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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Efforts to improve the quality of healthcare have failed to achieve a meaningful and sustainable improvement. Patients continue to experience fragmented, inconvenient, and unsafe care while providers are increasingly becoming overburdened with administrative tasks. The need for change is clear. Healthcare professionals need to take on new leadership roles in quality improvement (QI) projects to effect real change. The Quality Improvement Challenge in Healthcare equips readers with the skills and knowledge required to develop and implement successful operational improvement initiatives. Designed for healthcare providers seeking to apply QI in practice, this valuable resource delivers step-by-step guidance on improvement methodology, team dynamics, and organizational change management in the context of real-world healthcare environments. The text integrates the principles and practices of Lean Six Sigma, human-centered design, and neurosciences to present a field-tested framework. Detailed yet accessible chapters cover topics including identifying and prioritizing the problem, developing improvement ideas, defining the scope of the project, organizing the QI team, implementing and sustaining the improvement, and much more. Clearly explaining each step of the improvement process, this practical guide: * Presents the material in a logical sequence, gradually introducing each step of the process with clearly defined workflow templates * Features a wealth of examples demonstrating QI application, and case studies emphasizing key concepts to highlight successful and unsuccessful improvement initiatives * Includes end-of-chapter exercises and review questions for assessing and reinforcing comprehension * Offers practical tips and advice on communicating effectively, leading a team meeting, conducting a tollgate review, and motivating people to change Leading QI projects requires a specific set of skills not taught in medical school. The Quality Improvement Challenge in Healthcare bridges this gap for experienced and trainee healthcare providers, and serves as an important reference for residency program directors, physician educators, healthcare leaders, and health-related professional organizations.
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Veröffentlichungsjahr: 2021
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Table of Contents
Cover
Title Page
Copyright Page
Dedication Page
Why This Book?
About the Authors
List of Stories, Examples, Exercises and Case Studies
About the Companion Website
PART I: THE BASICS
CHAPTER 1: The Problem with Healthcare
SO, WHAT’S THE PROBLEM?
HOW DID WE GET HERE?
THE CHALLENGES TO IMPROVE HEALTHCARE
WHAT IS THE PHYSICIAN’S ROLE IN PROCESS IMPROVEMENT?
REFERENCES
CHAPTER 2: We Need to Improve the Way We Improve
WHAT’S THE GOAL OF A QI PROJECT?
A BETTER IMPROVEMENT STRATEGY
GUIDING PRINCIPLES
THE FIVE “RS” OF EVERY QI PROJECT
THE CHANGE SPACE
REFERENCES
PART II: THE FIRST “R”: THE RIGHT PROJECT
CHAPTER 3: The Project Selection Process
WHERE DO I START?
THE PROJECT SELECTION PROCESS
THE PROJECT SELECTION MATRIX: A TOOL TO PRIORITIZE QI PROJECTS
A PROJECT TYPE FOR EVERY PROBLEM
PROJECT TYPES FROM THE LENS OF CHANGE
HOW TO ESTABLISH YOUR PROJECT’S TIMELINES
CHAPTER 4: Frame Your Challenge
STORIES FROM THE FRONT LINES OF HEALTHCARE: MARTHA SANCHEZ, THE HEAD OF HOUSEKEEPING
THE PROBLEM STATEMENT
THE PROBLEM STATEMENT IS YOUR “ELEVATOR SPEECH”
THE PROJECT CHARTER
EXERCISE: A PROBLEM STATEMENT AND PROJECT CHARTER FOR YOUR QI PROJECT
PART III: THE SECOND “R”: THE RIGHT PEOPLE
CHAPTER 5: Don’t Go at It Alone
STORIES FROM THE FRONT LINES OF HEALTHCARE: TURN‐AROUND TIME FOR X‐RAYS IN THE ED
THE PRIMARY SPONSOR
WHO SHOULD BE YOUR PRIMARY SPONSOR?
REVIEW QUIZ
REFERENCES
CHAPTER 6: Organize Your QI Team and Select the Team Leader
THE QI TEAM
WHO SHOULD BE ON YOUR QI TEAM?
THE TEAM LEADER
THE TRUE ROLE OF THE QI TEAM
THE FIRST TOLLGATE REVIEW
EXERCISE: THE QI TEAM AT HEART MEDICAL CENTER
REFERENCES
PART IV: THE THIRD “R”: THE RIGHT PROBLEM
CHAPTER 7: What Is the Scope of the Project? The SIPOC Diagram
YOU NEED TO KNOW YOUR PROJECT’S SCOPE AND BOUNDARIES
THE TOOL: A SIPOC DIAGRAM
HOW TO DRAW A SIPOC DIAGRAM
CHAPTER 8: Who Are the “Customers,” and What Do They Need?
IN HEALTHCARE, WE ALSO HAVE “CUSTOMERS”
THE “CUSTOMER CONTINUUM”
THE VOICE OF THE CUSTOMER (VOC)
HOW DO WE COLLECT THE VOC?
CRITICAL‐TO‐QUALITY (CTQ)
THE CRITICAL‐TO‐QUALITY TREE
EXERCISE: CTQS FOR THE NEW WOMEN’S CENTER
CHAPTER 9: Who Are the “Stakeholders,” and What Challenges Do They Have?
THE FRONTLINE STAKEHOLDERS
THE VOICE OF THE STAKEHOLDERS
THE CRITICAL NEEDS OF THE STAKEHOLDERS
THE SECOND TOLLGATE REVIEW
PART V: THE FOURTH “R”: THE RIGHT CAUSE
CHAPTER 10: To Understand a Process, You Need to “Go See” and Create a Map
STORIES FROM THE FRONT LINES OF HEALTHCARE: ANDREA, THE QI PROJECT MANAGER
THE FIRST STEP IS TO “GO SEE”
AT THE GEMBA YOU SEE THE SYSTEM
IT’S ALL ABOUT THE PROCESS
THE PROCESS MAP
BASIC PROCESS FLOW MAP
THE SWIM LANE CHART
THE VALUE STREAM MAP
PROCESS DATA FOR THE VSM
EXERCISE: MAPPING “ORDERING BLOOD FROM THE BLOOD BANK”
CHAPTER 11: Get a Quick Win: Identify and Eliminate “Waste”
WASTE IS THE OPPOSITE OF VALUE
WHY TARGET WASTE?
WHO IS TIM WOOD?
TOOLS TO IDENTIFY AND ELIMINATE WASTE
MAPPING TECHNIQUES TO IDENTIFY WASTE
EXERCISE: IDENTIFYING WASTE IN THE PEDIATRIC UNIT
CHAPTER 12: Measure What Matters
MEASUREMENTS
METRICS
WHO DECIDES WHAT WE NEED TO MEASURE?
THE TWO TYPES OF METRICS USED IN QI PROJECTS
WHAT DOES A “GOOD” PROJECT METRIC LOOK LIKE?
METRICS ARE EXPRESSED AS TWO TYPES OF DATA
COMMON METRICS USED IN QI PROJECTS
REFERENCE
CHAPTER 13: Practicalities for Planning and Collecting Baseline Data
WHY DO WE NEED TO COLLECT DATA?
WHERE CAN I FIND THE DATA THAT I NEED?
WHAT MAKES DATA SO HARD TO GET?
THE KEY TO DATA COLLECTION IS TO START WITH A GOOD DATA COLLECTION PROCESS
THREE RULES OF DATA COLLECTION
MAKE YOUR DATA COLLECTION MORE EFFECTIVE WITH A DATA COLLECTION PLANNER
CHAPTER 14: Define Baseline Performance
HOW DO I ASSESS A PROCESS’S BASELINE PERFORMANCE?
WHY DO WE NEED A COMBINATION OF NUMBERS AND PICTURES?
GRAPHS ARE THE BEST TOOLS TO INTERPRET DATA
DO I NEED TO HAVE DATA NORMALLY DISTRIBUTED?
THE GRAPHICAL ANALYSIS
THE HISTOGRAM: A TOOL TO GET A SNAPSHOT WITH CONTINUOUS DATA
ADDITIONAL GRAPHS YOU CAN USE WITH CONTINUOUS DATA
THE BAR CHART: A TOOL TO GET A SNAPSHOT WITH DISCRETE DATA
ADDITIONAL CHARTS YOU CAN USE WITH DISCRETE DATA
CASE STUDY: IMPROVING RTA TIME AT ST. MICHAEL’S HOSPITAL
THE ANSWER TO THE PROBLEM OF VARIATION IS A GRAPH OF TIME‐ORDERED DATA
VARIATION GUIDES THE IMPROVEMENT STRATEGY
TIPS WHEN PRESENTING DATA
REFERENCES
CHAPTER 15: Tools to Characterize the Type of Variation
WHAT IS A RUN CHART?
MAKING A RUN CHART
INTERPRETING THE RUN CHART
REFERENCE
CHAPTER 16: Tools to Characterize the Type of Variation
THE CONTROL CHART
THE INDIVIDUALS AND MOVING RANGE (I‐MR) CHART
THE UPPER AND LOWER CONTROL LIMITS OF THE INDIVIDUALS CHART
UPPER CONTROL LIMIT OF THE MOVING RANGE (MR) CHART
HOW TO DETECT SPECIAL CAUSE VARIATION WITH THE I‐MR CHART
THE I‐MR CHART GUIDES THE IMPROVEMENT STRATEGY
ADDITIONAL CONTROL CHARTS
CASE STUDY: DOOR‐TO‐INFUSION (DTI) TIME AT HURON MEDICAL CENTER
REFERENCES
CHAPTER 17: Define Baseline Performance
IS THE PROCESS MEETING THE NEEDS OF THE CUSTOMER?
PROCESS CAPABILITY
CASE STUDY: THE NEW BALLOON ANGIOPLASTY CATHETER AT UIC
CAPABILITY INDICES
PROCESS CAPABILITY FOR DISCRETE DATA
THE PROCESS SIGMA OR SIGMA METRIC
PUTTING IT ALL TOGETHER: IS THE PROCESS STABLE? IS IT CAPABLE?
CHAPTER 18: How to Identify and Prioritize the Most Likely Cause of the Problem
STORIES FROM THE FRONT LINES OF HEALTHCARE: WAIT TIME IN THE ORTHOPEDIC OUTPATIENT CLINIC
THE THINGS WE DO THAT STIFLE OUR ANALYTICAL THINKING
CRUCIAL INTERACTION OF ACTIONS AND CONDITIONS
THE PATH TO THE ANALYSIS OF
Y
TOOLS TO IDENTIFY THE POSSIBLE CAUSE(S) OF THE PROBLEM
TOOLS YOU CAN USE TO FILTER AND PRIORITIZE THE MOST LIKELY CAUSE
EXERCISE: IN‐TRAINING EXAMINATION AT MASS GENERAL HOSPITAL
CHAPTER 19: Before Proceeding, Confirm the Cause‐and‐Effect Relationship
THE CAUSE‐AND‐EFFECT RELATIONSHIP
THE SCATTERPLOT: IS THERE A RELATIONSHIP?
THE CORRELATION COEFFICIENT: WHAT IS THE STRENGTH OF THE RELATIONSHIP?
REGRESSION ANALYSIS
HYPOTHESIS TESTING
THE THIRD TOLLGATE REVIEW
PART VI: THE FIFTH “R”: THE RIGHT SOLUTION
CHAPTER 20: Develop and Prioritize Your Improvement Ideas
BARRIERS TO CREATIVE THINKING
SETTING THE RIGHT CONDITIONS FOR CREATIVE THINKING
THE CREATIVE SCAFFOLD
DIVERGENT THINKING: DEVELOPING IDEAS USING EXISTING SOLUTIONS
DIVERGENT THINKING: FINDING NEW SOLUTIONS
CONVERGENT THINKING: USING THE TEAM’S KNOWLEDGE TO PRIORITIZE IDEAS
CONVERGENT THINKING: PRIORITIZE IDEAS BY COMPARING OPTIONS
CONVERGENT THINKING: PRIORITIZE IDEAS USING ASSESSMENT CRITERIA
CASE STUDY: DECREASING UNPLANNED READMISSIONS AFTER TONSILLECTOMY
ASSESSING RISK: FAILURE MODE AND EFFECTS ANALYSIS (FMEA)
USING THE FMEA WITHOUT THE RISK PRIORITY NUMBER (RPN)
REFERENCES
CHAPTER 21: Test the Effectiveness of Your Ideas with a Pilot
THE PILOT STUDY
THE BEST‐KNOWN PILOT IS THE PDSA CYCLE
ADVANTAGES OF THE PDSA CYCLE
THE PDSA CYCLE IS A “LEARNING RAMP”
REFERENCES
CHAPTER 22: Improve “Flow” and Work Conditions
PROCESS FLOW
STRATEGY FOR CREATING PROCESS FLOW
STEPS AND SEQUENCE TO CREATE FLOW
WHAT IS STANDARD WORK?
THE CRITICAL ROLE OF WORK CONDITIONS
5S TO OPTIMIZE YOUR WORKSPACE
VISUAL MANAGEMENT
MISTAKE‐PROOFING SYSTEMS
REFERENCES
CHAPTER 23: Now Roll‐Out Your Improvement Ideas and Make Them “Stick”
STORIES FROM THE FRONT LINES OF HEALTHCARE: THE EARLY DISCHARGE QI PROJECT AT MEMORIAL HOSPITAL
BEFORE YOU ROLL‐OUT, YOU NEED AN IMPLEMENTATION PLAN
ASSESS THE POTENTIAL IMPACT OF YOUR IMPROVEMENT IDEAS
ASSESS THE POTENTIAL FOR PUSHBACK: THE STAKEHOLDER ANALYSIS
YOUR STAKEHOLDER ENGAGEMENT STRATEGY
ASSESS THE LEVEL OF SUPPORT: THE LOCAL SPONSOR ANALYSIS
THE LOCAL SPONSOR STRATEGY
THE MONITORING AND CONTROL PLAN
THE FOURTH TOLLGATE REVIEW
PROJECT CLOSURE
REFERENCES
PART VII: ADDITIONAL THINGS YOU MAY NEED TO KNOW
CHAPTER 24: How to Prepare and Conduct a Tollgate Review
THE TOLLGATE REVIEWS
FOUR TOLLGATE REVIEWS OF A FIVE “R” PROJECT PHASE
CHAPTER 25: How to Communicate Effectively to Engage the Front Line
STORIES FROM THE FRONT LINES OF HEALTHCARE: THE NICU TEAM AT ST. AGNES HOSPITAL
THE IMPORTANCE OF COMMUNICATION
WHY PROJECTS OFTEN FAIL
PEOPLE’S BRAINS OFTEN CREATE BARRIERS TO EFFECTIVE COMMUNICATION
WHAT SHOULD YOU DO TO COMMUNICATE EFFECTIVELY?
TIPS FOR ONE‐ON‐ONE COMMUNICATION
USE A COMMUNICATION PLANNER TO MAKE IT EASIER
TIPS TO ANNOUNCING A DIFFICULT CHANGE
REFERENCES
CHAPTER 26: How to Lead an Effective Team Meeting
STORIES FROM THE FRONT LINES OF HEALTHCARE: BRANDON, THE AMBULATORY CLINIC MANAGER
THE IMPORTANCE OF MEETINGS
THE PROBLEM WITH MEETINGS
ANATOMY OF A GREAT MEETING
FIRST PHASE: BEFORE THE MEETING
SECOND PHASE: DURING THE MEETING
THIRD PHASE: AFTER THE MEETING
A TEMPLATE FOR ALL YOUR MEETINGS: THE TEAM MEETING ORGANIZER
TEAM MEETING GROUND RULES
BRUCE TUCKMAN AND THE FOUR STAGES OF TEAM DEVELOPMENT
UNDERSTANDING DIFFERENCES IN PEOPLE’S BEHAVIOR
REFERENCES
CHAPTER 27: How to Help Your QI Team Become a High‐Performing Team
THE USUAL REASONS WHY WE LAUNCH A QI TEAM
WHAT MAKES A TEAM, A TEAM?
THE CHALLENGE FOR QI TEAMS IN HEALTHCARE
FRAMEWORK FOR BUILDING A HIGH‐PERFORMING TEAM
THE FIRST STEP TO HIGH PERFORMANCE
THE TEAM “BUILDING BLOCKS”
HIGH LEVERAGE BEHAVIORS OF HIGH‐PERFORMING TEAMS
FOCUS ON THESE SIX DRIVERS TO ACHIEVE HIGH PERFORMANCE
HOW TO IMPROVE TEAM COMMUNICATION
WORKING WITH TEAM CONFLICT: THE KEYS TO MANAGING IT
CONFLICT RESOLUTION AND THE THOMAS KILMANN INSTRUMENT
REFERENCES
CHAPTER 28: Steps and Strategies for Effective Decision‐Making
PROBLEM‐SOLVING VERSUS DECISION‐MAKING
DECISIONS: TYPES & CONDITIONS
SOURCES OF ERRORS AND BIASES IN PEOPLE’S DECISION‐MAKING PROCESS
THE DECISION‐MAKING PROCESS
FOUR WAYS QI TEAMS CAN MAKE DECISIONS
IMPROVING THE EFFECTIVENESS OF A TEAM’S DECISION‐MAKING PROCESS
REFERENCES
CHAPTER 29: What Neurosciences Can Teach Us to Motivate People to Change
STORIES FROM THE FRONT LINES OF HEALTHCARE: “MAKE IT HAPPEN”
THERE IS NO IMPROVEMENT WITHOUT CHANGE
WE THINK OF CHANGE IN TERMS OF OUR OWN INTEREST
THE TRADITIONAL APPROACH TO MAKING CHANGE HAPPEN
TO UNDERSTAND CHANGE, WE NEED TO UNDERSTAND THE DRIVERS OF HUMAN BEHAVIOR
TO UNDERSTAND CHANGE WE NEED TO UNDERSTAND THE DRIVERS OF SOCIAL BEHAVIOR
CHANGE IS PSYCHOLOGICALLY PAINFUL
BASIC PRINCIPLES FOR LEADING A SUCCESSFUL CHANGE INITIATIVE
THE WINNING CHANGE STRATEGY
FIRST, MAKE IT SAFE: REMOVE UNCERTAINTY
SECOND, CREATE THE RIGHT CONDITIONS TO SAFEGUARD STATUS AND AUTONOMY
THIRD, MAKE IT STICK AND INTERNALIZE THE CHANGE
REFERENCES
CHAPTER 30: How Does it All Fit Together? The MRI Suite at St. Mary’s Hospital
SIMULATION BACKGROUND
THE FIRST “R”: THE RIGHT PROJECT
THE SECOND “R”: THE RIGHT PEOPLE
THE THIRD “R”: THE RIGHT PROBLEM
THE FOURTH “R”: THE RIGHT CAUSE
THE FIFTH “R”: THE RIGHT SOLUTION
APPENDIX
Appendix I: Common Improvement Tools and Techniques
Appendix II: Glossary of Improvement Terms
Additional Resources
BOOKS
ARTICLES
WEBSITES
Index
End User License Agreement
List of Tables
Chapter 2
TABLE 2‐1 THE QI PROJECT STEPS CHECKLIST
Chapter 3
TABLE 3‐1 Template for a Project Selection Matrix
Chapter 6
TABLE 6‐1 Heart Medical Center Hospital Roster
Chapter 12
TABLE 12‐1 Pros and Cons for Each Type of Data
Chapter 13
TABLE 13‐1 A Data Collection Planner Makes Our Data Collection Process Effect...
Chapter 14
TABLE 14‐1 Differences between research and quality improvement work.
TABLE 14‐2 The Anscombe’s Quartet data set.
TABLE 14‐3 The Anscombe’s Quartet summary statistics.
TABLE 14‐4 Analysis of Variation: the bottom line.
Chapter 15
TABLE 15‐1 The Run Chart Table for Interpretation of the Number of Runs
TABLE 15‐2 OTR Times for STAT ABGs at Mercy Hospital
TABLE 15‐3 Number of Narcotic Discrepancies at Chicago Med
TABLE 15‐4 C‐section Rates at London Memorial
Chapter 16
TABLE 16‐1 Door‐to‐Infusion Times for All Stroke Codes at Huron Medical Cente...
TABLE 16‐2 Calculation of Moving Range for Door‐to‐Infusion Times at Huron Me...
Chapter 17
TABLE 17‐1 Roadmap to Assess a Process’s Performance
TABLE 17‐2 Process Sigma Level Conversion Table
TABLE 17‐3 DVT Prophylaxis Process Sigma Levels
Chapter 18
TABLE 18‐1 The Cause and Effect Continuum
TABLE 18‐2 The Cause and Effect Matrix
Chapter 20
TABLE 20‐1 Paired Comparison Analysis
TABLE 20‐2 Paired Comparison Analysis Results
TABLE 20‐3 A Pugh Matrix
TABLE 20‐4 Solution Desirability Matrix Assessment Criteria
TABLE 20‐5 Solution Desirability Matrix Rank Results
Chapter 21
TABLE 21‐1 The PDSA Cycle Template
Chapter 22
TABLE 22‐1 The Aim of the 5S Steps
TABLE 22‐2 5S Audit Checklist
TABLE 22‐3 Mistake‐Proofing Techniques
Chapter 23
TABLE 23‐1 The Implementation Plan Checklist
TABLE 23‐2 The Impact Assessment Tool
TABLE 23‐3 A Stakeholder Analysis Template
TABLE 23‐4 Power & Influence Scores for Stakeholder Groups A to G
Chapter 24
TABLE 24‐1 First Tollgate Review Checklist
TABLE 24‐2 Second Tollgate Review Checklist
TABLE 24‐3 THIRD TOLLGATE REVIEW CHECKLIST
TABLE 24‐4 Fourth Tollgate Review Checklist
Chapter 25
TABLE 25‐1 The Different Roles for Communication
TABLE 25‐2 The Communication Planner
Chapter 26
TABLE 26‐1 The QI Team Meeting Organizer Template
Chapter 27
TABLE 27‐1 Characteristics of Teams versus Groups
Chapter 28
TABLE 28‐1 Conditions under which We Make Decisions.
Chapter 30
TABLE 30‐1 The QI Team Roster at St. Mary’s Hospital
TABLE 30‐2 Quick Wins: Waste Identification
TABLE 30‐3 The QI Project Metrics
TABLE 30‐4 List of Ideas for Improvement
TABLE 30‐5 Summary of QI Project Results
List of Illustrations
Chapter 2
FIGURE 2‐1 The new quality paradigm.
FIGURE 2‐2 The goal of improvement.
FIGURE 2‐3 The five “Rs” of all successful QI projects.
FIGURE 2‐4 The Project Roadmap.
Chapter 3
FIGURE 3‐1 Three main sources for project ideas.
FIGURE 3‐2 Project selection steps.
FIGURE 3‐3 Project types according to complexity and expected resistance.
Chapter 4
FIGURE 4‐1 The patient arrival‐to‐departure time at the PCP clinic.
Chapter 6
FIGURE 6‐1 The role of the QI team.
Chapter 7
FIGURE 7‐1 The SIPOC template.
FIGURE 7‐2 SIPOC diagram for “prescription to medication delivery.”
FIGURE 7‐3 A SIPOC diagram for “patient evaluation in the PEC clinic.”
Chapter 8
FIGURE 8‐1 The three types of customers in QI projects.
FIGURE 8‐2 The outcome expected by the customer (VOC) is defined by attribut...
FIGURE 8‐3 The CTQs are the specifications of the Voice of the Customer
FIGURE 8‐4 The attributes and requirements for patient satisfaction (CTQs) a...
FIGURE 8‐5 The attributes and requirements for staff and provider satisfacti...
Chapter 9
FIGURE 9‐1 Critical Needs tree defining the requirements for optimal perform...
Chapter 10
FIGURE 10‐1 Components of the system.
FIGURE 10‐2 A process is a series of interrelated steps, actions, and decisi...
FIGURE 10‐3 The Basic Process Flow map symbols.
FIGURE 10‐4 Basic Process Flow map for “turnover time (TOT) in the OR.”
FIGURE 10‐5 Swim Lane chart of “preoperative preparation.”
FIGURE 10‐6 The three flows of a Value Stream map.
FIGURE 10‐7 Current state Value Stream map for mammography at the Women’s Ce...
FIGURE 10‐8 Common process metrics for the Value Stream map.
Chapter 11
FIGURE 11‐1 TIM WOOD and the seven types of waste.
FIGURE 11‐2 Spaghetti diagram: a mapping technique to identify waste.
FIGURE 11‐3 Three types of process steps.
FIGURE 11‐4 The opportunity flowchart: a mapping technique to identify waste...
Chapter 12
FIGURE 12‐1 From concept to decision: concepts, measurements, data, and metr...
FIGURE 12‐2 The Voice of the Customer (VOC) defines what to measure.
FIGURE 12‐3 The Critical Needs (CN) of the front line can also define what w...
FIGURE 12‐4 The decisions of what to measure may need to be driven by stakeh...
FIGURE 12‐5 Project metrics to improve STAT chest X‐rays in the ICU are deri...
FIGURE 12‐6 Metrics of effectiveness assess our performance in meeting the s...
FIGURE 12‐7 Three types of data.
Chapter 14
FIGURE 14‐1 Different types of data require different types of summary stati...
FIGURE 14‐2 The Anscombe’s Quartet data set has a different interpretation w...
FIGURE 14‐3 The Graphic Analysis for different types of data.
FIGURE 14‐4 Types of histograms.
FIGURE 14‐5 The “box” and “whiskers” of a box plot.
FIGURE 14‐6 The individual value plot of patient falls in inpatient units pe...
FIGURE 14‐7 A Bar chart of “Critical care patients needing hemodialysis.”
FIGURE 14‐8 Time series plot of “Request To Administration (RTA) time at St....
FIGURE 14‐9 Relationships for Common Cause Variation.
FIGURE 14‐10 Relationships for Special Cause Variation.
FIGURE 14‐11 The improvement strategy.
Chapter 15
FIGURE 15‐1 Run chart of “Waiting time for mammography results” showing viol...
FIGURE 15‐2 Run chart of “Number of wasted prefilled syringes per day” showi...
FIGURE 15‐3 Run chart of “OTR times for STAT ABGs at Mercy Hospital’s MICU” ...
FIGURE 15‐4 Run chart of “Narcotic discrepancies at Chicago Med” showing the...
FIGURE 15‐5 Run chart of “C‐section rate at London Memorial” showing the num...
Chapter 16
FIGURE 16‐1 The Individuals and moving range (I‐mR) chart. Chart created wit...
FIGURE 16‐2 The three lines of an Individuals chart. Chart created with Mini...
FIGURE 16‐3 Individuals chart for “Catheter angioplasty balloon diameter” sh...
FIGURE 16‐4 The upper and lower control limits of the Individuals chart. Cha...
FIGURE 16‐5 Individuals chart showing violation of rule 1. Chart created wit...
FIGURE 16‐6 Zone A, B, and C on the Individuals chart can be used to detect ...
FIGURE 16‐7 Improvement in systolic blood pressure management appears as spe...
FIGURE 16‐8 Improvement in systolic blood pressure management is clearer whe...
FIGURE 16‐9 Types of Control charts for continuous and discrete data.
FIGURE 16‐10 Individuals chart of “door‐to‐infusion time” for all “stroke co...
Chapter 17
FIGURE 17‐1 There are four possible scenarios when evaluating a process’s pe...
FIGURE 17‐2 The relationship between specifications (VOC) and control limits...
FIGURE 17‐3 Data outside the upper and lower specification limits are consid...
FIGURE 17‐4 Capability analysis of “Catheter angioplasty balloon diameter” s...
FIGURE 17‐5 Assessing a process’s performance. Stability and capability guid...
Chapter 18
FIGURE 18‐1 Problems come from the interaction of actions and conditions.
FIGURE 18‐2 Path to analysis of
y
.
FIGURE 18‐3 Tools to identify potential causes of a problem.
FIGURE 18‐4 Fishbone diagram.
FIGURE 18‐5 Fishbone diagram showing the possible causes of Amenorrhea.
FIGURE 18‐6 An example of a The 5 whys diagram.
FIGURE 18‐7 Pie chart.
FIGURE 18‐8 Conditions for the Pareto principle to apply. Chart created with...
FIGURE 18‐9 This Pareto bar chart that does not hold the Pareto Principle. C...
FIGURE 18‐10 Pareto bar chart strategy.
Chapter 19
FIGURE 19‐1 Options for the analysis of the cause and effect.
FIGURE 19‐2 Tools used in the quantitative analysis of the cause and effect....
FIGURE 19‐3 The scatterplot.
FIGURE 19‐4 The scatterplot scatter tightness reflects the strength of the r...
FIGURE 19‐5 Positive and negative values for the Pearson coefficient.
FIGURE 19‐6 Analysis of residuals.
FIGURE 19‐7 Hypothesis testing for continuous data.
FIGURE 19‐8 Hypothesis testing for proportions.
Chapter 20
FIGURE 20‐1 The Double Diamond model.
FIGURE 20‐2 Tools for the divergent phase to generate a list of ideas.
FIGURE 20‐3 Tools for the convergent phase to filter and prioritize the best...
FIGURE 20‐4 The Impact Effort matrix.
FIGURE 20‐5 The How‐Now‐Wow matrix.
FIGURE 20‐6 The FMEA tool.
FIGURE 20‐7 Calculating the FMEA’s Risk Priority Index.
Chapter 21
FIGURE 21‐1 The PDSA is an acronym for Plan‐Do‐Study‐Act.
FIGURE 21‐2 The PDSA cycle steps and actions.
FIGURE 21‐3 The PDSA cycle is a systematic series of steps to gain valuable ...
Chapter 22
FIGURE 22‐1 The three types of process steps.
FIGURE 22‐2 Causes of time delay between value‐added (VA) steps.
FIGURE 22‐3 Strategy to create and improve process flow.
FIGURE 22‐4 Sequence to creating and improving flow.
FIGURE 22‐5 Approach to improving a queue.
FIGURE 22‐6 The red tag technique used for Sort in 5S.
Chapter 23
FIGURE 23‐1 The four zones of a Power & Influence (PxI) diagram.
FIGURE 23‐2 Stakeholder analysis using a Power & Influence diagram for stake...
FIGURE 23‐3 Stakeholder Analysis using a Stakeholder Bar Graph.
FIGURE 23‐4 Sponsor Analysis using an organizational chart.
Chapter 26
FIGURE 26‐1 Anatomy of a great meeting: what to do before the meeting.
FIGURE 26‐2 Anatomy of a great meeting: what to do during the meeting.
FIGURE 26‐3 The four stages of team development by Bruce Tuckman.
Chapter 27
FIGURE 27‐1 The four dimensions of team performance.
FIGURE 27‐2 The six drivers of team performance.
FIGURE 27‐3 The team cycle drives the team to a successful work product.
FIGURE 27‐4 The Johari Window.
FIGURE 27‐5 The Thomas‐Kilmann Conflict Mode Instrument.
Chapter 28
FIGURE 28‐1 The six‐step decision‐making process.
Chapter 29
FIGURE 29‐1 Success of change initiatives in healthcare.
FIGURE 29‐2 The brain’s Central Organizing Principle.
FIGURE 29‐3 Change affects our behavior through the Central Organizing Princ...
FIGURE 29‐4 The effects of change on our social needs.
FIGURE 29‐5 The Change Strategy.
Chapter 30
FIGURE 30‐1 The project scope and boundaries: the SIPOC diagram.
FIGURE 30‐2 The Critical Needs tree for the MRI staff.
FIGURE 30‐3 A Basic Process Flow map for an MRI study.
FIGURE 30‐4 Current state Value Stream map for an MRI study.
FIGURE 30‐5 Bar chart comparing the percentage of inpatients to outpatients....
FIGURE 30‐6 Bar chart showing the most common MRI scan protocol used.
FIGURE 30‐7 Pareto Bar chart showing the duration of the most common scan. C...
FIGURE 30‐8 Histogram showing “Scanner idle time” at baseline (before improv...
FIGURE 30‐9 Run chart of “Scanner idle time” before improvement. Chart creat...
FIGURE 30‐10 I‐mR chart of “Scanner idle time” before improvement. Chart cre...
FIGURE 30‐11 A Time Series plot (Run chart) of “Scanner idle time” shows the...
FIGURE 30‐12 Capability analysis of “Scanner idle time” shows a 50% defect r...
FIGURE 30‐13 Pareto Bar chart showing the most common causes of turn‐over ti...
FIGURE 30‐14 Fishbone diagram of possible causes of “Waiting for the next pa...
FIGURE 30‐15 Pareto Bar chart showing the most common cause of “Waiting for ...
FIGURE 30‐16 Histogram of “Scanner idle time” (turn‐over time) after improve...
FIGURE 30‐17 Histograms comparing “Scanner idle time” before and after impro...
FIGURE 30‐18 An I‐mR chart of “Scanner idle time” after improvement shows Co...
FIGURE 30‐19 Before and after Individuals chart of “Scanner idle time.” Char...
FIGURE 30‐20 A Process Capability report of “Scanner idle time” after improv...
FIGURE 30‐21 Capability Analysis of “Scanner idle time” before and after imp...
Guide
Cover Page
Title Page
Copyright Page
Dedication Page
Why This Book?
About the Authors
List of Stories, Examples, Exercises and Case Studies
About the Companion Website
Table of Contents
Begin Reading
Appendix I: Common Improvement Tools and Techniques
Appendix II: Glossary of Improvement Terms
Additional Resources
Index
Wiley End User License Agreement
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The Quality Improvement Challenge
A Practical Guide for Physicians
Richard J. Banchs, MD
Associate Professor of Anesthesiology
Associate Head, Department of Anesthesiology
Director, Quality and Safety
University of Illinois Hospital and Health Sciences System
USA
Michael R. Pop, SSMBB, MBA
Director of Business Process Improvement
Omron Automation Americas
USA
This edition first published 2021
© 2021 John Wiley & Sons Ltd
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The right of Richard J. Banchs and Michael R. Pop to be identified as the authors of this work has been asserted in accordance with law.
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Library of Congress Cataloging‐in‐Publication Data
Names: Banchs, Richard J., author. | Pop, Michael R., author.Title: The quality improvement challenge : a practical guide for physicians / Richard J. Banchs, Michael R. Pop.Description: First edition. | Hoboken, NJ : Wiley‐Blackwell, 2021. | Includes bibliographical references and index.Identifiers: LCCN 2020039053 (print) | LCCN 2020039054 (ebook) | ISBN 9781119698982 (paperback) | ISBN 9781119699002 (adobe PDF) | ISBN 9781119699019 (epub)Subjects: MESH: Quality Improvement | Physician's Role | Quality of Health Care–organization & administrationClassification: LCC R690 (print) | LCC R690 (ebook) | NLM WX 153 | DDC 610.69/5–dc23LC record available at https://lccn.loc.gov/2020039053LC ebook record available at https://lccn.loc.gov/2020039054
Cover Design: WileyCover Image: © Artur Debat/Getty Images
To Dr. David E. Schwartz, my Chair, who believed in me and supported me in my endeavors; to Alexander, Brandon, Kristian, and Luca, my kids, who patiently read my drafts and asked many thought‐provoking questions; and to Sharon, my wife, who stands by me with every new adventure.
Richard J. Banchs, MD
To my beautiful wife, Lorelle, who continues to support me on my continuous improvement journey through life. She makes me a better man.
Michael R. Pop, SSMBB, MBA
Why This Book?
Efforts to improve the quality of healthcare have focused on increasing accountability, measurements, and new payment models. These and other efforts have failed to achieve a meaningful and sustainable improvement. Patients continue to experience fragmented, impersonal, inconvenient, and unsafe care while providers are increasingly becoming burned out by a system overburdened with administrative tasks. The current approach seems at odds with the mission of providing high‐quality care. A fundamental change is needed in how we deliver care, and how we go about improving it.
It is widely accepted that physician leadership is an essential requirement for successful quality improvement efforts. Yet physicians have been reluctant to engage, either because of the constraints of their overbooked clinical schedules, their perception of QI, or because quality priorities are often set by outsiders rather than chosen by physicians based on their insights, experience, and expertise. As a result, physicians have been marginally involved in operational improvement, and for the most part, have relinquished that responsibility to managers and hospital administrators. A strategy for improving healthcare delivery that continues to ignore the engagement of physicians is doomed to fail. Physicians should lead improvement efforts: they are well positioned to accept the improvement challenge. They have valuable insights into processes, have been trained as problem‐solvers, and making things better speaks to their intrinsic motivation. Their engagement is critical, will serve their patients well, and may be the new role physicians need to gain a sense of purpose, restore their identity, and decrease burnout.
This new role is going to require knowledge and skills that graduate and postgraduate education has not provided. To date, medical education has focused almost exclusively on the acquisition of scientific knowledge and clinical facts. This book has been written to fill this knowledge gap. Principles and practices of improvement methodology, team dynamics, and organizational change management are presented in a straightforward and clear way for any physician, young or seasoned, seeking a template for an improvement initiative. The material in this book synthesizes current knowledge on the subject from multiple authoritative sources and combines disciplines as diverse as Lean, Six Sigma, Human‐Centered Design, and Neurosciences for organizational change. The goal is to provide the reader with an integrated and systematic approach to quality improvement projects and a roadmap to address the unique, change‐resistant features associated with the healthcare environment. It is our hope that physicians everywhere will embark on an improvement journey, for the benefit of their patients, organizations, and themselves.
Richard J. Banchs, MD
Michael R. Pop, SSMBB, MBA
About the Authors
Richard J. Banchs, MD is a board‐certified pediatric anesthesiologist. He is a Lean Six Sigma Black Belt and Change Management Experienced Practitioner. Since 2007 he has been combining his clinical responsibilities with improvement work. He has successfully used the improvement framework described in this book in the deployment of a broad variety of large‐ and small‐scale projects in the US and abroad. These improvement initiatives have included QI projects in operating rooms, emergency departments, outpatient clinics, and inpatient units both in small hospitals and large academic centers with the goals of improving quality, performance, and patient and provider’s satisfaction.
Dr. Banchs compiles his improvement knowledge and years of clinical experience in the front lines into a road map for healthcare practitioners to achieve success in their quality improvement projects. By being on both sides of the equation, he can offer a global perspective on the nature of improvement work and the best strategies to overcome the barriers to improvement in healthcare. In this book, he shares his knowledge and expertise with any physician wishing to successfully improve the practice of medicine.
Since 2013, Dr. Banchs has been teaching improvement methodology to staff, residents, and faculty at the University of Illinois Hospital in Chicago. He has served as the senior director of the Organizational Process Improvement (OPI) office, and is currently the Associate Head for Quality and Safety for the Department of Anesthesiology.
Michael R. Pop, SSMBB, MBA is a Lean Six Sigma Master Black Belt. He is an accomplished Quality Professional with 30 years of experience enhancing operations and leading teams through the implementation of effective solutions to permanently resolve quality issues. He is currently the director of Business Process Improvement for the Omron Automation Americas group. Prior to his current role, he was a senior consultant with Illinois Business Innovation Services spending the majority of his career providing Quality Systems Management, Lean, Six‐Sigma, Quality Management, and Quality Engineering support to various industries, including diversified manufacturers, education, healthcare, government and not‐for‐profits.
He has assisted multiple hospitals and clinics in implementing Lean Six Sigma Operations and has coached and mentored numerous healthcare leaders in the use of Statistical Process Control techniques to improve both process and healthcare services. As a quality consultant, Mr. Pop has assisted numerous organizations with becoming registered to ISO 9001, a set of international standards on quality management and quality assurance. He has trained over 200 Lean Six Sigma Black Belts and 500+ Green Belt students, helping them implement effective, efficient, and cost‐effective processes resulting in more than $20 million in savings for their organizations.
Michael R. Pop has a Master of Business Administration and a bachelor’s degree in Mechanical Engineering Technology, both from Purdue University, and is a Certified Six Sigma Master Black Belt, Certified Quality Engineer, and a Certified Quality Auditor. He is currently a senior member of the American Society for Quality (ASQ).
List of Stories, Examples, Exercises and Case Studies
Stories from the Front Lines of Healthcare
Martha Sanchez, the Head of Housekeeping (
Chapter 4
)
Turn‐Around Time for X‐rays in the ED (
Chapter 5
)
Andrea, the QI Project Manager (
Chapter 10
)
Wait Time in the Orthopedic Outpatient Clinic (
Chapter 18
)
The Early Discharge QI Project at Memorial Hospital (
Chapter 23
)
The NICU Team at St. Agnes Hospital (
Chapter 25
)
Brandon, the Ambulatory Clinic manager (
Chapter 26
)
“Make It Happen” (
Chapter 29
)
Examples
First‐Case On‐Time‐Start Accuracy at Fond‐du‐Lac Medical Center (
Chapter 4
)
Patient Arrival‐to‐Departure Time at the PCP Clinic (
Chapter 4
)
A SIPOC diagram for St. Barnabas Preoperative Evaluation Clinic (
Chapter 7
)
The “Customer” of a STAT Arterial Blood Gas (ABG) (
Chapter 8
)
Supply Chain Management for Patient Care Units (
Chapter 8
)
Patient Satisfaction with UI Health Outpatient Care Center (
Chapter 8
)
Improving the Organization of Medical Supplies in the EDRR (
Chapter 8
)
Improving MRI Patient Throughput (
Chapter 9
)
Improving STAT Chest X‐Rays in the ICU (
Chapter 12
)
Temperature Management on Arrival to the ED (
Chapter 13
)
Stratification Factors for “Time from Order to Arrival of TPN Bag” (
Chapter 13
)
Order‐to‐Result Time at Mercy Hospital (
Chapter 15
)
Narcotic Discrepancies at Chicago Med (
Chapter 15
)
C‐section Rate at London Memorial (
Chapter 15
)
The Individuals and Moving Range (I‐mR) Chart of a Patient’s SBP (
Chapter 16
)
Door‐to‐Infusion Time at Huron Medical Center (
Chapter 16
)
Improving DVT Prophylaxis (
Chapter 17
)
Medication Error before Initiating CPB (
Chapter 18
)
Patient Satisfaction with the ED Visit (
Chapter 18
)
Exercises
A Problem Statement and Project Charter for Your QI project (
Chapter 4
)
The QI team at Heart Medical Center (
Chapter 6
)
CTQs for the New Women’s Center (
Chapter 8
)
Mapping “Ordering Blood from the Blood Bank” (
Chapter 10
)
Identifying “Waste” in the Pediatric Unit (
Chapter 11
)
In‐training Examination at Mass General Hospital (
Chapter 18
)
Case Studies
Improving RTA Time at St. Michaels Hospital (
Chapter 14
)
Door‐to‐Infusion Time at Huron Medical Center (
Chapter 16
)
The New Balloon Angioplasty Catheter at UIC (
Chapter 17
)
Decreasing Unplanned Readmissions after Tonsillectomy (
Chapter 20
)
About the Companion Website
This book is accompanied by a companion website:
www.wiley.com/go/banchs/quality
The website includes:
Powerpoints of supplementary material of project templates and forms.
Scan this QR code to visit the companion website.
PART ITHE BASICS
CHAPTER 1The Problem with Healthcare
SO, WHAT’S THE PROBLEM?
In the last 20 years, science has made a number of transformational changes that have impacted the way we think about healthcare. Targeted cancer therapy, drug‐eluting cardiac stents, 3D printing, and the human genome project are but a few of the advances that have revolutionized medicine. Yet how we deliver care and the healthcare experience have not improved at the same rate. Despite significant efforts, regulatory mandates, and the sacrifice of many in the front line we have not achieved our goals of providing safe, efficient, and cost‐effective care for all. Standards and benchmarks often lag or fail to be followed, best‐practices have been slow to spread, and quality differences have persisted among providers and geographic areas. These accounts, coupled with highly publicized medical malpractice litigation, have eroded patients’ trust in the healthcare system.
The current crisis isn’t new. It has evolved over the last 30 years to the current level of intensity that we now face and can no longer ignore. Reports including the Institute of Medicine’s “To Err Is Human” (Kohn 2000), “Crossing the Quality Chasm” (IOM 2001), and “Transforming Healthcare: A Safety Imperative” (Leape 2009) have highlighted the inability of the healthcare system to reliably provide safe, high quality, cost‐effective patient care. The crisis has deepened by rising expectations of patients who are accustomed to a retail setting, where services are customer‐driven, efficient, and accessible 24/7 through mobile connectivity, and are demanding the same from healthcare. A true “patient‐to‐consumer revolution” (Wyman 2014) is demanding increased access, service, personalization, and speed from a healthcare system that is slow, inconvenient, confusing and difficult to navigate. Competition among healthcare organizations is no longer based solely on reputation, but on service, value, and price.
In this environment, healthcare organizations face a significant pressure to provide high‐quality, state‐of‐the‐art patient care while lowering costs and improving patients’ care experiences. These demands exist in the context of heightened accreditation requirements, uncertain governmental mandates, decreasing reimbursement, and overwhelmed clinicians and administrators. The negative results are experienced by both patients and healthcare professionals.
HOW DID WE GET HERE?
Many factors have contributed to the current state of affairs and the inability of healthcare to reliably deliver safe, high‐quality, cost‐effective patient care. Worth mentioning is an out‐of‐date business model, healthcare’s organizations’ inefficient organizational structure, the traditional quality paradigm, and an ineffective physician compensation model.
The business model.
Healthcare organizations have been anchored in a business model that may have been successful in the past but has outlasted the circumstances that created the need for it. Despite the needs of the current marketplace, healthcare organizations have continued to focus on providing a full spectrum of healthcare services, that is, all services to all patients. Clayton Christensen in his book
The Innovator’s Prescription
(Christensen 2009) describes two types of business models that any organization can follow: a
solution shop,
where a healthcare organization focuses on diagnostic activities, and a
value‐adding process
where the focus is on the efficient delivery of care and specific treatments. Christensen argues that these two models are different, and they require different resources, processes, organizational structures, and profit models. With the current technological and scientific progress, healthcare challenges, and diversity of needs, trying to provide all services to all patients is the wrong value proposition. The combination of these two models under one roof creates a system that requires an enormous amount of resources, and results in inefficiencies, waste, and duplication of efforts. It creates a system that functions, as Michael Porter describes, as a “confederation of stand‐alone units that replicate services” (Porter
2016
). For every dollar spent, a reported 30 cents are wasted in steps that do not add value, the result of excessive bureaucracy, defensive medicine, and duplication of services.
Organizational structure.
Healthcare organizations have customarily been organized according to clinical specialties. While this originally arose from the need to maintain the competency of clinicians to deliver high‐quality care, this structure has created
clinical silos
that have resulted in fragmented care and dysfuntional workflow across the healthcare organization. Rather than organizing care around specialty departments and special services, care should be organized around medical conditions with multiple subspecialties and teams converging on the specific patient condition. In the current system, effective synchronization, collaboration, and communication are often not present and are more often than not the cause of rework, mistakes, complications, and wasteful spending.
The quality paradigm.
In the
traditional quality paradigm
, quality was defined by the provider and by the effectiveness of care. In this view, quality is achieved when the right treatment is administered in response to a specific recognizable pattern, and results in the elimination of the disease condition. This long‐held view of quality ignored additional dimensions of quality care, such as the need for efficiency, timeliness, and patient‐centeredness (IOM 2001). Focusing only on effective care resulted in a healthcare experience that fell short of patients’ expectations. The traditional quality paradigm, a lack of oversight, and the inability of physicians to regulate their own profession has had a significant impact on the quality of care. As a result, we have seen unethical practices, high rates of patient injuries, and injustices in the ability to access care (Berwick
2016
).
The physician compensation model.
Incentives for payment have been completely misaligned with the goals of improving the quality of care. Providers and healthcare organizations have been paid for number of procedures performed (volume‐driven payment) rather than for the outcome and quality of care (value‐driven payment). This has resulted in excessive and unnecessary procedures, overly used diagnostic services, increased insurance premiums, and procedure‐related complications.
THE CHALLENGES TO IMPROVE HEALTHCARE
Efforts to improve the quality of care have focused on performance metrics, complex incentive formulas, and increased scrutiny from regulatory agencies. These and other measures have not addressed the real problem and, for the most part, have not significantly improved the quality of care. Patients continue to be disappointed with the healthcare experience, and staff and providers are getting increasingly burned out from the overwhelming day‐to‐day administrative burden. There is a generalized frustration among providers working in a system that is inefficient, overcomplicated, and seemingly at odds with the mission of providing high‐quality care. Despite significant efforts to improve, we have not achieved our goals. Accountability based on metrics developed by outsiders has failed to engage physicians, and too much of the efforts of healthcare organizations is spent on submitting reports, preparing for accreditation surveys, and ensuring adherence to regulatory mandates. Meeting the objectives of specific organizational metrics has become an all‐consuming activity, rather than developing a strategic and comprehensive improvement agenda. There is no question that the work involved to ensure survey readiness and regulation compliance is important, but too much effort is directed at achieving core measure targets and not enough on system redesign. By prioritizing improvement initiatives that address the underlying processes related to the regulatory compliance and core measure targets, we could address both regulatory mandates and improve the healthcare experience.
Quotable quote: “We are faced with a series of great opportunities brilliantly disguised as insoluble problems.” John W Gardner
Healthcare organizations continue to invest resources to improve the delivery of care but face unique challenges that impact the effectiveness of the improvement efforts they pursue. Process improvement is not easy, and it requires a clear understanding of the barriers:
The culture.
The primary role of a healthcare organization is to provide care to patients, a high‐stakes undertaking that may exacerbate patients’ clinical conditions if errors occur. As a result, healthcare professionals are risk averse, conservative, and hesitant to try new things compared to other industries. When quality improvement (QI) teams and organizations try to implement changes, they often encounter a resistant culture that labors to maintain the status quo. Incongruously, providers and staff often resist the adoption of standards and other evidence‐based guidelines that support improved patient outcomes in favor of time‐honored, and sometimes outdated, traditional approaches to patient care.
Silos.
Improvement initiatives are difficult in healthcare organizations unaccustomed to leveraging teamwork across silos to accomplish their goals. Silos not only exist within the clinical specialties but also exist between the clinical and the operational areas in healthcare organizations. These silos often cut from the top of the organization down to the front line staff members. They impact the effectiveness of any improvement initiative, ultimately leading to a fragmented operational approach that focuses only on individual tasks and departments without considering the entire patient experience. Coordination and collaboration give way to “suboptimization,” where every unit pursues its own “targets” independent of the needs and aims of the organization as a whole.
A lack of IT support.
Improvement initiatives depend on and should be guided by data. But QI teams often find it difficult to get their basic needs fulfilled, having to allocate additional team resources, or rely on manual data collection to obtain the data they need. It is difficult to understand why staff and providers have to struggle to get a report of the same data they just entered into the hospital’s electronic medical record.
A lack of active participation of senior hospital leaders.
The role of the leader is to legitimize improvement projects and facilitate the work of the improvement team. The leader establishes priorities for competing initiatives; provides resources for the team; resolves cross‐functional issues, and removes roadblocks that impede the success of the project. Senior leaders in healthcare are often not visible, active, or engaged in QI projects. When leaders are not present, projects flounder, have difficulty reaching their objectives, and often fail. Leaders are vital in building a coalition of key sponsors to achieve project success and facilitating change.
A lack of improvement experience.
Healthcare professionals often lack the experience and formal training needed to address the complex performance problems of the healthcare delivery system. Postgraduate healthcare education continues to be almost exclusively focused on the acquisition of scientific and clinical facts, and has not included the knowledge and skills that define competency in improvement work. QI competency needs to be developed with rigor, heightened focus, and consistency like any other discipline. Because they lack experience, often staff and providers rely on their subject‐matter expertise to complete a QI project. They fail to follow the required structured systematic approach and cannot achieve the goals of the improvement initiative. Improvement knowledge does not come as a natural evolution of clinical expertise. Improvement capability is not a natural ability!
The team dynamics
. QI teams in healthcare are often multidisciplinary in nature and are convened in an ad‐hoc manner, from different areas or departments. There is usually very little time to ensure cohesive functioning of the team members to avoid “silo” mentality. Physicians, nurses, staff, and administrators are brought together and expected to work as a team, even if they have never done so in the clinical arena.
A top‐down approach to improvement.
With multiple competing clinical priorities, improvement projects are often left in the hands of leaders and small teams of specialized subject‐matter experts (SMEs). This traditional model is no longer effective and cannot achieve the operational improvements in the large scale that are needed in today’s healthcare organizations. Engagement of the front line is critical to succeed and, yet, is not always present. This traditional approach to QI perpetuates the belief that
process improvement is the responsibility of a small number of individuals in the organization and it does not have the same critical nature as the “clinical side” of care
. Even when the front line is engaged, organizations don’t provide sufficient time, resources, or support. It becomes challenging to convene regular meetings with key stakeholders who must juggle their clinical and nonclinical responsibilities with project activities.
Lack of a robust change management strategy.
There is often more focus on the technical or clinical aspects of the problem than on how the solution will be received by the front line. It is important to remember that
all improvement is a change, and change is going to have a significant effect on the professionals in the front line
. Change management is often an afterthought, with the main focus being on designing, testing, and deploying the solution that addresses the needs of the project. Managing the effects of change is often reactive, and implemented without a clear plan. Communication and engagement with the front lines is not given sufficient emphasis leaving the project team unable to implement the much‐needed solution.
Too many competing initiatives.
In healthcare, there are too many competing initiatives that result in
improvement fatigue.
Healthcare providers face a constant barrage of mandates to change practice from external stakeholders, including accrediting organizations, regulatory bodies, third‐party payers, and professional associations. Front lines often become overwhelmed by the number of changes that occur in their work routines. There is a lack of leadership with proper selection, stratification, and improvement focus at the front line.
Excessive focus on the methodology rather than the improvement opportunity.
In the late 1980s, healthcare organizations began incorporating industrial quality‐management methodologies including Lean, Six Sigma, and Lean Six Sigma in their strategies to improve delivery of care. The Lean Six Sigma approach attempts to address the non‐value‐added activities, inefficient workflows, and disorganized work environments that interfere with clinicians’ ability to provide safe, high‐quality patient care. It merges the customer‐orientation and waste‐reduction techniques of Lean (time‐driven focus) with the more statistical and data‐driven systematic error reduction strategies of Six Sigma (quality‐driven focus). When implemented as an overarching management system and organizational philosophy, Lean Six Sigma process improvement methodology has been shown to improve patients’ experience, staff and providers’ work environment, and the quality of patient care (Nicolay
2012
). Not all QI projects have been successful using Lean Six Sigma. Some teams have had disappointing results. For these teams, Lean Six Sigma lacked some of the critical elements they needed for success. When applied to medicine, industrial quality management methodologies have several problems:
Heavy use of technical and business terminology. These improvement methodologies are derived from the manufacturing sector and often carry with them an overemphasis on improvement jargon that seems complex, counterintuitive, and far removed from the clinician’s front line.
Improvement is often carried out by small teams of certified Lean Six Sigma practitioners who make up their own distinct department. These SMEs lead improvement efforts in a “top‐down” approach but often fail to create the conditions for the front line stakeholders to engage. Changes are pushed through without the front line professionals’ involvement in developing, revising, or monitoring the performance of key processes.
Physicians have a limited understanding of these improvement methodologies and in general regard them as something outside of the scope of medicine, showing little interest in learning them. Most industries make great products with average employees working with brilliant processes. Healthcare does great work with brilliant employees working with mediocre processes.
WHAT IS THE PHYSICIAN’S ROLE IN PROCESS IMPROVEMENT?
It is widely accepted that physician engagement is an essential requirement for any successful quality improvement project, and yet we have not seen the full engagement of clinicians. Physicians have a pivotal role within the organization. However, they are often not involved in healthcare organization improvement efforts, either because of the constraints of their overbooked clinical schedules or because of the perception that they are not directly responsible for the improvement of the operational aspects of delivering care.
Physicians express a strong support for QI projects, but often have a different view of what this entails. Although this is probably not you (the reader!), physicians in general
View improvement projects as taking time away from patient care, interfering with their schedule, and adding complexity to their workflow, even when that very workflow is the cause of the problem. This unfavorable view of QI projects is further perpetuated when their improvement efforts are not recognized with professional advancement or other incentives.
Are often reluctant to participate in QI projects because they believe the improvement initiative will be ineffective.
View quality assessment as an integral element of the practice of medicine and resist any improvement initiative that challenges this view.
View clinical guidelines and pathways as hampering individual provider’s freedom.
Have a lack of expertise in project management, team dynamics, and communication.
Physicians have historically been responsible for the quality of clinical care by virtue of their credentials. This has resulted in their implicit expectation that the burden of operational improvement should be left to staff and hospital administration, a tenet described by Kornacki as “The Physician Compact” (Kornacki 2012): “The Physician Compact is an implicit psychological contract that defines the actions physicians believe are expected of them and the response they expect in return from their employers.”
