“The Bicycle Book” is an administrative book containing the names of individuals who ride their bikes to work instead of using a gas-fuel based transportation. The book was written in World War II to establish how to compensate workers who saved fuel with extra food. It is still used today, but holds no value for healthcare systems. This infamous book, and many other inefficient rules implemented by healthcare providers, is still being utilized, according to the findings of a study published in JAMA.

A major complaint in healthcare systems is the number of rules that constitute no beneficial outcomes, as they are an added hindrance to the already lengthy process of hospital and healthcare procedures. The Leadership Alliance, convened by the Institute for Healthcare Improvement (IHI), held a “Break the Rules for Better Care Week,” during which 40 North American hospitals took surveys about healthcare rules to answer the question: “If you could break or change any rule in service of a better care experience for patients or staff, what would it be?” In 1 week, with the assistance of patients, families, and clinical and nonclinical staff, 342 rules were identified that provide little or no value to patients and staff.

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The rules that were deemed inconvenient and unsuitable were broken down into 3 categories:

  1. Habits embedded in organizational behaviors
  2. Organization-specific requirements that local leaders could change without running afoul of any formal statute
  3. Actual statutory and regulatory requirements

The 4 actions most commonly taken to counteract these rules were:

  1. Debunking myths about non-existent regulatory rules through staff education
  2. Seeking clarity from appropriate regulatory agencies about the true scope of the rules
  3. Changing local administrative policies for which no sufficient rationale could be found
  4. Speaking with a “collective voice” to policy makers about regulations harmful to care

Appallingly, the rules that seemed unnecessary to patients were in fact completely within the healthcare system’s rights to administer and manage as they saw fit. The underlying problem of healthcare rules was the recognition of patients’ need for comfort on “physical, emotional, and financial concerns.”

The researchers noted that “Break the Rules for Care” had several limitations because “it was not always possible to determine whether a suggested rule was a habit, myth, or in fact a rule for which alteration required modifying a regulation or law.”

“Generalizing from this effort to a clear profile of wasteful habits, myths, regulations, and laws is not appropriate,” the researchers noted. “A more complete study would standardize data definitions and processes for eliciting candidate rules for change.”

However, the Leadership Alliance noted that healthcare organizations can reduce administrative waste “without requiring politically difficult battles to alter regulations, laws, or payment rules.” Healthcare leaders could ask clinicians, staff, and patients in a safe environment to identify habits and rules that may be harming care without providing any corresponding benefits, and take action to change them.


Berwick D, Leohrer S,  Gunther-Murphy C. Breaking the rules for better care. JAMA. 2017;317(21):2161-2162. doi:10.1001/jama.2017.4703

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