Improvement project: The evolution of a hospital sign
All photos provided by Dr. Wong and Dr. Stroud
By Dr. Brian Wong, FRCPC, and Dr. Lynfa Stroud, FRCPC
At this point in the COVID-19 pandemic, we’re sure many of you have “near miss” stories. We want to tell you one of ours — how one of us almost walked into a patient room on our dedicated COVID-19 unit at the Sunnybrook Health Sciences Centre in Toronto with the wrong mask on. We’ll also share how we turned that incident into a practice improvement opportunity and reported it in MAINPORT ePortfolio for Maintenance of Certification (MOC) Program credits. This is something you can do, too.
There are many everyday opportunities to turn your problem-solving efforts into MOC credits, which a lot of us overlook. We hope this tip will encourage you to bring a quality improvement lens to your day-to-day tasks, and show how you can claim credit for work you are already doing.
At our hospital, as the pandemic progressed, we started to use high-flow oxygen on our General Internal Medicine floors to lessen the burden on our Intensive Care Unit. This required a change in behaviour: we now sometimes had to wear N95 masks instead of just surgical masks on our shift.
Sometimes it was difficult to remember this new practice change.
Despite the precautions put in place (such as safety officers posted outside patient rooms) one of us narrowly missed exposure to the COVID-19 virus when we almost walked into a room — without wearing an N95 mask — where a patient with a COVID-19 infection was receiving high-flow oxygen.
An N95 reminder sign was on the door, so how did this happen?
It became clear to us that here was an opportunity for practice improvement.
We quickly assembled a group of colleagues — physicians, nurses, therapists, a pharmacist, a social worker, a safety officer and a team leader — and came up with a redesigned sign prototype that we thought would be effective.
We trialed it on a door. In general, people were quite positive but felt that it still needed work. So, we took it to colleagues in Communications and Infection Prevention and Control, who also made recommendations. Together, we finalized a new sign that was much better received — a big yellow diamond with only one word: N95.
The new signs have caught on. In our unit, we leave them on all doors at all times, and flip them as soon as a N95 is required. The signs also have clear-space around them, to help them stand out.
We are especially proud that our in-the-moment, team-based continuous quality improvement (CQI) approach led to a lasting impact: our sign is used across our hospital where N95 masks need to be worn, including in our ICU and all unit wards.
All photos provided by Dr. Wong and Dr. Stroud
This is what a typical patient door looked like at Sunnybrook. The sign with the yellow diamond was meant to alert providers to the fact that an N95 mask should be worn when entering the room.
Attempts were made to remove the extraneous clutter from around existing signs to draw attention to them.
In addition to the fact that the N95 reminder sign would get lost among all the other signage on patient doors, the actual warning itself was not clear: the N95 print was very small and there is a lot of extraneous information.
Front-line clinicians started to modify the signs to make the reminder more conspicuous. For example, this photo shows how someone wrote N95 in bold marker on the existing sign.
In an attempt to reinforce the message, someone posted a new sheet of paper with “N95” handwritten in bold. This sheet of paper was actually moved from door to door, as it was felt to be more effective than the official sign.
Another tactic used to draw attention to key messaging was the addition of the words “AIRVO” and “N95” next to the biggest “STOP” sign on the door.
The first prototype of a new sign was a simple triangle with the text “N95” encased in it. This sign came from a brainstorm with people working on Sunnybrook’s COVID unit including physicians, nurses, a pharmacist, safety officer and our team leader.
The new prototype sign was trialed on one of the patient doors. Generally speaking, it received positive reviews but feedback suggested that a different colour of sign would be better.
This is the new standard-of-use sign that was finalized following feedback, and assistance from the hospital’s director of Infection Prevention & Control and the communications team. This sign is now being used throughout Sunnybrook.
Here is an example of the new sign in use. It is left on all doors, at all times, so that it can be “flipped” quickly when a N95 mask is required. Surrounding clutter on the door has also been removed.
Ours was not a traditional quality improvement project but is more an example of how to bring that mindset to day-to-day problem solving. We are sure that many of you have had similar experiences, contributing to a variety of innovations (big and small) in the context of the COVID-19 pandemic. We hope our story and the MOC guidance note below inspires you to report your own experiences for Section 3 MOC credits.
Brian Wong, MD, FRCPC, is a staff physician in General Internal Medicine at the Sunnybrook Health Sciences Centre in Toronto, Ont., and director of the University of Toronto Centre for Quality Improvement and Patient Safety.
Lynfa Stroud, MD, FRCPC, is the division head of General Internal Medicine at the Sunnybrook Health Sciences Centre in Toronto, Ont.