SQUIRE Blogs
More about the Balancing Act
Susan Mooney
Time
The hardest part is finding the time to sit and look at the data and think. As I try to balance my clinical, administrative and academic responsibilities (not to mention my personal life), I sometimes feel as though I am shoveling waves at the beach. Take today for example. I got out of the OR at 10:30 with the best of intentions to come back to my office and work on this paper. Now it is past noon, the phone has not rung in 5 minutes and no one is standing in my doorway wanting to talk. So, here I sit, an hour and a half behind schedule, trying to write something worth reading.
Balance
It is a challenge to balance my time. It is an even greater challenge to balance the worlds that I inhabit. Having graduated from the VA National Quality Scholars Fellowship and having obtained a Master's Degree from Dartmouth, and working for the SQUIRE project, I appreciate the necesity of bringing some academic rigor to my improvement work. But I work at a very small, rural, community hospital. Many folks here are bright and talented and dedicated to their jobs. And they are far removed from the academic world. Few have any formal training in Quality Improvement. Many have never taken a statistics class. Everyday I struggle with this. When I do an improvement project, do I need to use statistical process control? Or can I be less rigorous? How do I talk about sample size and ANOM analysis without alienating everyone in the room? How do I celebrate someone's success even when I know that the "improvement" they are talking about is really only common cause variation? Balancing between an academic and a non-academic world keeps me intellectually engaged and grounded in the real world. I don't want to be anywhere else. But sometimes I do feel as though I am perched on a very narrow balancing beam.
The Project
It seems simple - all pregnant women should have a urine culture performed during the first trimester as part of routine prenatal care. The thing that interests me the most about improvement work is that the things that seem so simple are so hard to pull off. The local problem (as the guidelines like to call it) that I have been working on is this: Two years ago, while working on my Master's degree, I discovered that not all women who get their prenatal care at APD, get first trimester urine cultures. Interestingly, they do reliably get other recommended care (like a blood type and Rh test). I actually had several goals for this project and, not surprisingly, they have evolved over time. Initially, I set out to pilot test a data gathering methodology that was part of a larger QI project. Once I discovered the aforementioned gap, I set out to try to close it which necesitated that I understand why it existed in the first place. Now I am trying to understand why half the practice got better while the other half did not...And I am trying to figure out what to do about the half that has shown no improvment. Lots to think about, and write about, if I can find the time.
Comments
By Frank Davidoff on 2009.05.27
Two things that might help here:
1) Balance
In thinking about how to keep from falling off your narrow balance beam, it might help to read the article by Leif Solberg et al called “The three faces of performance measurement: improvement, accountability, and research. Journal on Quality Improvement [this was the precursor to the Joint Commission Journal on Quality and Safety], 1997;23:135-47 - if you don’t already know it. As the title implies, it makes the point that the way you go about measuring depends on what you’re using the information for. It gets into the specifics of measuring for the three different purposes. (Interestingly, it uses the management of UTIs as one of its main examples.)
2) Time
Finding the time (and the enthusiasm) to write is a universal problem. There’s no easy solution, but there are a couple of books on the subject that might be helpful (if you have the time to read them! - but they’re not long, and they’re easy to read). They’re both by Joan Bolker, a writing coach in the Boston area. One is titled “Writing Your Dissertation in Fifteen Minutes a Day.” Even though it’s directed primarily at people writing doctoral dissertations there’s a lot of useful information in it about writing in general. The other is “The Writer’s Home Companion,” a collection of writings about writing by a lot of terrific writers, e.g., Ursula LeGuin, Anne Tyler, Bernard Shaw, etc. Both of them are published by Owl Books.