QI Lessons about Commitment from the Frontlines
Learning from Every PatientA Newsletter for Frontline Healthcare Team Members and Quality Improvement ProfessionalsLife in the trenches. Real cases. Practical improvements. Stronger voices at the bedside.
Answer the Trivia Question for a Chance to Win a $100 Gift Card!Read to the bottom to find the trivia question and instructions. We will draw the winner's name on the first day of next quarter. The answer and lucky winner will be shared by email and announced in the following Newsletter! What is Missing from Healthcare Quality Improvement Initiatives?BLUF: We can include all the right stakeholders, measure all the right things, and use all the right tools at the right time — and still not make a difference. We need something more than tools… maybe a guiding strategic operating system for reliable application of improvement science. Execution is not a word I use lightly — especially when referring to what we do for patients to improve their well-being. In a recent LinkedIn survey conducted by Dr. Jeffrey Glasheen, Director of IHQSE at UCHealth, respondents reported that only 6–15% of their institutional QI initiatives were successful, with sustained improvement beyond five years. Personally, I think that’s generous. What’s missing is the reliable — yet flexible — execution of a foundational strategic operating system, buoyed by continuous, internally motivated personal leadership development. We’ve been told what tools to use — PDSA (Plan-Do-Study-Act) for rapid testing, FMEA (Failure Mode and Effects Analysis) for risk identification, DMAIC (Define-Measure-Analyze-Improve-Control) for structured problem-solving, Lean for eliminating waste, and small tests of change for iterative experimentation. We have certifications to prove we did the work. Yet too often, a team will do all of the right things — only to find out, sometimes after a year of effort, that nothing lasted. These tools are invaluable. They provide clear steps for addressing specific issues in patient care delivery. But here’s the challenge many of us face: these tools, while excellent tactics, often operate in isolation. They tell us the mechanics of improvement — but don’t address the bigger picture — the how of reliably executing them in complex, real-world healthcare environments where buy-in, alignment, deep discovery, and sustained adoption are make-or-break factors. Without a guiding system, even the best tools can lead to fragmented efforts, stalled initiatives, or changes that don’t stick… leaving us frustrated, and patient outcomes unchanged. Breaking the Cycle: The Famous "Insanity" Quote and Its Relevance to Healthcare ImprovementBLUF: Our current tactics and application of great tools are not making enough progress. We can — and must — do better for patients and for each other. “Over nearly 20 years, OIG has identified high patient harm rates nationwide in hospitals… Hospitals did not capture half of patient harm events that occurred among hospitalized Medicare patients.” — Office of Inspector General (OIG), U.S. Department of Health and Human Services Nationally, entire careers — mine included — and billions of dollars have been spent… for this outcome. Not to mention the relentless drain on our frontline teams — nurses, physicians, pharmacists — who face recurring process failures that impact patient care every single day. If that doesn’t make you think of Einstein’s definition of insanity, I’m not sure what will. Sticking to outdated methods will not spark the change we need. So… what do we do with that? Stating the obvious again — for those of us who do the work — is nothing but discouraging. How do we move forward? Personally, it’s why I went back to school for that industrial engineering degree. My thinking then — and still, a decade later — is that there must be a different path forward. One that borrows the relevant pieces and parts of improvement work from across industries (not just the tools) and carefully translates them into our complex, human-centered healthcare world — where humans are taking care of humans. One of my engineering school projects was a detailed, systematic analysis of every QI initiative I had ever participated in or led. I had to break down the minute details — the whys, the whos, the hows, every process step. Patterns in both failures and successes emerged — and they were often opposite sides of the same coin. After dozens of iterations, I grouped these patterns into a strategic operating system with three phases, each with two components. I committed at the time to honor that work — captured in my thesis — and to use it to do my absolute best to effectively execute what my organization needed to improve patient care. The first phase of my approach is PREPARE, comprising the components COMMIT and ALIGN. Over the next few newsletters, I’ll share examples and stories from my own experiences. The Inconvenience of Commitment - In Memory of Dr. Dennis Manning.BLUF: Leading and meaningfully participating in QI work requires a personal commitment to curiosity — and to doing the unexpected. Dr. Manning joined me on a project to increase the number of patients discharged before 10 AM. Most of us interpreted the mandate as: round earlier, be more efficient, write the discharge order the night before — and magic would happen the next morning. Easy, peasy. Done. He was not convinced we were solving the right problem. As a great general internist — and closet engineer — he decided to create a “differential diagnosis” of patients’ issues at the time of discharge. What he did next is, to this day, genius — and it reflects the kind of personal commitment it takes to be part of a successful QI team. Keep in mind: he was not the team leader; I was. And no one asked him to do this. It was entirely his own initiative — bringing his innovative best to improving patient care. He led from the trenches. So what did he do? He sat with patients on their day of discharge — from early morning until they actually left the building. He just hung out with them for hours. He did this on multiple days until a pattern emerged. He defined “time duration of discharge” and identified one key dependency no one had ever considered. Here’s what he found:
We were one meeting away from doing work that would not work. Instead, we developed a process to communicate with the patient — shocking, I know! — to engage their “ride” the day before anticipated discharge. Enter our first patient-bedside whiteboard. If you’d like the details, I’m happy to chat. And here’s the publication: J Hosp Med, 2007 Jan;2(1):13-6. doi: 10.1002/jhm.146. Another Moment of Inconvenient Commitment - Thank you, Dennis.BLUF: Being in the trenches is HARD. Without the fruit grown from committing to care for each other, it is impossible. In the first six-plus years of Hospital Medicine at Mayo Clinic, we were heavily focused on perioperative orthopedic care — from preop evaluation to postop rehab. On one of those afternoons, my patient had just been transferred from the PACU to a general medical floor — the orthopedic floor was full. He developed unexpected chest pain and dyspnea. An ECG was pending… when my pager went off. It was the daycare center. My then 6-year-old daughter had an accident, and I had forgotten to pack her a change of clothes. The ECG showed evidence of a STEMI. My brain immediately split in two — warring factions, paralyzing me. Does the patient come first? Or does your daughter — whose father had recently been deployed to Afghanistan? It has been 20+ years… and that brief moment of paralysis feels like it’s happening right now. I was in a panicked fog. I knew I would stay by the patient’s side — it was obvious. But wow, did my heart hurt. I looked up and saw Dr. Manning walking down the hall toward me. He must have read my face, because he approached without pause. I told him the dilemma. Dennis made the decision for me. I went home, found a change of clothes, took them to her, and held her in the embarrassment and fear of that moment. The patient survived. I will never forget the personal cost of Dennis’s commitment to our team — the energy, the time required to pivot quickly and change his plans for the day… for any patient, for any colleague. He stepped up for my family — and for me. Thank you, Dennis. I miss you. Quarterly Newsletter Trivia QuestionIt is simple. Reply to the newsletter trivia question/email for a single entry into our "drawing" for a $100 gift card. Correct or incorrect answer... doesn't matter. You will be included. Each newsletter will have a different trivia question and you can reply once for each question. This means that your name can go in the drawing up to 12 times each quarter (once for each newsletter published). As long as you respond to any of these newsletters, published during the quarter, before the end of the quarter, you will be included in the drawing. We will do the drawing on the first day of each calendar quarter. The winner will be notified by email and the answers to the question will be published in the Newsletter. Trivia Question for Week of February 23, 2026Dr. Dennis Manning was a student of many things, including the Latin origins of words. He also loved to coin words when the appropriate English word did not exist. In our first 100-case mortality review project, End-of-Life opportunities for improvement topped the list of areas for improvement. This was before the field of Palliative Care existed. Trivia Question: What word did Dr. Manning create to describe the opportunity of "not enough end-of-life care" identified during our mortality reviews? Just send a quick note to the email address below. You will be entered into the $100 gift card drawing. About this NewsletterLearning From Every Patient is a case-based patient safety and quality newsletter for frontline clinicians and healthcare quality improvement professionals who want to stop preventable harm. Each issue features rotating content, including real cases, expert commentary, a short “Loved One Lens” reflection, a brief look at “what worked” in successful improvement efforts, tips and tricks for quality improvement and patient safety projects, and quick scans of relevant new evidence. Published by HB Healthcare Safety, SBC, and powered by Influence Ignited!, the newsletter is edited by Jeanne M. Huddleston, MD, MS, and is designed to turn everyday stories and process defects into practical, actionable lessons you can use on your next shift. Editor: Jeanne M Huddleston, MD, MS
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Learning from Every Patient
Editor Jeanne Huddleston, MD, MS.