Why process improvements don’t last
Provide resources for behavior change
By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR
Imagine that you’re the performance improvement director at a large and successful hospital. You’ve just learned about a new initiative that will revolutionize patient flow. This initiative represents a significant advancement over your organization’s current efforts and has a proven track record for improving communication of patient information during hand-offs between units. You train everyone in how to use this new initiative and kick things off with a great fanfare. Yet, six months down the road the initiative is struggling just to survive. The intended activities are all but stopped, expected performance results are nowhere to be seen, and the people who seemed so enthusiastic a few short months ago now seem ambivalent, or worse, cynical. So, what happened? And what do you do next?
Scenarios such as this are all too common and not unique to improvements attempted in patient care departments. Any process improvements, both in clinical and non-clinical areas, can fall victim to similar outcomes.
Many organizations have tried a variety of strategies, approaches, and initiatives intended to bring about improvements, only to find that enthusiasm doesn’t always translate into actions. People who seem to genuinely care about continuous improvement aren’t engaged by the new initiative, oftentimes slipping back into doing things the way they had always been done.
Even facilities that have achieved some successes can be haunted by lack of engagement. They may experience a lingering lack of trust between staff members and managers, struggles to maintain direction, or a long plateau after initial gains in performance. A common question for all organizations striving to make things better: Why don’t people change?
Instead of assigning blame, it is helpful to examine the underlying reasons behind failed improvement projects. There are several common symptoms to watch out for and practical steps that can be taken to build a high-performing organization.
It may be hard to understand why people don’t automatically adopt the changes necessary to achieve a higher level of performance. After all, no one wants to be known as a low performer, especially when it is clear what needs to be done to make improvements. Yet it turns out that a good improvement strategy is only part of the battle.
When implementing process change is a struggle, it is often because of built-in cultural roadblocks to success. The culture, or "the way we do things around here," can be such that physicians, managers, and staff are actually discouraged from participating in improvement initiatives. These cultural roadblocks often are so ingrained that they are not easily recognized. This leads to a cycle of missed improvement opportunities and frustration.
The revolving door syndrome is an example of a malady that affects many improvement initiatives. Employees can become hesitant to commit to anything when they have been subjected to many changes involving the same process over a short period of time. The same thing can happen when there is high turnover in improvement models used within the organization. Employees learn that it’s better to just "go through the motions" rather than invest in an effort that soon will be abandoned. Also known as "flavor of the month," the revolving door effect can go on for years, generating a sense of impermanence around improvement activities and cynicism about the organization’s commitment to quality and its ability to solve problems. As a result, managers and senior leaders will find it increasingly difficult to get buy-in for new improvement initiatives.
Excess baggage is another malady that affects improvement initiatives. This baggage shows up as negative cultural attitudes. Good employees, at any level in the organization, often acquire this baggage through years of flawed work experiences. Negative experiences that contribute to employee baggage don’t have to be major events. They can be as simple as seeing financial priorities take precedence over a patient safety concern or failure on the part of management to follow through on a promise for assistance. While every organization experiences occasional lapses in fairness or consistency, prolonged or repeated lapses lead employees to form beliefs that the organization does not care about them, doesn’t treat them fairly, or even that certain high-level people in the organization are not credible. The baggage that physicians and employees get from these experiences makes generating the commitment for an improvement effort very hard to do.
Even without the revolving door effects or disruptive baggage, managers and senior leaders can be frustrated in their attempts to communicate improvement objectives and priorities. One hospital CEO recounted the story of his recent implementation of a "zero tolerance" patient safety policy. The goal of the policy was admirable; the CEO sought to create an environment where patient safety was the deciding factor on how work was performed. However, this vision meant different things to people at different levels within the organization. As the initiative was communicated from managers to supervisors, the intent went from "Let’s not trade patient safety for improved financial performance" to "We won’t settle for any unsafe processes." By the time the message was communicated to front-line staff, the message had become, "We won’t stand for any mistakes" — a message that was drastically different from the CEO’s original vision. Communicating about quality and patient safety is critical to performance improvement. But when people at different levels perceive the goal of such initiatives to be punitive, employees will be discouraged from investing in the change effort.
Finally, many organizations inadvertently handicap themselves by not providing the resources that employees need to change their behavior and adopt new practices. Performance improvement initiatives require people to change how they approach tasks and job duties. When people lack the skills or tools needed to integrate new tasks into their daily routine, they are less likely to view the improvement initiative positively. And if employees feel that the burden has been put on them alone to make the new initiative succeed, they are likely to question the level of the organization’s commitment to quality.
When an initiative requires people to take on new responsibilities, learn new skills, and integrate new tasks into their existing activities, success depends on having a supportive culture. Characteristics that research has shown are indicative of high-performing organizations and predictive of successful improvement initiatives are:
- teamwork — the effectiveness of workgroups in meeting targets and deadlines;
- workgroup relations — the degree to which coworkers respect each other;
- procedural justice — the level that employees rate the fairness of first-level supervisors;
- perceived organizational support — the level to which employees feel the organization is concerned for their overall well-being;
- leader-staff member exchange — the strength of relationship that workers feel they have with their supervisors;
- management credibility — the perception of consistency and fairness of management in dealing with employees;
- organizational value for quality and patient safety — the perceived level of the organization’s commitment;
- upward communication — the adequacy of upward messages about quality and patient safety;
- approaching others — the probability that employees will speak to each other about performance issues.
Organizations without these characteristics are more likely to find it a struggle to implement improvements. Staff members may readily see quality problems but not feel comfortable discussing them with co-workers. Supervisors may want to provide support to ongoing improvement projects but may perceive that productivity is more highly valued by their managers. Managers and senior leaders may want to broaden improvement initiatives but may be hampered by scant involvement of physicians or front-line staff.
Moving performance improvement initiatives beyond cultural roadblocks takes an approach that targets every level of the organization. The first step is to develop an accurate picture of how your organization is functioning right now.
Cultural assessment tools are available from many sources, including the Agency for Healthcare Research and Quality (www.ahrq.gov/qual/hospculture).
Using this assessment as a blueprint, the leaders should define your desired culture in terms that are measurable and attainable. For example, for the characteristic of management credibility, the desired culture could be described as one in which managers consistently follow through on commitments, supervisors demonstrate fairness in personnel decisions, and managers hold themselves to the same standards and expectations as high-performing organizations.
Research repeatedly has shown the most critical factor in the success of quality and patient safety improvement efforts is leadership. Through what they choose to focus on and how they go about doing the things they do, leaders telegraph what is really important to the organization. Using the characteristics of high-performing organizations as a guide, leaders can develop personal action plans that target specific activities in their sphere of influence, such as communication of patient safety priorities, providing adequate resources for removing the barriers to high-quality and safe performance, and setting stretch expectations.
Supervisors have the most influence over day-to-day activities that affect performance outcomes. They can smooth the way by providing work coverage so employees can participate in improvement projects, engaging in problem solving at the front-lines, and integrating quality priorities with productivity needs. Organizations must support supervisors in these efforts by providing positive reinforcement for improvement activities and training in performance management skills.
Front-line employees are at the heart of all systems and processes. To get staff members to participate in new performance improvement initiatives, organizations need to provide mechanisms that allow for meaningful involvement. One way to do this is by engaging staff in capturing data on performance problems and using those data to remove barriers that hinder high-quality, safe practices.
The trend toward increased reporting of patient incidents by front-line staff is an example of how to engage employees in patient safety. But they will only remain engaged as long as the incident information is used to make positive workplace or process changes. If promised improvements don’t materialize, the experience will become just another piece of excess baggage.
Quality and patient safety improvements rely on more than a good strategy; they requires a receptive organizational culture. High-performing characteristics such as trust, communication, and teamwork create a culture where important change initiatives are readily integrated with daily activities.
Imagine that youre the performance improvement director at a large and successful hospital. Youve just learned about a new initiative that will revolutionize patient flow. This initiative represents a significant advancement over your organizations current efforts and has a proven track record for improving communication of patient information during hand-offs between units.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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