The Quality Improvement Challenge. Richard J. Banchs
In the clinical arena, there are several project types and approaches to improvement. We have chosen to call them type I, type II, and type III.
Type I. These are the quick wins and “just do it” projects. These are rapid‐improvement projects usually initiated by an individual or a small team to address a simple problem that affects a limited area. People are just trying to make their workflow or work environment better. This type of project usually seeks a practical and inexpensive solution, which is typically already known or requires little investigation. The project needs a loose framework and can be done in a couple of days. Examples of a project type I are: Improve the organization and prioritization of incoming faxes; make sure patient demographic information is documented in the chart accurately and in a timely fashion; organize a supply room.
Type II. The project addresses a simple performance problem that affects a small area or department. The root causes of the problem may be known or unknown, but the solution in general is not known. The project requires some data, the use of some improvement tools, and basic statistics. There is a low to moderate risk if the solution fails. These projects are done using different frameworks and tools. For example
Kaizen events. A Kaizen event (the word comes from the Japanese) is a focused, short‐term project event attended by leaders, mid‐level managers, and frontline staff and providers to make improvements to an existing process for which they are responsible for. A Kaizen event is traditionally scheduled as a week‐long event.
A3 projects. A3 is a structured problem‐solving and continuous improvement approach that is simple, visual, and provides a structure to guide individuals or teams in problem solving. The approach typically uses a single sheet of ISO‐A3‐size paper to document all the information that relates to the project. The A3 sheet includes seven common sections: background, current conditions, goals, analysis, solutions, plan for improvement, and follow‐up.
Rapid Cycle Improvement. A team leader takes mid‐level managers and frontline staff and providers through a four‐step improvement cycle called the PDSA cycle: Plan‐Do‐Study‐Act (see chapter 21). The PDSA cycle helps the team understand the problem, formulate a hypothesis, develop a solution, create a plan of action, test the solution, and learn from the experience. Solutions are developed quickly and implementation can be done rapidly.
Type III. These projects require the engagement of a formal QI team in order to address a complex performance problem that affects a core process. These are big projects. The root causes of the problem and the solution/s are unknown. These projects usually require the QI team to come up with a multifaceted solution. The change will affect multiple departments and/or locations, and may impact a large number of people. Type III improvement projects require an in‐depth analysis of the problem, a stepwise structured approach, and a large amount of data used for statistical analysis. There is high organizational risk if the solution fails. Adequate resources and leadership are critical. Examples: Improve throughput in the Emergency Department; improve turnover time in the operating rooms; decrease complication rates on the patient care units.
PROJECT TYPES FROM THE LENS OF CHANGE
All improvement is a change, and change is always met with varying degrees of resistance. You can also sort projects according to the amount of effort required to find a solution and the engagement or push‐back you can expect (see Figure 3‐3).
Type A. These projects require a small investment of time to find the right solution. Once the solution has been appropriately trialed, the proposed changes will be well received and rapidly adopted by staff and providers. These types of projects require a small team and limited resources.
Type B. These projects require significant efforts to find the best solution. However, the proposed changes will be generally well accepted and rapidly adopted by the front line. These projects require leaders and teams to focus on finding the best solution.
Type C. These projects require a formal investigation of the causes, and a structured approach to finding the solution. Changes will be met with pushback and resistance from the front line. These projects are common in the clinical setting, where best‐practice and clinical pathways are being implemented.
Type D. These are complex projects. They require significant resources to find the most likely cause of the problem and the best solution. Once the solution is rolled out full‐scale, the QI team is going to encounter significant pushback and resistance from key stakeholders. These projects are resource intensive for leaders, teams, and healthcare organizations, and require experience in both project and change management.
FIGURE 3‐3 Project types according to complexity and expected resistance.
HOW TO ESTABLISH YOUR PROJECT’S TIMELINES
Administrators, sponsors, and clinical leaders may require an estimated project duration to monitor the project and ascertain when they can expect project deliverables. Other project stakeholders and frontline employees may need to know the estimated project timeline to evaluate the feasibility of their participation in the project. All face multiple competing priorities every day. They may hesitate to become involved in your project if they fear the project is going to interfere with their other responsibilities. You should develop a project schedule based on realistic estimates of activity duration prior to engaging team members. The two most common scheduling practices are schedule set and PERT:
Schedule set. The QI team may receive the expected timeline for implementation of process improvements by senior leadership or the primary sponsor. Based on the expected date of project completion, you may have to work backward to determine the amount of time you can allocate for each activity to develop the project schedule. Schedule activity estimates can be a one‐point, best‐guess estimate based on your quality improvement experience in conducting similar process improvement projects, or historical information from the organization’s subject‐matter experts. These estimates can provide a general guide to a projected project timeline, initially with progressive specificity as the project activities unfold.
Program Evaluation and Review Technique (PERT). Another way to develop a schedule is to use the Program Evaluation and Review Technique, which relies on historical information or expert opinions to approximate optimistic, pessimistic, and most likely estimates of the duration of each activity, which are then combined to yield the project schedule. The formula for determining the activity duration using PERT is: (O + P + 4ML) / 6, where O is the optimistic estimate, P is the pessimistic estimate, and ML is the most likely estimate.
Regardless of the method of estimating that is used, the schedule will need to be updated when new information becomes available. You may need to align your project activities with the schedule, as the project team members, leaders, local sponsors, and frontline stakeholders usually have multiple conflicting priorities with restricted availability for project work. When the schedule gets off track, two schedule‐compression techniques may be employed in an attempt to restore the timeline:
Parallel processing involves performing two activities that are usually completed in a sequential manner in a parallel manner instead. This technique increases the risk of rework due to the change in the process.
Crashing involves using additional human resources to complete the activity faster. This technique impacts the cost of the project according to the type and number of resources used. It may also be performed