Don’t get caught in the activity trap
Focus on results expected from QI project
By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR
It has happened to everyone. A quality improvement (QI) project team is formed to achieve an improvement goal, and the group gets sidetracked on the action plan. This can happen when members of the team don’t share the same sense of clarity around the problem.
The activity trap sets in when the team establishes a goal that focuses on the activity needed to solve the problem rather than on the results expected from the QI project. The activity trap must be avoided to ensure that resources are being properly leveraged and quality goals are reached.
Let’s look at an example. The quality department has been asked to solve a problem that is loosely defined as overuse of potentially confusing abbreviations in patient records. A team of physicians, nurses, and other clinicians who document in patient charts is formed. After conducting two meetings, the team defines the goal of the project: Develop a list of abbreviations approved for use in patient records by Feb. 1.
The team spends considerable time research-ing medical abbreviations and obtains lists of approved abbreviations used by other hospitals. They work hard and meet their deadline. The list of approved abbreviations is circulated to the medical staff, nursing, and other clinical departments. The team celebrates and disbands — they completed their task and all is well, right?
Wrong. The problem was that no actual change in practice took place. When departments received the list of approved abbreviations, it probably received some attention from the director and a small percentage of physicians and staff members. But within days, the urgency diminished and the outcome (no use of unacceptable abbreviations) was not satisfactory. Another high-activity project with negligible results!
Results-oriented goals
What went wrong in the abbreviation project? The process for sharing the approved abbreviation list was weak, and unfortunately, the activity of creating the list did not address the flaws in the process that allows for use of nonapproved abbreviations. What the team should have done differently was to dig into the cause of the problem and define results-oriented goals.
The team should have measured the scope of the problem by examining existing practices. How does information get documented in the patient’s chart? What disciplines are responsible for the majority of ambiguous abbreviations? What will motivate people to change their long-standing abbreviation habits? Who will approach people and ask them to rewrite the chart note or order when a nonapproved abbreviation is used? Who is best qualified to discuss the patient safety concerns associated with abbreviations with medical staff and hospital departments? What format would be most effective for sharing the list of approved abbreviations? How will compliance with the new abbreviation requirements be measured?
Once these questions are addressed, the team can construct results-oriented goals. In this example, it could have been: By Feb. 1, share information about the safety hazards associated with abbreviations with 100% of physicians and staff members who write in patient records. By March 31, identify acceptable abbreviations and those not considered appropriate. By April 30, 100% of physicians and staff members who write in charts will receive education in the use of acceptable abbreviations. Decrease the use of nonapproved abbreviations to zero by June 1.
Notice the difference between the results-oriented goals and the original activity-focused goal formulated by the team?
Creating a list of approved abbreviations is nothing more than an activity. It is not a quality result. It does not ensure that any improvement will occur after the action is implemented. That’s not to say that a list of approved record abbreviations is the wrong thing to do. In fact, such a list is a common starting point for this type of QI project. But creation of the list is an enabling step toward the result, not the result. Often people become so engrossed in the activity that they lose sight of its purpose or they ignore new facts that affect the end result of the project.
The activity trap is prevalent in health care organizations. Think about how many QI projects you have with goals like this: Create a database; make a recommendation; conduct a survey; provide training. These are all activity goals. They may be enablers to results, but they are often so disconnected from a real quality result that the effect is never felt. All of these activities keep QI project teams busy; however, they use up resources and can end up accomplishing very little.
Sometimes, focusing on an activity is safer than tackling the real problems that are driving the quality concerns. Teams may need an extra push from leadership to become results driven. Right from the outset of the project, you may sense some confusion among participants when the goal is discussed. There may be lots of dialogue around the subject because everyone on the team has something to contribute; however, the group may end up being unclear as to what it actually is trying to accomplish. Teams can lose focus or enthusiasm when this happens.
To keep the team on track toward results, one very helpful technique is to ask the question: In your own words, what is the problem we are trying to solve? Ask the team members to take a few minutes silently and independently to write their answers on a piece of paper. Then ask each participant in turn to read his or her response to the full team. Amazingly, answers often vary widely or may even conflict. In some situations, people may indicate that they have no idea what the problem is that the team is trying to solve.
This questioning technique allows the team leader to address potential roadblocks up front. The QI project should not proceed until the team is able to develop a clear statement of the problem that makes sense to everyone. This keeps team members focused on mutually agreed upon results. A clear problem statement eliminates ambiguity and misunderstandings.
Once the problem statement is formulated, ask team members: What will happen if we don’t solve this problem now? The answers to this question will allow the group to judge the problem’s priority level.
If the consequence of not solving the problem is a potential loss of revenue or increased likelihood of patient harm, it should be viewed as a high-priority problem. If, however, solving the problem would not have a significant impact on financial or clinical outcomes, it may be difficult to garner sustained enthusiasm from the team members. Instead of tackling a low-priority problem, ask the team to redefine the challenge until everyone agrees that it makes sense to fix it now. When the QI project team is committed to a purpose, everyone’s eagerness to resolve the problem grows rather than diminishes.
When organizations fall into the activity trap, many quality problems don’t get completely resolved, and some even get worse. The activity trap kills motivation for continual improvement activities. To stay out of this trap, be sure QI project teams focus on results, not activities, and share the same sense of clarity, urgency, and enthusiasm around a quality problem.
It has happened to everyone. A quality improvement (QI) project team is formed to achieve an improvement goal, and the group gets sidetracked on the action plan. This can happen when members of the team dont share the same sense of clarity around the problem.
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