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Success Story: Easy Fixes for “Pebble in Shoe” Problems Have Big Impact

Based on an American Medical Association news article published April 15, 2019 and Sara Berg's interview with Narayana S. Murali, MD, Nephrologist and Executive Director at Marshfield Clinic Health System, Wisconsin.

Learn how Marshfield Clinic Health System listens to team members, sorts problems into categories, and prioritizes easy fixes to promote organizational change.

What Was the Problem?

Nothing puts a hitch in your step like a pebble in your shoe. On the other hand, few problems in life are as easy to fix. Take off your clodhopper, knock out the little stone and—voila—it feels like you're walking on a cloud.

Leaders at Wisconsin's Marshfield Clinic Health System (Marshfield) have undertaken an effort to find what they call “pebble in the shoe” problems afflicting their physicians and other health professionals.

Developing the Intervention

Once a year, leaders at Marshfield invite doctors and others to roundtable events where they share what they're frustrated by. The pebble in the shoe problems are ones that could be solved within 3 weeks—a mere moment in time in the health care world.

One notable example: a physician complained that the toilet was broken and had not been repaired for nearly a month. It meant he had to walk to a distant bathroom and made it harder for the practice to stay on schedule.

“The chief administrative officer of the facility was right there and it became very evident that nobody knew about it,” said Narayana S. Murali, MD. “They got that fixed.”

Issues submitted at the roundtables are categorized into 3 areas:

“We had a facilitator who broke the physicians into different groups to have the conversation internally so that they could come up with the key areas where they saw gaps,” said Dr Murali. “We took that material back to our clinic board and addressed some of those elements and created a sequence in terms of what we need to address at the board level.”


About 1200 line-item issues were brought to the attention of leadership through roundtable events across the health system. To date, about 30% that were deemed “pebbles” were resolved. The others were tied to processes across the system.

When at the Marshfield site in Eau Claire, Wisconsin, leadership learned the lights where the surgeons park were not working. This issue was taken care of “almost immediately” because it affected the surgeons' ability to get to the parking lot, Dr Murali said.

Another pebble popped up at a new facility in Eau Claire. A physician noted the surgical operating room lacked a place to hang coats or put on aprons, while another said the TV remotes were missing.

Not all asks are quick fixes

Marshfield health centers also shared frustrations that required longer periods of time for a solution or were tied to key elements of the organization. In one practice, new building signs had not gone up yet.

“We thought building signs could be done in less than 2 weeks, but by the time we went through the process of getting it approved, having it go to an external vendor, it took us 6 or 7 plus weeks,” said Dr Murali. “It also exposed a gap in the process of how you've gone about it. The process got fixed so that the next time we don't run into some of those issues.”

Another physician suggested fixing the electronic health record, but that can't be fixed overnight.

“We by no means have fixed all the issues, but we are doing our very best to make sure that we meet as much as is practically possible given the constraints of all the things that we are doing as a health system,” said Dr Murali.

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