Take the lead out of quality improvement projects
Don't accept sluggish changes
The purpose of quality improvement projects is to help people and organizations become more efficient, reduce wait times, cut costs, and provide better service faster. Quality improvement teams themselves, however, typically waste as much as 40% of their time clarifying mission statements and rehashing the same issues, says Chip Caldwell, FACHE, vice president of the Juran Institute, a quality management firm based in Wilson, CT.
A team may spend as many as 60 days developing a mission statement that should have taken no more than four or five hours, he says. Accelerating the slow pace of quality improvement projects has been an ongoing concern of Caldwell, who runs Juran's health care improvement division. The Juran Institute has pioneered a three-phase program for accelerating quality improvement projects that Caldwell says can trim months off reform efforts, resulting in huge savings for organizations.
The Mayo Clinic in Rochester, MN, which sought help from Juran, is averaging a half million dollars in savings every five weeks as a result of its accelerated improvement projects, Caldwell estimates. As a result, in 1995 Mayo will realize a total of more than $17 million in cost reductions, he projects. To combat the most common delays in quality improvement, Caldwell suggests three basic steps:
* Develop a process to create a mission statement within a few hours after an idea or problem is identified.
It doesn't take a rocket scientist to charter a team within three hours of identifying a problem, says Caldwell. "It's just a matter of setting a goal and sitting down and doing it," he says.
* Reduce the redundant work that frequently occurs in team meetings.
The solution to redundancy is to hold team meetings of no less than 90 minutes, but preferably two hours, every week, says Caldwell. "If it's been a couple of weeks since you've been in a meeting, whether it's a committee or a team, the first third of the meeting is devoted to just rehashing what happened last time," Caldwell says. Typically the team is just getting down to business when the hour is up. "By having a weekly meeting, you eliminate that entirely." The trick to making such meetings effective, however, is to ensure that the team mission is significant enough to warrant two hours a week.
For example, assigning a team to the task of reducing the length of stay for hip replacement surgery from 8.3 days to 7 days makes sense because that would represent a savings of several hundred thousand dollars for most organizations, says Caldwell. On the other hand, chartering a team to consider changing the type of suture used in a hip case would probably be a waste of resources.
"It's a matter really of degree and scope and return on investment," Caldwell says. "Organizations usually don't have a lot of help making that kind of decision. Teams get chartered, and over time what happens is people leave the meeting early, they come late, they get beeped in the middle of the meeting, and it's a clear signal that that topic really isn't that serious to people sitting around the table. It's the first symptom to look for."
* Plan for acceleration turns success of others into your success.
The third step in the Juran program involves what Caldwell has labeled "accelerated replication." This process involves implementing a structured method for recognizing, testing, and instituting advances made and published by other organizations. Following this plan, clinical chiefs and department managers meet on a monthly or biweekly basis to conduct literature reviews of quality improvement projects, to develop pilot programs, and to report on the results.
Promote the right team structure
Caldwell illustrates how this works by pointing to a study reported in the October 1994 issue of the Journal of Pediatric Disease that found wearing gowns and gloves in neonatal intensive care units did not reduce infections.
"Every hospital in this study saved $250,000 by eliminating gowning and gloving, and the infection rates went down," said Caldwell. If an organization has a structure in place to identify and try to replicate this kind of study, within a week an organization could begin realizing a quarter of a million dollar savings, he says. Without such a structure in place, says Caldwell, "someone might read that and say, 'Hey, that's a great idea. Why don't we think about doing that?' And by the time they get around to perhaps setting up something to discuss it, several months have gone by."
Another version of this process is what is known as "internal accelerated replication." As described by Maureen Bisognano, executive vice president/ chief operating officer for the Institute for Health Care Improvement in Boston, this method involves making a small improvement in one part of an organization and then replicating it where appropriate. This process enables an organization to institute manageable changes quickly, rather than trying to alter the whole system at once.
For example, one nursing unit may be assigned to work on pain management. Once they improve their performance, the results of their efforts can be passed on and implemented in other units.
In addition to providing the right team structures, promoting the right attitude about change is vital to ensuring the swift deployment of improvement projects. In particular, overcoming complacency is one of the greatest obstacles to the swift implementation of quality improvement programs. "Most people don't want to change. They're happy maintaining the status quo," says Ellen Gaucher, MSN, MPH, senior associate director at University of Michigan Hospitals in Ann Arbor. "Unless there's a crisis that says, 'Aha, we have to change or we're going to go out of business,' people would rather keep on doing what they've always done."
It is up to leadership to create the sense of urgency that will get the improvement process moving, Gaucher says. In choosing people to oversee quality improvement projects, look to those who are not happy with the status quo, says Joane Goodroe, RN, MBA, president of Goodroe & Company, an Atlanta firm that works with hospitals and physicians to re-engineer existing services.
"You want the people who are competitive in nature, and basically you want to produce data for them showing them that there is opportunity for improvement," she says."There are always people who fit into that category."
Another obstacle to accelerated quality improvement programs is lack of planning or vague concepts.
"What we try to teach people is leverage-point thinking so that they will do planning around key factors like what are the major reasons why patients complain about your organization or your system," says Gaucher. "Something that people can get their arms around."
Decide, for example, which diagnosis-related groups are the most common admissions in the organization and plan a strategy for reducing the cost on each one separately.
Gaucher also suggests using "stretch targets" to motivate people. "Each department in the organization has to ask itself, 'How can we help improve clinical diagnosis across the institution?' and they need to set a target," she says. For example, an improvement team may want to speed up the time it takes for the radiology department to get X-rays to physicians. If the turnaround time is currently an hour, the team may set a stretch goal to bring it down to fifteen minutes, Gaucher says. "That's how you generate some energy around the goal."
It's important to get people thinking about the difference between first- and second-order change in order to achieve "breakthrough" in quality improvement projects, Gaucher says. First-order change involves incremental, reversible improvements. Second-order change involves more systematic improvements that will stay in place permanently. (See story on achieving breakthrough, below.)
The best way to get physicians on board quickly with quality improvement projects is to take advantage of the traits that make them who they are: their scientific nature and their competitiveness, say Gaucher and Goodroe. Doctors work well with data and tend to respond positively when given evidence supporting a project, so it is important to present them with the facts behind new programs.
"They're very linked to the scientific projects and tools like control charts," says Gaucher. "Usually when you show them how the tools and techniques can make a difference, there are physicians who volunteer to get involved."
Using such techniques, the staff at the University of Michigan Hospitals were able to revamp their Breast Care Center in 212 days in 1995, Gaucher says. During the 212 days, they gathered 175 suggestions for improvements, came up with pilot projects to test new ideas, and added 50 appointment slots a week for new patients.
"Everybody said, 'Well, we just can't change; we just can't do anything differently.' And yet we were able to study it to look at some recommendations and then draft a series of pilot projects to begin to streamline the process for patient care in the breast cancer center, and it worked very well," Gaucher says. *
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