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Post by Melinda Ashton, MD
Chief Quality Officer Hawai’i Pacific Health

Addressing inefficiencies

The ABIM Foundation paired frontline physicians and leading experts to discuss building trust in health care.

Christine Sinsky, a physician and AMA official, and Melinda Ashton, a physician, and chief quality officer, focused on efforts to build trust by eliminating inefficiencies.

Narrator: The ABIM Foundation paired frontline physicians and leading experts to discuss building trust in healthcare. Christine Sinsky, a physician and AMA official and Melinda Ashton, a physician and chief quality officer, focused on efforts to build trust by eliminating inefficiencies.

Christine Sinsky: Well, hi Melinda. I am so thrilled to meet you. I’m Chris Sinsky. I’m a general internist. I also work at the American Medical Association as vice president of Joy in Medicine.

Melinda Ashton: Chris, it’s so nice to meet you. I’ve been looking forward to this. I’m Melinda Ashton. I’m the chief quality officer at Hawaii Pacific Health and also a pediatrician.

Christine Sinsky: Great. Great. Well, I first learned about you in your New England Journal article and the work that you’ve been doing about getting rid of stupid stuff and I wonder if you can tell me a little bit more about what you did and why.

Melinda Ashton: Yeah. It’s a funny story really. I had seen over the years that there were the occasional documentation thing in the chart when I was reviewing a chart where I was pretty sure that whatever was being documented wasn’t actually really accurate to what occurred. And then we bumped into a couple of more worrisome areas where we had clearly allowed to be created in our EHR documentation requirements that just were plain stupid. And so we talked to our—I’m a member of the executive team, we talked to the rest of the executive team and said, maybe we should do something about this. We’ve stumbled on these. I wonder what else is out there. And we decided that we would create this program at our place where we just invited anybody who was, you know, using the EHR in any way to tell us what was just plain stupid. None of that was intentional, of course. We sort of started off by saying stupid is in the eye of the beholder here, you know, what we now are saying is stupid was well intentioned when it was started. And we’ve been really pleased and surprised by the amount of interest and involvement from our staff and outside of our hospital as well. Health system are it.

Christine Sinsky: Well, one of my favorite examples was a nurse had mentioned that she thought it was odd that she was having to document the status of at the umbilical cord in the teenager.

Melinda Ashton: Yes.

Christine Sinsky: And perhaps you can tell me more about that.

Melinda Ashton: Yeah, that was one of the very early nominations as we call them. And we were just beside ourselves. I mean it was hard to believe that we had had this particular documentation requirement in our EHR for patients in the pediatric hospital that we have for at least ten years. And this was the first time that we heard from a nurse that she really would hope that we would take away the need to document that the cord was absent in the patients that she cared for, which were adolescent and oncology patients, almost never newborns. All that was was a simple failure to put in the age restriction that was intended when we built the EHR. And it was just mind boggling that for year after year, patient after patient, a nurse who was actually very strong advocate of her patients hadn’t spoken up for her own behalf to say, please make this go away. And as soon as she did, we made it go away.

Christine Sinsky: But you had a process, right?

Melinda Ashton: Right.

Christine Sinsky: I’ve been through two different EHR implementations, actually three, if you count our hospital implementation, and I and others filled out many forms for suggestions for enhancements or improvements or getting—we didn’t have that term—getting rid of stupid stuff. But after a while, you learned that that was a futile exercise and yet there’s something different in what you did that made it not a futile exercise.

Melinda Ashton: I think that is one of the things that we’ve heard that has made it a bit different than others. Now, we are well past implementation, we implemented our EHR back in the 2004 to 2010 time range. So it’s been a long time. At that time, we had our IT staff got really good at building because they built four separate hospital implementations, each one a bit different. They got very good at that. So over the ensuing time, what happened was, they were really good at responding to requests for improvement. And now, what we found is some of those improvements actually have turned out to be, you know, unintendedly bad. At the same time, the EHR, any EHR is so complex that any implementation, I think, is likely to miss some of these little things. And so we found a few of those. Not as many as perhaps we thought we might, but those are the fun ones. Those are the ones that you just sort of shake your head and say, how could that possibly be true? But those have been there, just some, but many of them have been things that, you know, a group of folks thought was a really good idea to do something. And then, you know, years later, you look at it and you think, oh, that was, that did not work out as intended. That was kind of stupid. It results in a lot of road work by nurses, by therapists, by staff, like just pulls into their time for talking to their patients, relating to one another, doing the work they really should be doing.

Christine Sinsky: You know, we’re here at this conference around trust and I’m thinking about my own experience when I and other physicians did raise examples of things that could be eliminated, could be changed, ways to make the usage faster, quicker, more efficient, and almost feeling as if there was a social cost to be paid for those who raise those objections. And yet I’m understanding what you did as having been a source of building trust among the physicians and among the other clinicians. And I wonder, am I right on that?

Melinda Ashton: Yeah, I think you are. I mean, I can’t tell you how many nice emails I’ve had from people that rarely say nice things. And so I think that, and we’ve heard a little bit of a hey, I said something, and you changed it kind of a building of trust, I guess. In that term, the difference I think is first of all, we had executive sponsorship of this. This was something that our CEO on down really bought into. Our CEO, for example, found one of his own examples of something that was completely stupid that have been going on for years and years that he was willing to go out and talk about.

And so that was helpful. We had a couple of really good examples to start us off. I think that was helpful. And then our partnership with the IT was critical, and we already had an infrastructure. We had work groups that were specialty specific or discipline specific that were ready and in place and doing this kind of work. And they were able to then take those practice requests and actually implement them, actually—well, evaluate them. First of all, we don’t do things just because one person asks for it. We make sure that it’s not going to be another stupid something that we built. And so, but those work groups are really helpful in terms of doing the evaluation and then actually, you know, making sure that the build happens then that it gets done in a timely way and so forth. And we stay in touch with the people that make the recommendation to us as well.

Christine Sinsky: I would think there needs to be a fairly lead deep level of trust between IT and the physician leadership because they’re the ones who are probably going to feel the most judged.

Melinda Ashton: Yes.

Christine Sinsky: Or the most threatened by this. We built it this way, just live with it, or something along those lines. So how did that happen that they were not overly defensive?

Melinda Ashton: That’s actually a really interesting set of thoughts because when we were first known to be working on this, getting rid of stupid stuff, our CIO got a number of emails from friends and colleagues around the country all saying, what are you thinking? And he sort of chuckled and his response, at least internally, he was sort of saying, well I just say back to them, do you have that much stupid stuff that you’re worried about? But the real truth is that we’ve built the IT clinical relationship over years, and they are very much our partners. They really understand that their role is to help us provide really good clinical care. And I think that’s a little different than perhaps in other organizations. Now, I should say that years and years and years ago, when I first started to try to interact with it, I was told by the same CIO that he told every one of his people first answer to any question is no.

Christine Sinsky: Yes.

Melinda Ashton: And then you think about it, we changed that thinking.

Christine Sinsky: I think you’ve really hit on something there. As I was thinking about your initiative, getting rid of stupid stuff and trust, I was thinking about how as a physician, I, early on in my career, absolutely implicitly trusted my leaders to help me take good care of patients. And then the EHR was instituted and it made it really much harder for me to take care of patients in some regards, in other regards, that made it easier. But I felt like there was so much pressure and that trust was broken because I no longer trusted that the leaders were actually there to help me take better care of patients. The message became implement the EHR and don’t complain and stay quiet. And you may have started, that sounds like, with a little bit of that attitude, but that evolved and I’m guessing they’re getting rid of stupid stuff helped that, helped others trust that that had evolved.

Melinda Ashton: I think so. I think being able to go out there and say that we are gonna work on getting rid of stupid stuff, which by itself is a little bit in your face.

Christine Sinsky: Yes.

Melinda Ashton: That was helpful. And that message and actually, the article in the New England Journal of course gave it a bit more credibility as well. But I think all of that plus the fact that we were able to make the changes that were being requested. We really sincerely wanted to know what, what we had created that wasn’t helpful. And I think it is absolutely true that it’s the leadership’s role to set the environment. You know, the individual clinicians can’t change that by themselves. It’s only leadership that can, and leadership can’t do it if they don’t know what’s needed. So we need that partnership there.

Christine Sinsky: I’m curious about the name.

Melinda Ashton: Yes.

Christine Sinsky: I love the name. And I think if you just had a comment box and ask people to put in comments, you probably wouldn’t have gotten as much engagement.

Melinda Ashton: Right, right.

Christine Sinsky: But I’ve also heard a little bit of pushback about stupid.

Melinda Ashton: I agree.

Christine Sinsky: And yet I think if you didn’t have stupid, it wouldn’t have worked. That stupid just resonates with us and know that’s what spending, what’s taking up so much time.

Melinda Ashton: It does. We actually had some serious conversation at the executive team level about whether we were going to call it stupid. And at first, it was, you know, I just, when I was presenting the examples that we don’t covered, I basically throw up my hands and said, this is just plain stupid. And then we talked about we would have a program for administrative simplification, and I think the system goal actually had that terminology in it, but then we looked at each other and we said, no, we need to go out there and tell people this is, we really want to get rid of this stuff that’s totally stupid.

Christine Sinsky: In fact, I think by saying getting rid of stupid stuff, you actually engender trust because you were able to tell it like it was.

Melinda Ashton: Right.

Christine Sinsky: Right. You weren’t sugarcoating it. You weren’t saying it’s optimization. We really weren’t wrong at the beginning, you know, we’re just optimizing. No, we’re saying, you know, there’s a lot of stupid stuff here. To me, that just resonated so clearly.

Melinda Ashton: It was interesting as I went out to present this as a new program to our managers, directors’ meetings, across the system. We have four hospitals, four of those meetings Plus one at the system level. Every time I put the title up and started to talk about it, the room—there was just a ripple of kind of sheepish laughter that went through the room each time. And I had one of the people that reports to me tell me that if I hadn’t been up there standing them telling them that that’s what we were truly thinking about doing, that somehow it wouldn’t have been as trusted, I guess.

Christine Sinsky: I would say there’s a leader who understands something about my life if I heard you speaking that. I want to tell you, I had the chance to visit another organization, another academic medical center or unacademic medical center, and they had just called someone from your department and were reinstated. They were going to replay that initiative or copy that initiative and they were really enthused about it. They had gotten, I believe, 450 suggestions in the first three weeks.

Melinda Ashton: Wow. That’s great.

Christine Sinsky: Yes.

Melinda Ashton: I just love the fact that other people have decided there’s something here that they want to kind of replicate or I’d love to see it just ripple. I think it’s great.

Christine Sinsky: Yes. And I want to thank you because you’re helping us make that ripple. You’re helping us write a toolkit online at the American Medical Association on getting rid of stupid stuff so others can be inspired.

Melinda Ashton: We’re happy to talk to anybody and help anybody do this. I think it’s so exciting that others want to do it.

Christine Sinsky: I think we learn by example, and you’ve just given us a great example.

Melinda Ashton: That’s good.

Christine Sinsky: So I’m really pleased that you’ve made the trek all the way from Hawaii to come and share what you’ve learned with the larger organization, the larger group here at the forum.

Melinda Ashton: And I’m really pleased that I was invited to come in and do that. I’m absolutely excited to be part of this.

Christine Sinsky: Great. Well, thanks. I think you started a movement.

Melinda Ashton: Thank you.

Narrator: Visit buildingtrust.org to learn more.