Wednesday, August 26, 2015

Intros to KM concepts from the NHS. Bravo and let's keep going!

Anne Gray, Knowledge Officer at the NHS shared this set of videos recently that I'd like to share here: In her words: the goal was to "encourage people to consider the importance of KM improve quality of care, outcomes and patient experience." They are worth a look:

Of course I see things that could be tweaked...but I embrace these as nice tools to introduce the concepts associated with KM to a wide range of individuals. There are many professions/services that can contribute to effective knowledge sharing in healthcare--none of which are explicitly called out--so I don't think librarians, clinicians, informaticians or patients should feel left out here. We all have knowledge to share, so let's not quibble and get defensive if our roles or professions aren't called out.

I have a challenge for the NHS thou. I am interested in how they are going to use these to help healthcare understand how to:

1) measure the impact of true KM in the healthcare environment.
2) support and implement a knowledge sharing culture and how it concretely contributes to safe care
3) truly articulate the costs involved in changing culture to support true knowledge sharing
4) implement strategies to create accountability for both organizations and individuals that work in healthcare to share what they know
5) identify KM barriers and work through them in the same fashion that healthcare approaches patient safety improvement barriers. If we can present lack of knowledge sharing as a contributor to unsafe care--can support for improvements be articulated in a way that generates support and interest in sustainable change?

To those who might feel they already do this so why do we need to focus energy on KM -- respectfully, it doesn't move innovation forward for any of us to say--we already do this, we do it well -- even thou we might. If we can't articulate it, measure it and improve it the case hasn't been effectively made.

What stories are out there that translate what is being done concretely to manage and share knowledge (not data, not info and not evidence) as a component of safe, highly reliable care? Do tell, please, DO TELL! Don't keep that knowledge under a bushel! 

Friday, July 24, 2015

Expert Insights for Info Pros to "Ratchet it up" for Patient Safety

The following commentary was originally published earlier this year as a part of the "Whoo Says" article series on the NNLM/MidContinental Region web site

While the comments are closed on the original, they are open here. Please share your thoughts!


Dear Whooo,

I am a hospital librarian who is very interested in keeping my library active and relevant to the needs of my hospital. Lately, I have been considering the issue of patient safety; my thoughts were triggered by hospital activities during this year’s Patient Safety Awareness Week, and Barb Jones’ call for feedback from librarians involved in patient safety initiatives. I thought about the work I do with various units and professions within my hospital, and how the overall goal is the safety and good health of our patients. I wonder if there is something I am overlooking, or missing in the patient safety discussion. I do lots of searches for quality improvement, protocols, and individual treatment. Is there more?  Wondering

Dear Wondering,

Thank you so much for writing, Wondering. I am glad to see that you are involved with a variety of units within your hospital and are considering the issue of patient safety as well as addressing specific inquiries that involve patient safety problems.

Since you have been observing the priorities of your hospital, you are probably aware of the emphasis on high reliability. Weick and Sutcliffe have written about how high reliability organizations function and stay safe. Their description of a HRO (high-reliability organization) is “an environment of ‘collective mindfulness’ in which all workers look for, and report, small problems or unsafe conditions before they pose a substantial risk to the organization and when they are easy to fix.”1 This description generally does not describe the conditions found in healthcare. “…in health care, uncoordinated and poorly designed and maintained mechanical systems (like medical device alarms) are tolerated, even though they are not safe. Intimidating behaviors suppress reporting and lead to additional unsafe behaviors as caregivers create workarounds to avoid repetitive exposure to intimidators. Errors are not seen as valuable information, essential to a hospital’s ability to improve patient safety.”2 Thus, I think you will agree that the current emphasis on high reliability is justified, and time spent on high reliability is time well spent.

I think all of us who work in hospitals can point out the validity of these statements. We see issues on nursing units, in the emergency department, in the hierarchy that occurs among the healthcare personnel, and in many other places. The question for us, Wondering, is whether we see any of these issues in the library or in library services provided. Every health sciences librarian I know truly believes that services provided by librarians lead to a higher quality of care. These librarians are conscientious, well-educated, and highly skilled professionals. However, they are all people and are subject to the same errors and lapses in judgment as members of any other profession.3

So, the answer to your question is yes, there is more. As conscientious professionals, librarians need to be sure to examine their own practices for small mistakes, workarounds, and potential for error. We need to be unafraid to find and admit our errors, and be willing to use those errors to learn how to perform in a highly reliable way. We need to examine our systems within the context of the larger hospital system to identify where the evidence/information we provide intersects with others, and ensure that intersection is fully functional. This is a continual effort; it cannot be addressed once and then put aside with the conviction that all is well.

All of this is pretty theoretical and abstract. To bring it down to the practical level, here are some examples of areas that librarians should address in the daily practice of their profession.

Peer review of searches: Do you ever have another librarian or information seeker review your search strategy and evaluate its effectiveness? Obviously, this is not practical for every search, and is difficult if you are a solo librarian. Maybe you can find someone in another hospital and ask your colleague to review your strategy for a difficult search or at a predetermined interval. You can offer to reciprocate which will ensure that both of you will benefit.

Complete the communication loop: When you perform a search for a user and deliver the results, do you attempt to close the communication loop and find out if your search was useful, and if so, why? All of the librarians I know have drawers full of compliments from users stating how wonderful the librarian’s service was. Few of those compliments state why the service was so useful. It is impossible to learn and improve without the knowledge of what is expected and what works.

Clarity in reference interview: Once you have received a search request, and you find when searching that you are not really clear about the specific need of the user, are you able to contact that person for clarification? Often complex topics require some dialogue to identify the precise need.

Completeness of database selection: When you are conducting a search, are you open to searching in multiple databases? What about the gray literature? What about in other disciplines? Medicine and healthcare are highly complex fields, and often the required “answer” is found in sources other than traditional medical sources. For instance, information on the reliability of medical equipment may be found in the engineering literature.

These are only a few of the ways librarians need to examine their processes and work to uncover error. For a more complete discussion of this topic, you may want to read the chapter “Analyzing Breakdowns in the EIK Pathway”4 in the recent text Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer edited by Lorri Zipperer in 2014.

Thank you again for your question, Wondering. This is an issue that I care about very deeply, and I think that our profession should consider it seriously. I hope this has been helpful. Please write again if you have further questions.



Jones B. Patient Safety: Librarians have nothing to do with that, right? April 2015. Plaines to Peaks Post.

Weick K, Sutcliffe K. 2007. Managing the Unexpected: Resilient Performance in an Age of Uncertainty. San Francisco, CA: Jossey Bass.

Chassin MR, Loeb JM. High-reliability health care: getting there from here.
Milbank Q. 2013;91:459-490. p. 462-3.

Tavris, Carol. Mistakes Were Made (But Not by Me): Why We Justify Foolish Beliefs, Bad Decisions, and Hurtful Acts. Harcourt, Inc. 2008.

Jones BB, Graber M and Alligood, E. “Analyzing Breakdowns in the EIK Pathway” in Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer. L. Zipperer, ed. Gower. 2014.

This story was originally published in the Vol 13 No 4 - April 2015 issue of the Plains to Peaks Post. It is used here with permission by the author. The Plains to Peaks Post is published quarterly by the National Network of Libraries of Medicine NNLM/MidContinental Region.

Thursday, May 21, 2015

What are the top three skills needed to drive knowledge sharing in healthcare today?

Always interesting to hear from colleagues on these types of questions. Is knowledge management in healthcare "old news" for hospitals? I heard that indirectly from a librarian at a recent conference. Maybe -- but I guess it depends on how you define KM. If we look at knowledge as what the "knower knows" (Prusak and Davenport, 1999) and place its management in the sphere of safety science, high reliability and systems thinking -- I am not so convinced it is old news. Either way, what would you say are the primary skills to help make knowledge (not evidence, not info, not data) more usable, accessible and reliable as a resource to support high quality safe patient care?

Friday, March 13, 2015

Evidence seeking and checklists: does it make sense?

Atul Gawande's The Checklist Manefesto placed the use of checklists as failure prevention mechanisms in the laps of health care professionals and management worldwide, Since the book came out in 2009, checklists have now been planted in the minds of many in healthcare as tools to improve patient safety that typically wouldn't have considered them. 

Take librarians, for example. "My work is too messy", they say, "to use a checklist."

I would submit that most of the functions that librarians deliver in the course of their work in hospitals are NOT complex -- but the world they function in is. (I would love to have that discussion with my peers in this forum -- if they are game. But I digress ... ). This isn't and shouldn't be taken as a insult--and I apologize up front if its received in that light. The notion of when a tool like a checklist is needed and **should** be used is an important question--and determining the type of process its being applied to is important. It certainly isn't useful to pile more paperwork and process into the daily work of anyone - especially if it doesn't really improve anything--or to do so for a process that is complex vs complicated. or even simple, for that matter.

For sake of discussion, I do think there may be applicability of a checklist in some areas of the clinical librarian / Informationist domain, such as in the reference review process. For instance, gaps that happen due to communication failures, cognitive biases and production pressures should cause us to think about ways to make the reference interview process more reliable via structured communication tools and/or a checklist. Especially in an emergent situation.

I do also wonder if the checklist idea would be useful in an organizational.system sense. Let's face it: librarians aren't the only ones doing lit reviews in hospitals and, as demonstrated by the gaps in the lit review process at Hopkins that contributed to the research volunteer death some years back that are discussed here, we know it can result in failure if not completed effectively. Perhaps a tool that would enable more reliable searching no matter **who** does the work, would have multidisciplinary impact.

One example of a review tool that may serve as the model for a checklist to help examine the robustness and reliability of the search activities at the sharp end is the CADTH Peer Review Checklist for Search Strategies.

I would say IRB activity, systematic review support and similar "project and task flow" examples of evidence and information seeking may be "complicated" (ie "building the space shuttle") rather than "complex" (ie performing surgery, raising children) If we consider complexity theory in all of this, the CADTH tool (complicated task review) would probably benefit from the application of "local context" to help us all understand how to apply it in real time to shore up the effectiveness of search that frontline info seekers--librarians or others--undertake to inform info seeking actions that take place in a more complex context--in the midst of clinical decision making. 

Its important for librarians, and the clinicians that require the best evidence/information to do their work in complex situations, to explore how such a checklist could be enabled to affect patient safety in this intersection of professions. Can we draw from existing safety tools and processes in other high-risk domains such as aviation and nuclear power plants-- to help enlighten a discussion around how the information/evidence identification, acquisition and dissemination process in hospitals can be made more "highly reliable" through the use of checklists?

Wednesday, February 18, 2015

The value of sharing stories ... a request to hear some!

What Flavor Lifesaver are you?
Barb Jones
(used with permission: )

As a health sciences librarian, your work buoys the diagnosis and treatment of many people in many different ways. What activities do you do that contribute to the safety of the patients treated in your hospital? Which of the following lifesavers apply to you?

Orange – You are on the team that develops protocols for the various units in your hospital.

Lime – You have worked with your nursing staff and your hospital has achieved Magnet status.

Pineapple – You often work with the Quality Improvement team.

Cherry – You attend the M & M meetings.

Grape – You are a clinical librarian.

There are several other lifesaver flavors, and many other library-related activities that contribute to the safety of hospital patients. Can you think of others that you are involved with? What flavor are YOU?

Share your contributions with your colleagues! Contact Barb Jones (jonesbarb or @BarbJones17) to tell your story. Or comment right here on this blog!

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: 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:

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:

There is one on DxError:
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.

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: )-- that also provides some thinking about search in patient safety:

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

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.