In this video, Dr. Chescheir says:
So early on we got some OIs that related to things like work environment – there weren’t enough chairs in the Labor and Delivery unit, the shower curtain in the call room wasn’t hitting the floor so water was getting all over the floor, those sorts of things.
As those Opportunities for Improvement got acted on and people could see that there were changes, they began to put in more and more important kind of Opportunities for Improvement. And it’s interesting; over the last year and half or so that we’ve been doing this now we’ve had over 120 OIs that have been completed and worked on, and these really range from sort of banal and simple to much more complex things.
For example, we had a very difficult delivery a while ago in that at one point the patient had to have a hysterectomy in the middle of having a caesarian section. Following such a hysterectomy the common practice is to do a cystoscopy in which one looks into the bladder to make sure the ureters and the bladder have not been injured. The resident who did that case afterwards was quite frustrated because the cysto tower didn’t work properly, and promptly put in an OI saying “Look, this is really important; these things happen with, unfortunately, some regularity and we need the equipment working.”
The Labor and Delivery team that went about trying to figure out what had happened to it found that the cysto tower was indeed working, but that there was a user error. And it was really gratifying that the resident who put this in and the team that was involved with that particular case didn’t get defensive about that.
The learning that happened because of this OI was really important one. Number one, it made the teams all look at how the tower is actually supposed to work, and it reinforced trust between the nursing team and the physician team to be able to say “This was not an equipment problem. It was a user problem.”
I think this is a real tribute to KaiNexus as well as other efforts that we’re putting forth at UNC to develop a culture of quality and improvement. People now increasingly feel like when they have something that they want to suggest, that it will be heard.