here” mentality, problem denial and ignorance, and “doesn’t apply to me so it’s not useful” approaches can scuttle chances to learn from the misfortune of others. True tragedy can occur. Such blockades can be breeched through effective evidence, information and knowledge sharing.
   

Next actions:

These apply to both organisational and individual “learning from failure” commitments

·       Design time to reflect on what was done well and what could have been improved into processes. If the habit of thinking about and discussing failure as a learning opportunity is hardwired in to projects throughout their lifetime, the tougher ones that result in delay, disruption and disaster will be more effectively and expertly dealt with.

·       Dig deep to get to the second story of failure / avoid blame and look at problems from a systems view

·       Walk the talk: practice at home, at school, at social events. Lots of little failures happen often so they’ll be plenty of opportunities to hone the skills.

·       Review additional reading and discuss what is provocative with others.

 
Additional reading:

Choo CW. Information failures and organisational disasters. Sloan Management review. Spring 2005;8-10.

Edmondson A. Strategies for learning from failure. Harvard Business Review. April 2011;89:48-55.

"Brilliant Mistakes": Finding Opportunity in Failures. Knowledge@Wharton

Zipperer, L. A future in failure? You bet. SLA 365 blog. Dec, 2011

Friday, March 08, 2013

Failing in order to succeed. Part 2:

Failing is never really fun. Admitting it is even less fun. Although there is a move afoot to see failure as an opportunity to learn, it’s easier said than done. This 3-part article seeks to provide a provocative perspective on how to think about learning from unintentional failure through the use of evidence, information and knowledge (EI&K).

Failing in order to succeed. Part 2:

Lorri Zipperer
Zipperer Project Management
www.zpm1.com
Albuquerque, NM
Copyright 2013

Learning and the failure librarian

It should be recognised that leadership is pivotal in ensuring a learning culture is in place. Despite the fact it seems trite to say so, everyone has a role in learning from failure. It isn’t just management’s role. Enabling effective and respectful learning from failure is not a solo gig. In looking at this phenomenon from the team perspective a new role could be envisioned that presents organisations with an opportunity to learn from missteps more successfully: the failure librarian. This role could be applied to support learning from either intentional or unintentional failure. The latter will require a new paradigm for the engagement of librarians in this work.

Librarians are well suited to contribute to learning from failure by:
  • Being appreciative of leaders and administrators and what makes them tick
  • Understanding of organisational boundaries and silos and how to navigate them for knowledge and information identification;
  • Identifying external evidence that could help recognize factors contributing to failure, minimize their impact and inform next steps, and;
  • Distributing external stories of failure organisation-wide to raise awareness of problems plaguing others to proactively flag risk in-house.
The failure librarian has to do more than identify, accumulate and disseminate stuff. They need to get into the muck of the failure experience to understand how EI&K could help transform the situation into a positive experience for their organisations based on trust, transparency and teamwork.

They have the additional qualification and position to understand how poor EI&K can contribute to failure. They are in an excellent position to raise awareness of gaps that others may not see due to the latency of the problems.

The failure librarian will have a heightened understanding of what makes EI&K work reliable. Knowing how to constructively discuss systemic EI&K weaknesses as a risk management tactic can be an invaluable asset. Once the individual sees failure through the prism of their own mistakes they are better able to share that story and avenues for improvement in a sensitive, impactful way. For example:

A staff member with whom a librarian has a good relationship emails her with a search query. At the librarian’s request, the colleague sends her the strategy they used for the work. The librarian looks it over. It’s not bad -- but has some problems that should be addressed for the search to be complete. The librarian does her own work, and shared her results but does not explain to her colleague how he could have done a better search. She assumes the colleague had talked to other peers to get in-house insights and gather knowledge on his project. He is busy and they are friends, so she decides against explaining her search strategy rather than making him look bad.

Two weeks later, while the librarian is out of town, the colleague does another search to support a rapid turnaround proposal for a new client. The requesting client dismissed the proposal upon review of its competitive analysis. The analysis on which it was based was incomplete—despite the fact that the staff involved worked hard on the information and evidence review for the project. Senior staff, who were not involved in the project -- were not interviewed and hence their knowledge was not applied. The company fires her colleague for the misstep.

The problems in this scenario beyond the obvious lack of a complete literature review could include the librarian’s:
  • Failure to provide feedback to her colleague to improve his work.
  • Failure to approach her peer to offer services and get directly involved in the project
  • Assumption that her colleague did not have the time to receive counsel to improve their search process, hence letting the opportunity for staff improvement fall to the wayside.
  • Assumption that her colleague had done knowledge gathering by discussing his project with in-house experts rather than recommending that as part of a standard process for project work.

Part 3 will describe next actions to the concept of the failure librarian to both organisational and individual commitments to learning from stumbles.

Part 1 is available here: