The Quality Improvement Challenge. Richard J. Banchs
creating a network of middle‐level leaders to support the changes. Successful improvement initiatives must rely on the collective efforts of all leaders, both clinical and operational.
2 Shared knowledge. Improvement competency needs to be supported and shared throughout the organization. For a healthcare organization to be successful with its improvement agenda, a large portion of the front line must be trained in the knowledge and skills that define improvement competency. Improvement knowledge needs to be democratized. Improvement capability cannot just be in the hands of a small team of experts while the front line lacks the skillset to successfully complete a QI project. Outsourcing process improvement expertise (i.e., hiring a consultant) cannot be the only solution. Relying solely on expert consultants often results in short‐lived success and considerable expense. Investing in human capital and broadening the base of improvement experts within an organization is a more cost‐effective and permanent strategy. To that end, educating healthcare providers and staff to become the future leaders of improvement initiatives keeps the path moving toward an improved healthcare delivery system.
3 Physician driven. Physicians need to look at the practice of medicine through a new paradigm: knowledge of patient processes – how diseases affect physiology – is as important as the knowledge of system processes – how the system and its components affect the delivery of care. While therapeutic interventions improve the health of our patients, redesigning processes improves the health of the system in which care is delivered. Physicians need to be engaged and drive the improvement and change management initiatives. They have a pivotal role and are the linchpin that drives the success of improvement efforts. Today’s physicians have two roles: deliver outstanding clinical care and improve the quality of the healthcare delivery system.
GUIDING PRINCIPLES
These five guiding principles are the values that establish our framework for all improvement efforts in the healthcare environment:
1 Problems need to be approached using the lens of the customer. To understand a problem, we need to see the problem from the lens of the people who experience them; we need to “walk” in their shoes, understand their issues, and be willing to address their needs. Improvement is only realized when we place the end user’s needs and experiences at the heart of the process. Value is created by focusing the efforts of staff and providers on the needs and expectations of the patient or the end user. End users are the experts of their own experience, and are central to the process of creating a solution that delivers on their expectations.
2 Consider the people who deliver care as the key to the solution. The people who deliver care and experience the problems of the system are the key; we need to bring them along in the improvement process because they are the ones who understand the system and hold the key to the solution. Healthcare professionals see and understand the challenges our patients face. Their understanding of the process and proximity to the patients makes them uniquely suited to identify and deliver potential solutions that can improve the healthcare experience. To improve, we must engage providers and staff. They have a pivotal role and are the linchpin that makes possible the success of the improvement efforts. Front line stakeholders have valuable insights into their processes and the barriers they face in delivering high‐quality patient care, but they often have minimal opportunity to share that proficiency in modifying their workflows. In most organizations, there is an enormous reservoir of “energy, ideas, and engagement that is never tapped into because of management practices that reduce intrinsic motivation and hinder joy and creativity in work” (Rena Awdish 2018).
3 Be willing to try, fail, and try again. Improvement in healthcare is complicated. Improvement is an imperfect process that requires our willingness to design and test solutions, and when they fail, to learn from our mistakes. In a risk‐averse culture such as healthcare, improvement is difficult. We just need to make sure that our failures do not harm our patients. Engaging in the right kind of testing produces the right kind of failures from which we can learn. Quotable quote: “Fall seven times. Stand up eight.” Japanese proverb
4 To improve, sometimes we must think “out of the box.” The traditional formula of continuous incremental improvements sometimes delivers disappointing results when it comes to the operational side of healthcare. We may not achieve the dramatic results we expected, largely because we may have been trying to improve the “old way” of doing things. Sometimes we have to stop focusing on improving what appears to be outdated models that were successful in the past but have outlasted the circumstances that created the need for them. For these processes, improvements cannot address what is fundamentally wrong with them. They have underlying deficiencies in their conceptualization, structure, job design, workflows, and control mechanisms because they were designed to address the needs of a different time. Improvement cannot succeed when it relies on an obsolete paradigm. When this is the case, we must redesign our processes using our knowledge, and a clear understanding of the needs of our patients.
5 Consider all improvement a change. All improvement is a change, and change is always met with varying degrees of resistance. For change to occur, QI teams must create a space where growth can develop, giving the frontline professionals the opportunity to understand the problem, discuss barriers to success, and engage in the co‐creation and implementation of solutions. The effectiveness of our improvement effort results not only from the quality of the solution but also from the engagement and buy‐in of the frontline professionals. If staff and providers do not accept the change, it is very unlikely that improvement will succeed. We must understand what drives change at the front line, and then design strategies to overcome the natural resistance that so often derails our improvements efforts. Change cannot succeed without the commitment of the people that it will affect.
THE FIVE “RS” OF EVERY QI PROJECT
All projects need a structured approach that moves through several distinctive phases. To achieve the goals of any QI project, an improvement team needs to successfully transition through five phases (see Figure 2‐3). These phases define a logical flow to problem solving that starts with understanding the problem and continue through dissecting the process to identify root causes of defects and breakdowns, and creating solutions that address the needs of the people that experience the problem.
FIGURE 2‐3 The five “Rs” of all successful QI projects.
Each phase follows the Project Roadmap, drawing from a set of steps and tools to help reach the final destination (see Figure 2‐4).
FIGURE 2‐4 The Project Roadmap.
The first “R”: The Right Project. First, identify project opportunities. Once you have selected your project, ask yourself: Is this the right project? Is this project feasible? Can the project goals be achieved? Confirm feasibility, jot down some ideas, and write the first draft of your Problem Statement. Then create your Project Charter. The Problem Statement and Project Charter will help you and your team focus on the right project.
The second “R”: The Right People. All projects must have the “right people on the bus” (Bossidy 2002). Projects need a senior leader (primary sponsor) to legitimize the project, provide resources, and resolve cross‐functional issues. The primary sponsor must be present and active throughout the lifecycle of the project. Project teams need a competent leader and team members from the front line with subject‐matter expertise and the appropriate mix of skills.
The third “R”: The Right