What is "exnovation" and where does it fit in with hospitals that are striving to become High Reliability Organizations (HROs)? In this article, we speak to Bruce Spurlock, MD, President, and CEO of Convergence Health, to explore this term and its importance in hospital quality improvement. Also, find out what he likes best about working in quality improvement, what is behind the numbers, and upcoming challenges for hospitals in their HRO journey.
Q. Can you tell us a little about how you got involved in working with health care organizations to improve patient care?
A. Back in the late nineties, clinicians had this crazy idea that there was a difference between patient satisfaction and patient experience. In California, we used a patient experience survey in hospitals that was our first sort of foray into the idea that quality is broader than what we thought about previously. We believed then that a patient's experience helps to understand quality through the eyes of the patient.
Secondly, through the work that we had done in California and other places, I got connected with the staff at Stanford University. After the U.S. Institute of Medicine (IOM) report, To Error is Human, came out, we worked on the topic of patient safety culture. It was exciting to think that maybe we could make a difference and improve things if we tried to improve quality on a large scale.
Q. What do you like best about working in quality improvement (QI)?
A. I think there are two exciting parts to working in QI. First, watching frontline and QI staff “get it,” when the lightbulb goes on in their minds and they discover, see change, and experience improvement - that discovery process is exhilarating. I equate it to what teachers witness when their students experience a lightbulb moment - they suddenly understand a concept being taught to them. That's fun to watch.
Secondly, having objective evidence that we’ve made a difference. When you see measures and results improve, knowing what that means to the lives of people – the numbers represent actual patients and families.
Q. What do you think are the biggest quality improvement challenges hospitals will face in the next five years?
A. Some of the same challenges hospitals have now, they'll be having in five years. But the new challenges, the things that might be different are both exciting and scary.
First, is the opportunity that we might be able to get our arms around real-time data to drive quality improvement efforts. The use of real-time data will bring new challenges in terms of figuring out how to use the data and how to use it correctly. It is also going to probably be one of the biggest opportunities to be able to make the kinds of strides we would like to see in quality improvement. Anytime you do an intervention, or you do any kind of activity in quality improvement, the longer you have to wait for the results of that intervention, the harder it is to see the linkage between the intervention and the outcome.
There was a decision-making model in the fifties, developed by a fighter pilot and military strategist, John Boyd, called the observe, orient, decide, and act (OODA) loop. The OODA loop is a four-step approach to decision-making that focuses on filtering information, putting it into context, and quickly making the most appropriate decision. It was determined that pilots who processed the OODA loop more quickly would win more battles.
In health care, our OODA loops are often broken. A good example is hand hygiene. We don't know that hand hygiene is tied to an infection because the infection usually happens days or weeks later. Not getting immediate feedback on the impact of following/not following hand hygiene best practices creates a break in the OODA loop. Add to this the 1–3-month data lag from infection reports makes improvement harder. Being able to provide feedback closer to the time a quality improvement intervention is implemented will offer both exciting opportunities and new challenges.
Second, everybody talks about artificial Intelligence (AI). I teach a QI course and ask participants, “Who is excited about AI?” Half of my students put their hand up in the air. Then I ask, “Who's nervous about it?” And the other half of my students raise their hand. It's one of those things that is going to present both an opportunity and a challenge.
Physicians and nurses are burned out from medical documentation. They dislike electronic health records (EHRs); however, AI might be helpful. Some physicians are practicing with AI in their clinic notes. The notes are not 100 percent accurate, but they're getting better and better. So, if there's a way to make life easier, that might be a positive outcome. A negative outcome is when we use AI and get biases that don't tell us the right answer for the right patients. So, there are opportunities and challenges ahead.
Q. Can you tell us more about exnovation and how it aligns with High Reliability Organizations (HRO) principles?
A. Let’s start with what is exnovation. I first saw the term “exnovation” when I was reading a New England Journal article. It is an interesting term - it's an engineering term developed by an engineer in the eighties. He said, every intervention, every innovation, every practice, every new device goes through a lifecycle. In the beginning, it's an innovation; it's new; it's different; it adds value; it makes things simpler or easier and more effective. Over time it starts wearing out, and other things start replacing it as being more effective.
What we need to do is we need to exnovate or “take out” what were previous innovations and put in a new innovation. After I read the article, I looked at those words and thought, “That's what I do every single day. That is what QI is.” QI is taking out the old practices and putting in new practices and new ways of organizing health care that are more effective and better. And people don't like it that much when you take some of those things away because they've held onto those practices often for years.
I started talking to people about it and it was ironic. Two people I spoke to about exnovation referenced The Life-Changing Magic of Tidying Up by Marie Kondo. Kondo says that if you reduce, shrink, simplify, and take out stuff, your life gets better for it. That is exnovation.
Is enovation easy? When we put new innovations in, it's easier. It's tough to exnovate when you don't have anything new to put in a process.
A good example is the Choosing Wisely Campaign that began in 2012 with nine national specialty societies (representing 375,000 clinicians) offering 45 examples of tests or treatments that were commonly used in their fields but lacked strong supporting evidence. Therefore, clinicians didn’t need to do them very often. It's been modestly successful because it's exnovating a practice without putting in a replacement innovation.
This taught me a lot. Hardcore exnovation is taking out these things that clinicians have done for years when you don’t offer something to replace the old practice. Examples include antibiotics for bronchitis and sinusitis, x-rays for back pain and chest x-rays for everybody in the intensive care unit. All the practices physicians got trained in, they would be asked to stop doing them. Then physicians asked themselves, “Well what do we do?” We just stopped doing them. So exnovation can be difficult as well as necessary. That's a lot of what quality improvement is.
Q. Can innovation and exnovation both play a role in a hospital’s journey to being an HRO? If so, how?
A. Innovation and exnovation are byproducts of the HRO process. A good example is looking at what’s called “abusive resilience” which represents how organizations inappropriately depend on people to be resilient. At their core, organizations and people are hugely resilient – they find workarounds to solve problems all the time.
For example, a nurse needs to warm a patient up before surgery because we know that reduces infections. The nurse goes to the closet to get a blanket but there aren’t any blankets in the closet. So, the nurse goes to the next unit and steals a blanket. This is a work-around, or we can also call it resilience. However, this is an abusive form of resilience because the workaround doesn’t help the system get any better. Ultimately, the nurse knows that the system is broken.
HROs have incredible communication mechanisms to say, “I had a breakdown today because there were no blankets in the closet, what is going on?” This question allows people to solve the problem on a real-time basis. If exnovation was applied, a step would be taken out of the process and an innovation would be added - such as a counting system that would allow for blankets placed in the closet to be counted before use.
Q. How can HQICs continue to support hospitals on their HRO journey?
HQICs are good at sharing with hospitals what other organizations are doing well as HROs and sharing that practice. This can motivate hospitals to want to utilize HRO as they see and hear of others being successful.
This material was prepared by The Bizzell Group (Bizzell), the Data Validation and Administrative (DVA) contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. 12SOW/Bizzell/DVA-1311-03/13/24