Small system changes can bring big joy to patients and physicians

In about a 10-hour span and to a tune of about $5,000, a 15-year-old athlete with a swollen, painful elbow visited four health care facilities—complete with an ambulance ride between two of the facilities—only to be told he’d need elective surgery for a fracture.

By the time the boy reached Nemours Children’s Health in Wilmington, Delaware, his elbow had already been put in a splint and physicians there could only tell him—and his exacerbated mother—to head home and schedule the surgery. So, why couldn’t the boy have learned that information before being sent to so many facilities?

Alfred Atanda, MD, a pediatric orthopedic surgeon and director of clinician well-being at Nemours Children’s Health, asked that question and knew there had to be a way to improve the system that was so filled with inefficiencies.

In the AMA STEPS Forward® podcast episode “Small Interventions Matter,” Dr. Atanda discussed how he and his colleagues worked to change the system to prevent other patients from experiencing what that 15-year-old boy and his mother did. You can listen on Apple Podcasts or Spotify.

“Coming up with a systems-level infrastructure change to overhaul something like this can have a profound effect throughout the health care ecosystem,” Dr. Atanda said.

These changes that help patient care, in turn, help improve the well-being of the physicians and other health professionals, while inspiring others to go about making changes in their own practices.

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“A lot of times we don’t really think that way,” he said. “We think: Oh, physicians are burnt out—they just need a few days off or they need a rest room, or we need a retreat where people can go for a few days.”

Those are all good things, but Dr. Atanda said, “it’s kind of like the canary in the coal mine: if you don’t improve the environment—day-to-day inefficiencies and the things that are really nudging and tugging the people and making their work environment unpleasant—you are not really going to overall solve the problem that people are facing.”

After speaking to all of the stakeholders to find out how to improve everyone’s situation, Nemours has made a few small changes that have had a big impact.

Calls about transfers to the pediatric hospital still filter through the pediatric intensive care unit (PICU) fellow, but the fellow now involves orthopedic residents and fellows early and often to help determine whether a pediatric orthopedic patient really needs to be transferred to Nemours or if the institution the child is at can handle the situation.

“It is these kinds of small interventions that I think are very powerful,” Dr. Atanda said.

Read about how Nemours Children’s Health is helping doctors find the leader in themselves to cut burnout.

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They are now studying how the change has impacted the transfer rate. The expectation is that the data will show patients aren’t being sent unnecessarily at the rate they used to be. That cuts down on the patient’s aggravation, the paperwork and the physician and care team members’ frustrations of not being able to do more for a patient.

“As a physician I was observant of something that was going on in my environment and my administration and my organization are now listening and supporting me to do something about it and make a change,” said Dr. Atanda. “Empowering individual-level physicians to take it upon themselves and use their own time and effort to really try to improve things and bring awareness to the larger health care ecosystem is something that a lot of physicians don’t necessary think they have the ability to do.”

He said that’s why he likes to share his story.

“It may take a little bit of time and effort but in most reasonable organizations you can really make some meaningful and impactful changes. You just have to persevere a little bit and go about telling your story the right way to the right people,” Dr. Atanda said.

To learn more, access the AMA STEPS Forward “Getting Rid of Stupid Stuff” toolkit.

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