The Quality Improvement Challenge. Richard J. Banchs
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THE CHANGE SPACE
A QI project is always a change project. Change rolled out “top down” often fails because it is rarely embraced, and results in doubt, pushback, and even open resistance. To be embraced, change must be socially constructed (Hamel 2016). Successful change requires an engaged front line. Engagement
happens when the front line is given the opportunity to be involved in the improvement process, and;
requires participation in the search for causes and the creation of possible solutions. Quotable quote: “In times of change the learners will inherit the earth, while the knowers will find themselves beautifully equipped to deal with a world that no longer exists.” Eric Hoffer
Frontline professionals must share responsibility for change needs. All successful projects need a change space, or framework, that engages frontline professionals in a shared vision of the problem and the co‐creation of solutions. The role of the improvement team is not to find solutions and implement changes but to create the conditions and provide the tools that enable the front line to find solutions.
REFERENCES
1 1. Awdish R. (2018). Keynote Speaker. Institute for Healthcare Improvement National Forum.
2 2. Bossidy L. (2002). Execution: the discipline of getting things done. Random House.
3 3. Hamel G. (2016). Build a change platform, not a change program. McKinsey & Company.
4 4. Pennington R. (2017). The Pennington Group. www.penningtongroup.com.
CHAPTER 3 The Project Selection Process
WHERE DO I START?
Ask the Right Questions
Improvement projects are launched to address patients’ expectations for quality and service; frontline staff and providers’ workflow issues; a department’s strategic initiatives; or disappointing performance and undesirable outcomes. If you clearly know what problem you are going to address, then you are ready to move to the next steps. But if you are not sure where to focus your efforts, start with the right questions.
Scan the environment, listen to people, and observe the work environment around you. Start by asking yourself these four questions:
1 What is important to my patients? What are their needs and expectations? What do they want from the care we provide? Where does our performance fall short?
2 What are the needs of providers and staff? What do they need to succeed? What are their challenges? What are their “pain points”?
3 What is my area struggling with? What are the issues affecting us (unit or department)? What are the strategic initiatives planned for this year? Where do we fall short in our performance?
4 What is my hospital struggling with? What are some of the hospital’s strategic initiatives, and how do these translate to my daily work? What issues affect our hospital (healthcare organization)?
The answer to these and other questions may give you an insight into what improvements are most urgently needed. Sometimes a quality improvement (QI) project idea may come from your own daily experience. What are you struggling with? What are the challenges and barriers that prevent you from doing your work? What can be improved in your work environment?
Your personal experience, the needs of your patients, and challenges of the frontline staff and providers are all sources of project ideas. If you are a healthcare leader, all ideas should be considered: top‐down from supervisors and leaders and bottom‐up from providers and frontline staff. Anyone should be able to suggest an improvement idea. Timely, constructive feedback should be provided by leaders to those who forward an improvement idea, regardless of the final decision to move ahead with a QI project.
Consider the Three “Voices” for Project Ideas
In general, project ideas come from three sources. We call them the voices. They are the “Voice of the Customer,” the “Voice of the Stakeholder,” and the “Voice of the Process” (see Figure 3‐1).
FIGURE 3‐1 Three main sources for project ideas.
The Voice of the Customer (VOC)
The VOC is the expression of the needs and expectations of the customers. In healthcare, patients are our “customers,” and their needs and expectations should drive our QI efforts. However, as in healthcare, most organizations have two types of customers:
1 External customers. These are our patients. We launch improvement projects to address their needs, concerns, and expectations. When we listen to our patients at the point‐of‐care, review patient surveys, or speak to their families we may find patients’ expectations are not met. We may then ask ourselves, how can we improve the care we provide and make their experience a better one?
2 Internal customers. The internal customers are the staff and providers at the front line. Sometimes the customer is not the patient. Frontline staff and providers depend on others for the work they do. They are the end users. Clinical practice involves caring for patients. But to care for patients, providers and staff need consultations, diagnostic imaging, lab work, demographic and insurance information, nutritional services, and so on. Providers and staff provide services to patients, but in turn depend on other providers and staff for their work. When these providers and staff receive the work product of other providers and staff, we call them customers. The providers and staff that perform services for other providers and staff are called stakeholders. Stakeholders are the professionals “doing the work.” Improvement initiatives sometimes are needed to improve the work products our internal customers receive. Example: When you, as a provider, order a chest X‐ray, you are the “customer,” not the patient. The patient will benefit from the treatment approach you prescribe and is the ultimate and last customer. But for the chest X‐ray, you are the customer. What will happen if the radiology technician routinely takes an hour to show up? What if the official reading of a STAT chest X‐ray takes a day? What if a large number of chest X‐rays are overpenetrated, underpenetrated, or miss the costo‐phrenic angle? You, the customer, will not be happy (and rightfully so!). Based on the VOC (internal customer), the radiology department may decide to initiate a QI project.
The Voice of the Stakeholder (VOS)
The VOS is the expression of the needs and requirements of the frontline professionals. Stakeholders are the frontline staff and providers; they are the people “doing the work”; they are the professionals with the subject‐matter expertise and knowledge of the process. Stakeholders understand the system and are the experts needed for the process to deliver what the customer needs and expects. Stakeholders may be staff, physicians, nurses, or