Breaking the Rules
for Better Care
Resource Guide
ihi.org
Contents
An Invitation to Break the Rules 3
Getting Started: What Is “Breaking the Rules for Better Care”? 5
Step 1: Plan Your Participation 6
Step 2: Share 6
Step 3: Mobilize 7
Step 4: Take Action and Report Back 10
Resources 11
Sample Email/Newsletter Announcement Text 12
Talking Points 13
Sample Questions 14
Sample Template 15
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RESOURCE GUIDE: Breaking the Rules for Better Care
An Invitation
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RESOURCE GUIDE: Breaking the Rules for Better Care
An Invitation to Break the Rules
Dear Colleagues,
We are thrilled that your organization will be joining changing
agents from all over the world to participate in a global effort to
“Breaking the Rules for Better Care.”
You are setting a powerful example for your staff and the health
care community at large by embracing the principles of radical
redesign and continually seeking to improve the experiences of
our patients and staff. We know these efforts will be illuminating,
inspiring, and impactful. The actions taken as a result of this
initiative by your individual organizations have the potential to profoundly enhance the
experiences of our patients, their families, community members, and our staff over the weeks,
months, and years ahead. We are grateful to be a part of such an impressive and brave
community of improvers.
More helpful resources can be found on our website. And don’t forget to share your efforts on
social media using the hashtag #IHIBreakingTheRules. Should you have any questions or if we
can be of any support, please do not hesitate to reach out to our IHI Alliance Team.
Sincerely,
Don Berwick, MD, MPP, FRCP Jill Duncan, RN, MS, MPH
President Emeritus and Senior Fellow Vice President
Institute for Healthcare Improvement Institute for Healthcare Improvement
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RESOURCE GUIDE: Breaking the Rules for Better Care
Getting Started
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RESOURCE GUIDE: Breaking the Rules for Better Care
What Is “Breaking the Rules for Better Care”?
“Breaking the Rules for Better Care” was developed and initiated by the IHI Leadership Alliance in
2016 as a way to identify health care “rules” that get in the way of the care experience. As health
care leaders, we aim to provide positive experiences for patients, families, and staff. However,
sometimes we may inadvertently create processes or policies that have an unintended impact on
the people we work to serve and support. In 2017, 10 members of the IHI Health Improvement
Alliance Europe (HIAE) conducted their own “Breaking the Rules for Better Care” week, amassing
500 proposed rules by means of feedback boxes in cafeterias, postcards, stickers, comment
boards, and staff brainstorming sessions. One organization even ran an underground “guerilla
campaign,” covering its hallways and doorways with red masking tape to illustrate “breaking the
rules” in action. To view the existing system with a new lens, organizations from these two IHI
networks have been asking: If you could break or change one rule in service of a better care
experience for patients or staff, what would it be and why?
In February 2023, the IHI Leadership Alliance, IHI Healthcare Improvement Alliance Europe, and
global members led the third iteration of the "Breaking the Rules for Better Care" initiative. Over
100 organizations participated in the Breaking the Rules for Better Care coalition, and in one
week over 1200 rules were identified. Our collective efforts allowed redesigning, reimagining to
thrive. If we get it right, our work to remove barriers, improve patient and staff engagement, and
innovate in system improvement will be an oasis for some, and the spark many of us need for the
work ahead.
IHI has prepared this resource guide to help your organization get started with similar “Breaking
the Rules” efforts.
Step 1: Plan Your Participation
Consider participating as one team, one unit, one floor, one facility, or as a whole organization.
We’d recommend having a focused time period for your efforts, such as one week or one day.
Step 2: Share
To get the word out about “Breaking the Rules for Better Care” and engage your staff, you can:
• Share your participation on social media and connect with others using the hashtag
#IHIBreakingTheRules
• Include a sample announcement in an upcoming staff email or newsletter (page 12)
• Educate your colleagues with these talking points (page 13)
• Ask patients, their families, and staff these sample questions (page 14)
• Create a template to record suggestions for rules to break or change (page 15)
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RESOURCE GUIDE: Breaking the Rules for Better Care
• Review IHI’s New Rules for Radical Redesign to get your staff thinking creatively about
care redesign
• Read the JAMA Viewpoint article “Breaking the Rules
for Better Care” or listen to the WIHI: Breaking the
Rules: Lessons from IHI’s Leadership Alliance
Encourage members to have fun, including visual tools to
indicate participation. For example, IHI distributed stickers
to participating organizations. Others have taken advantage
of common areas like waiting rooms, staff break areas, and
entrance spaces to query in person or collect asynchronous
feedback.
Step 3: Mobilize
Who do you want to ask?
Decide who from your organization you would like to participate. You can engage on whatever
scale makes sense to you, whether that means asking only staff, only patients, or asking a small
team to participate (versus requesting that the organization at large contribute). At this time, it
will also be important to decide how and when you will communicate the outputs and potential
next steps to those who participated. (Suggestions for communication are included below.)
How will you ask?
Decide on the most effective method to collect suggestions from patients, families, and staff at
your organization. Some suggested approaches include:
• In person: Consider asking in waiting rooms, break rooms, or during team meetings.
• Huddles or other daily management tools: Create simple scripts that could be leveraged in
daily management systems.
• Email: Email your staff and ask that they send you their suggestions for what rules they
would break or change and why.
• Survey: Create a simple survey using an online survey tool. This may be the best approach if
you think anonymity will be important.
• QR codes: Create asynchronous methods for patients, families, and your teams to submit
ideas and insights using simple scanning technologies from various entry or exit points, or
high flow spaces throughout your organization to link to a simple data repository.
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RESOURCE GUIDE: Breaking the Rules for Better Care
What will you ask?
We recommend asking staff, patients, and their families: If you could break or change one rule in
service of a better care experience for patients or staff, what would it be and why? or refer to this
list for some alternative questions.
What will you do with the suggestions you receive?
This is perhaps one of the most important steps for your preparation: How will you respond to
what you learn? Staff, patients, and colleagues will be eager to understand what your leadership
team does with the information they share. They might also be curious to understand how and
when they can help.
• How to collect suggestions:
Create a simple template that works for you to record and categorize the suggestions you
receive. One Leadership Alliance member found it helpful to recruit health professional
students to populate the template.
Based on the experiences of our early adopters, the suggestions and potential actions will
likely fall into three categories (see table on the next page).
• Inform staff how you will follow up:
When you start collecting suggestions, let participants know how you will follow up with
them after they submit their ideas. For example:
“Our organization aims to collect X (number) suggestions and will report back to you on our
plans to take action by Y (date). The suggestions we receive will be used to improve care at
our organization as well as generate a national dialogue about rules that get in the way of
delivering better care.”
Don’t forget to thank participants for contributing to this effort!
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RESOURCE GUIDE: Breaking the Rules for Better Care
Category Definition Potential Action Example
Rules that need clarity • Myths that are • Debunk One organization
perceived to be organizational consulted their local
rules. myths Board of Pharmacy
• Habits that • Tie the rationale about regulations
reflect "the ways back to the rule preventing sending
we do things patients home with the
• Seek clarification
around here". medications they had
from the entities
been using during their
• Unclear based that put in place the
stay in the hospital. They
on interpretation rules (e.g.,
discovered that, in fact, if
of policies, communicating
inpatient pharmacists
regulations, or with the US
relabeled those
the influence of Department of
medications, they were
local culture. Health & Human
able to send them home
Services about
safely with patients, thus
HIPAA)
preventing waste.
Rules that need redesign Administrative • Select rules to An organization realized
rules that we, as revise that partners in the
leaders, have the • Connect with family birthing center
power to change. colleagues through were hungry after long
professional hours waiting for
associations or mothers to deliver. Staff
other affiliations suggested the idea to
about how they redesign the rules and
may have tackled provide food to “feed all
similar challenges the partners” in the
birthing center.
Rules that need advocacy Rules that are in Either independently or During the Leadership
place due to with professional Alliance’s “Breaking the
regulations or networks, use the Rules for Better Care”
policies beyond power of collective Week, many
organizational voice to engage the organizations identified
control appropriate entities wanting to eliminate the
and advocate for rules CMS 3-day rule, requiring
to be changed a patient to spend 3
consecutive days as an
inpatient in a hospital to
qualify for Medicare
coverage of a skilled
nursing facility. Alliance
members spoke directly
with representatives
from CMS at an in-
person meeting about
the 3-day rule to
advocate for change.
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RESOURCE GUIDE: Breaking the Rules for Better Care
Step 4: Take Action and Report Back
After sorting the submissions using the three categories of rules and surfacing the themes
(myths, habits, administrative rules, and-or policy/regulatory), determine with your staff and
patients what action you will take. We are thrilled that you are taking part in this effort, and we
are excited to hear more about your experiences and findings.
The IHI team is eager to learn from your experiences so that we can celebrate your efforts as
well as help other Rule Breakers around the world based on what you learned. We invite you to
complete this short survey to share any ideas, insights, and data from your local “Breaking the
Rules” iteration.
Thank you for your partnership in Breaking the Rules for Better Care. Additional questions about
Breaking the Rules for Better Care can be directed to [email protected].
If you are interested in learning more about the Leadership Alliance, please contact the IHI
Alliance Team at [email protected].
If you are interested in learning more about the Health Improvement Alliance Europe, please
contact theHIAE Team at [email protected].
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RESOURCE GUIDE: Breaking the Rules for Better Care
Resources
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RESOURCE GUIDE: Breaking the Rules for Better Care
Resources
Sample Email/Newsletter Announcement Text
Feel free to modify the following announcement to raise awareness within your organization
about “Breaking the Rules for Better Care.”
[Your organization name] is proud to announce that we are engaging in an effort to provide a
better care experience for patients, families, and staff by participating in “Breaking the Rules for
Better Care” Week [or another timeframe] on [insert dates here].
As an organization, we aim to provide positive experiences for patients, families, and staff.
However, sometimes we inadvertently create processes or policies that have an unintended
impact on the people we work to serve and support. To view the existing system through a new
lens, for one week [or another timeframe] we will encourage our patients, families, and staff to
answer the question: If you could break or change one rule in service of a better care experience
for patients or staff, what would it be and why?
The suggestions we receive will be used to improve care at our organization [insert other actions,
as needed].
[Insert how here]
For more information, or to learn how to share your idea(s) for a rule you would like to see
changed, please email [insert contact person here].
Sincerely,
[Insert names]
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RESOURCE GUIDE: Breaking the Rules for Better Care
Talking Points
Modify and utilize this page as a reference guide to share information and answer any questions
your staff may have about “Breaking the Rules for Better Care” efforts.
What is “Breaking the Rules for Better Care” Week? “Breaking the Rules for Better Care”
Weekwas developed and led by the Institute for Healthcare Improvement (IHI) Leadership
Alliance. The initial week-long event took place in 2016 and challenged health systems to identify
the rules, habits, policies, or procedures that may get in the way of positive experiences for our
staff and patients.
For one week, Alliance members asked their patients, their families, and our staff: If you could
break or change one rule in service of better care for patients or staff, what would it be and why?
How do I suggest a rule I’d like to break or change? [Modify based on how you decide to collect
suggestions.]
What will happen with the rules once we submit them? We will work to categorize your
submissions and take action as follows: [Modify based on how you decide to take action.]
Category Definition Potential Action
Rules that need clarity Myths that are perceived to be • Debunk organizational myths
rules. • Tie the rationale back to the rule
• Seek clarification from the
Habits that reflect "the ways we
entities that put them in place
do things around here".
(e.g., HIPAA)
Unclear based on interpretation
of policies, regulations, or the
influence of local culture.
Rules that need redesign Administrative rules that we, as • Select rules to revise and
leaders, have the power to redesign
change • Connect with colleagues
through professional
associations/affiliations about
how to advance forward
Rules that need advocacy Rules that are in place due to • Either independently or through
regulations or policies beyond professional networks, use the
organizational control power of collective voice to
engage the appropriate entities
and advocate for rules to be
changed
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RESOURCE GUIDE: Breaking the Rules for Better Care
What is the IHI Leadership Alliance? The IHI Leadership Alliance, a dynamic collaboration of
leaders from health systems across North America, is united by a common mission: to work with
one another — and in partnership with our patients, workforces, and communities — to deliver on
the full promise of the IHI Triple Aim. The Alliance is a learning community characterized by
courage, creativity, and a commitment to champion the radical redesign of health care. The
Alliance gives members access to experts across the country, provides opportunity to
collaborate and innovate with leading thinkers, and advances a collective voice to guide change
for national impact.
What is the IHI Health Improvement Alliance Europe? The Health Improvement Alliance Europe
(HIAE), representing a diverse group of leaders from across Europe, is a community of
colleagues working to co-create systematic improvements in conjunction with the staff and
users in our regions to achieve health and well-being better than we’ve ever seen, care better than
we’ve ever known, at a cost we can all afford with every person every time.
Sample Questions
Use the following questions as a guide for how to ask patients, their families, and staff
about the rules they would like to break or change.
Original Question:
If you could break or change one rule in service of a better care experience
for patients or staff, what would it be and why?
Alternative Options:
• “What would you like to see us do differently?”
• “What would you change to provide a better experience for patients and/or staff at
[Name of Organization]?”
• “What is one wish you would make to deliver better care for patients or staff?”
• (For patients/families) “Is there anything our organization has done during your stay
that has gotten in the way of your family member’s care?”
• (For patients) “What do we do routinely that has made things more challenging for you?"
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RESOURCE GUIDE: Breaking the Rules for Better Care
Sample Template
Use the following template to record the rules that patients, their families, and staff would like to
break or change. We recommend having one point person on your team collect and code the
information.
Download the Breaking the Rules for Better Care collection tool to capture and categorize ideas,
insights, and data.
Date Unit/Dept/Team Employee/Patient/ What Rule Why Break Type of
Relationship to Would You or Change Rule
Patient Break or This Rule?
Improve?
Rule that
needs
redesign
Rule that
needs
clarity
Rule that
needs
advocacy
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