You've probably seen the little hand-crafted signs that hang near many of America's fireplaces. On one side, they read, “The flue is open,” and on the other they read, “The flue is closed.” And you're just as likely to have seen their kitchen cousins, the magnetized dishwasher signs that read “Clean” on one side and “Dirty” on the other.

I've managed to fight off the temptation to buy signs like these. One big reason is that I know how likely I would be to forget to flip the sign after opening the flue or emptying the dishwasher. Day after day, I'd find myself peering into the dishwasher trying to figure out if the sign was right before I put a dirty cup into the top rack. And I'd still check the flue before lighting a fire. I know people who are much more systematic than I in their approach to life, and for all I know, their flue signs never lie — but I have a little trouble believing it.

And when any of several people might have last flipped the sign (or not), its usefulness nearly vanishes. What started me thinking about dishwashers was a story told by Donald M. Berwick, MD, MPP, president and CEO of the Institute for Healthcare Improvement (IHI) about signs on the doors of IHI restrooms. The idea was that the user would flip the sign to “Occupied” on entering and to “Vacant” on leaving, and the system had predictably poor success. It turned out that someone who always guessed that the restroom was vacant would be right about as often as someone who always believed the sign.

The disconnect

Indicators like these signs offer an interesting perspective on the old adage “If it's not documented, it didn't happen.” The adage one might derive from experience with a dishwasher sign is “If it's documented, it might have happened. Who knows?” Actually, such signs highlight a problem with virtually all documentation: It is not directly connected to the event it documents. Even with the best of intentions, one can do something and fail to document it, document something and fail to do it, document one thing and do another, and so on. You can vow to maintain the connection, you can leave yourself reminders, you can double-check yourself, but you can't escape the disconnect. That's life.

And, of course, documentation isn't the only place where the disconnect shows up in practice. Any two separate actions that are supposed to accompany one another can become disconnected, as when the patient leaves with a new prescription but not the drug information sheet you wanted him to have, or when the HCFA 1500 form goes out with a procedure code but no diagnosis code entered or … but I'm sure you can come up with a hundred better examples.

Making the connection

The solution to the problem — how to make sure that two actions that are supposed to go together actually do — is to link them in such a way that doing one without doing the other becomes hard, or even impossible. Berwick gives the example of the airplane restroom designed so that the action of locking the door causes the “Occupied” sign to appear. Or think of the fireplace with a visible flue-control handle, where the position of the handle tells the user unequivocally whether the flue is closed.

Your practice already has many examples of yoked actions like this. As one mundane example, consider the chart pockets on your exam room doors that allow a nurse to tell you which patient is in which room waiting and at the same time make sure you get the chart. Again, I bet you can think of many other examples — but, as long as things continue to fall through the cracks, not nearly enough.

One of the major challenges in quality improvement is finding ways to yoke actions together, to make more and more sure that when A happens, B follows automatically.

Computers are good at this. One benefit of computerized prescribing, for instance, is that the simple act of writing a prescription can cause the computer to check the patient's allergies list and medications list for potential problems — and check the formulary of the patient's health plan, if necessary, and print a drug information sheet. But computers aren't the only way. Consider the nursing note flow sheet suggested by James M. Giovino, MD, in his article in this issue for the administration of Depo-Provera. This one piece of paper helps ensure a complete nursing note while making it hard to inject the drug without first ruling out pregnancy.

That's something to keep in mind when what's supposed to happen in your practice doesn't: Do you need to institute a new procedure to double-check the person who's supposed to be checking to be sure that B happens when A does, or would you do better looking for a way to make sure that B happens without any need for checking, let alone double-checking?