Evolution of a Cluster Board

I would like to share an enlightening experience I had one recent morning on Workplace Rounds with our Primary Care leadership at Burien.

We spent about an hour in good discussion about the state of our clinic as represented graphically on our clinic level (tier 2) data board. These talks are always lively and, though I had initially dreaded them, they always lead to new insights and push our clinic group to improve our processes. I like these rounds.

Discussion continued in our East cluster while viewing our cluster (tier 1) board. It isn't always clear to clinical staff like me just what we're supposed to do with this kind of space. The stuff on the tier 2 boards is all data produced at the clinic level and is hard to adapt to daily flow.

But in clusters we don't really collect data. We see patients, we put them in rooms, talk to them, examine them, do procedures on them, give them medications, make plans, and send them back into the world to do and feel better. But we don't collect data. Or make charts. We're too busy doing work as it arrives, and it arrives fast, like a giant game of Human Tetris that runs non-stop all day.

So we'd been reluctant to wrap our arms around using data to run our day. One morning our team stood at the board, which was plastered with charts about things like performance on colon cancer screening last month. We asked of each chart, "how does this help me do my work today?" If a chart wasn't helpful, we marked it up to make it useful or took it down. It didn't take long before we had nothing on our board.

Better!

But still not helpful in doing today's work, so we made the blank board legitimately blank--and not just empty--by covering the space with white poster paper. We then added a question to the board: "How was your day?" The blank space now seemed a little more hopeful, a canvas instead of a wall. And people wrote about their days:

"I was behind all day and patients were mad at me."

"Great day. Great teamwork."

"Why was it so cold in here all day?"

This board became a place to describe the kinds of things that make days satisfying, great, or times of suffering and regret. It also became a place to stand and talk about those things, to celebrate the good and fix what was broken. And that process kind of helped us focus on doing better work "today," but the days sometimes still got out of control: we got behind, rushed, frustrated, and our patients got to feeling the same way.

So around we came that day on Workplace Rounds, and we talked about the evolution of that board from useless data heap to blank space to a free-speech zone, graffiti-style problem solving space. But still, it wasn't a real time board helping us problem-solve as problems appeared. And a good discussion started with this:

"Well, how do you know how you're doing when you're, say, halfway through the morning?"

"I just know. I know whether I'm okay or in terrible trouble. I feel it. Trouble is sometimes about being late, or a difficult visit I just had, or too much information coming too fast: pages, calls, questions, distractions. Does that make sense?"

"Sure. And if you're in trouble, what do you do then?"

"I usually say, to no one in particular, 'Wow, I'm really in trouble,' and then I put my head down and go back to work. What else can you do?"

"Mmm. Yes. What else can you do?"

"I...I don't know. I don't really know how the board can help with that."

And it sort of ended like that. No real idea of an answer, but my brain wouldn't let go of the question. It felt like the awkward stage of learning something in which you think you might be near a breakthrough, or you might just as easily be deluding yourself and will never figure out what the heck you're supposed to do.

Later that day our team talked and shared ideas about what a real time board might look like, one that helps you when the wheels fly off and you don't know what to do but curse and keep driving on screeching rims. We settled on a simple experiment with two pieces of paper: one red, one green.

Here it is. We've posted four laminated cards made from contstruction paper I took from my kids. Each care team (dyad) has one, marked by a letter, posted where they're visible to everyone, often. If things are going well, you show the green side. If things start falling apart, you flip it to red. There's no clear definition of when you go to red. You call that on your own: could be about time, could be about workload, anything.

When you need help, you go red.

Amazingly, this simple agreement to use a visible symbol to represent if things are okay or not goes a long way to making things okay more often. On the occasions when things aren't going smoothly, I flip to red, people see, and we can quickly talk about ways to get things back on track. We look for a catch up spot in the schedule, start a workup before I see the patient, call in flow staff backup, or shift a patient to another provider with an open appointment to prevent patients waiting too long. We improvise. Sometimes there's no great answer and the solution is just to let patients know things are behind, and this seems to be appreciated.

Overall, the experiment seems successful. It helps bring a healthy perspective to what's happening right now: Are we we doing what we've planned to do, and if not, how can we get back on track?

I still don't think I totally get how I might use the cluster board to help me with my day as I move from room to office to room, doing work, Tetris-style, and trying to keep myself in the flow, giving patients the care and the time they deserve. If I had a tool to do that--respectful of workflow, time, and patient needs--I'd use it.

And if I find it, I'll tell you.