Exploring Innovation and Quality Improvement in Health Care Micro-Systems: A Cross-Case Analysis (2000)

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APPENDIX A Example of Thin and Thick Description for Qualitative Analysis THICK DESCRIPTION I was interested in end of life care, but it really started as an interest in pain and pain management. . . . We put together a pain steering committee. Physicians weren’t convinced that pain and pain management was an issue. They wanted us to do more baseline data gathering, which was fine, but we just confirmed what others had found. We had to convince them that this was an issue for us, too. We had to get through that before we could design any interventions. I struggled with nurses and physicians to get them to appreciate work that had been done elsewhere and not reinvent the wheel. We got to the point where we had all this data but we weren’t doing anything. A lot of the steering group members started to drop out because they couldn’t see any value in what we were doing. It’s hard for smaller departments to give the people and the time to work on projects. This was making it hard for our steering committee to be interdisciplinary. . . . We worked on getting the physicians involved in the process. We started out with a pilot unit . . . but the first few months were really hard because they thought they really did a good job with pain management already. We tried to emphasize that it wasn’t that they weren’t doing a good job, but they were very resistant, almost angry. It took a long time for them to see that we were not criticizing them. It was hard to convince them that they could improve without insulting them. But the fact was that we weren’t managing pain very well. There are various ways that health care workers let patients know that we are busy“Don’t tell us that you are having a problem because we don’t have time to deal with that.” For a lot of nurses the reason for being a nurse was to relieve pain and suffering. But then we send patients the message that we don’t have time to help you. Now, we have pain scales in every room in the hospital. The nurses didn’t want the pain scales in the room because they thought that it would be worse for the patient if we brought it to their attention, but we know that just isn’t the case. We graph pain on the vital sign sheet just below temperature and . . . document whether the pain management is effective. A lot of the nurses get stuck on getting a numberthat may be hard for a patient. So I get them to listen to what the patient says about the pain, not just a number. We can look at 65 

66 INNOVATION AND QUALITY IMPROVEMENT IN MICRO-SYSTEMS the pain rating, but also look at what the patient is doing and is able to do. The patient needs to understand that there are things that we can do, but sometimes we can’t eliminate all pain. The pain scales have #1–10, but they also have word attached to the scale: 2 = mild, 5 = moderate, 8 = severe, 10 = worse possible. So if a patient gives words, a number can be attached and it can be graphed. We work on non-pharmacologic as well as pharmacologic interventions. A conversation with the patient assesses what level of pain is acceptable. A post-surgery patient, for example, should be able to breathe deeply and get up and walk and do more for themselves each day. A terminally-ill patient should be able to eat and visit with people. When a person has pain that is a 5 or more we have to talk with them to understand what that means. The nurse is learning and the patient is learning too so that they understand that this is not about how much pain can you stand. . . . You have to make it easy to do the right thing. It has to be easy to manage pain. We developed some algorithmswe worked on them for about a year and a half. Putting them out on the unit won’t be enough. The algorithm can jog someone’s memory, but they have to have a good foundation about what to do. I’m trying to develop pain resource nursesnurses on every unit that are knowledgeable about pain, collect data, and work to improve pain management. I’m meeting a lot of resistance to do this, but we have to get this down to the people who are doing this every day. Otherwise they aren’t going to buy into the changes. . . . We have a strategic plan and goals around pain management. Without that focus, the daily, weekly, and monthly issues will start to take over. Eventually pain will only get attention when something bad happens. . . . Patients get the best care when you have health care workers who communicate very well and collaborate very well. One of the biggest problems I see is physicians not talking to each other. . . . THIN DESCRIPTION After difficulty getting nurse and physician involvement, the site has focused on responsiveness to patients’ pain. Site has pain algorithms, an interdisciplinary steering committee that sets goals, and wall charts to use in asking patients about their pain. Pain is charted as a vital sign and has become fairly well accepted, but pain management will need constant attention. Site is trying to develop a pain resource nurse. Intra- and cross-discipline communication identified as a problem.