The 4 Clinical Teams Needed to Drive Sustainable Improvement

clinical teamsMost healthcare organizations and clinical teams understand the ongoing need to make improvements to their clinical, financial, and operational outcomes. Not only do these improvements affect patient outcomes, quality of life, and overall healthcare experience, but as the industry shifts from fee-for-service to pay-for-performance and accountable care, there are now financial viability drivers. An organization that can improve care receives reimbursement bonuses, avoids penalties, and is established as the provider of choice in its area.

Best Practices Clinical Content and Healthcare Analytics Are a Start

One of the methods health systems use to improve quality and influence outcomes is to acquire an extensive library of evidence-based protocols, best practices, order sets, guidelines, and other literature, which they then make available through a centralized best practice system. Even the most dedicated clinicians are challenged to keep up with the volume of information. The goal of the best practice system isn’t just to collect and store information, but to make it easy for clinicians to get the information they need.

Making sense of all the data an organization is accumulating about patient populations through EHRs, financial systems, claims systems, patient satisfaction ratings, and other technologies is also important. Most of these systems primarily collect and store data the way a blood bank collects and stores blood. They’re not designed to combine data from the various systems to deliver deeper insights and guidance around the quality and cost of care. To achieve a deeper level of insight, a healthcare analytics system is needed. The analytics system reveals variations in care, the most effective treatments and protocols, the areas or providers that show opportunities for improvement, as well as several other measures that reflect organizational performance. Today most organizations have made initial forays into analytics either through applications attached to their EHR, best-of-breed analytics applications, or a full-on data warehouse analytics initiative.

Many healthcare organizations believe that having a great best practice and analytics system is all that is needed to achieve clinical quality improvement. This approach may be sufficient for a series of one-off initiatives, but as improvement efforts expand, it becomes difficult to systematically improve and sustain care across the organization. In order to make quality improvement sustainable, one more element is needed: a cross-functional, team-based approach that accelerates the implementation of change throughout the organization. This is where clinical teams and the adoption system come into play. Without a adoption system, improvement initiatives become a series of science projects that provide temporary performance improvement but soon return to the previous level.

Establishing Clinical Teams Makes Improvement Actually Happen

One of the most important aspects to remember when building any sort of team structure is all the team members must be integrated from across the organization and the team must be permanent. If a team is thrown together to perform an analytics-based process improvement, and then disbanded once improvement begins, gains made will not be sustainable. It is critical for the team to remain accountable and to continue monitoring performance to sustain success. For example, one healthcare organization decided to use a rotating team of surgeons on a “whoever is available that week” basis only to see the clinical quality improvement effort fail.

Team members must be engaged and understand the long-term commitment required to drive sustainable change in any improvement effort. Attending meetings, analyzing data, offering evidence-based recommendations, and providing workflow understanding may feel like a full-time job. In smaller organizations it is likely that participation on an improvement initiative team will be on top of other duties, so it is important that team members understand the time required.

Building a successful adoption system requires a commitment from at least four teams:

  • Leadership team—This team is accountable for and prioritizes all quality initiatives across the healthcare organization. Team members generally include C-level executives such as the CEO, CMO, CNO, CIO, and CMIO. This group understands the big picture strategy for the hospital or health system and can help identify who within the organization is capable of leading an improvement initiative.
  • Guidance teams—These teams are accountable for clinical quality across the continuum of care in a specific domain (e.g., Women and Children’s or Cardiovascular) and consist primarily of clinicians and administrative leaders. Their role is to set goals within their clinical area (or domain), prioritize work, allocate resources, foster communication, and eliminate barriers to ensure successful, continuous process improvement. Guidance teams assign accountability to Outcomes Improvement teams to improve care within a care process family. An outcomes analyst who understands statistics and data may also be helpful to assist with data analysis. The Guidance team reports their progress to the Leadership team.
  • Outcome Improvement teams—Usually a physician and nurse who are well respected within their specialty and can influence other clinicians within specific areas of the organization lead these teams. The teams consist of front-line staff who possess a fundamental knowledge of each major activity within a care process family such as heart failure, AMI, CABG, etc. Their role is to refine work group outputs, lead implementation of process improvements, and create work group teams to perform the detailed processes within a care process family.
  • Work groups—This is where the heavy lifting of quality improvement occurs. A physician and nurse subject matter expert generally lead these cross-functional teams. A pharmacist, respiratory therapist or a finance or lab director can also lead depending on the type of improvement project being implemented. These small teams also include analytics and technical experts. The work group develops aim statements, identifies interventions, drafts knowledge assets (such as order sets, patient safety protocols, etc.), define the analytic visualizations, and provide ongoing feedback of the status of the care process improvement initiatives. Outputs from this team are taken to the Outcomes Improvement team for review.

Effective leaders, selected based on their knowledge of the clinical or organizational process, as well as their leadership, facilitation and communication skills, are critical to the success of the initiative. Clinical team members should also be prepared to lead their co-workers through the improvement processes that have been developed and help drive the change in practice.

Clinical Teams Taking Action

Once the teams are established, the Outcomes Improvement team develops goal statements and the workgroups identify aim statements. To gain buy-in clinicians need to have a sense of ownership in developing clinical improvements – and ensure the teams are rowing in the same direction.

Take heart failure, for example. The Cardiovascular group may agree heart failure issues need to be addressed. However, to one person or group that may mean reducing readmissions and improving compliance on CMS’s metrics. Another part of the team may want to focus on risk stratification for best utilization of resources, while others believe transitions of care should be the priority.

Implementation of a Key Performance Analysis (KPA) tool will enable the team to analyze the data and determine which areas will deliver the best ROI. The team’s knowledge of organizational readiness will help determine which initiative will have the greatest impact and chance for success. The Guidance team presents the recommendations for approval to the Executive team. Upon approval, the priorities are shared with the Outcomes Improvement team to establish a work group to address them The goal is to ensure alignment throughout the adoption system and a clear vision of what needs to be done – and why.

Agile Development Key to Success

Clinical quality improvement does not have a beginning, middle, or end. As such, employing Agile development methods is important. Agile development lends itself to an ongoing, iterative approach that allows continuous improvement over time. It also provides teams with the ability to change priorities quickly if original assumptions about the current state are incorrect.

An example:

A healthcare system wanted to build an exclusive breastfeeding subject area mart (SAM) for the enterprise data warehouse (EDW). The initial quality goal was to increase the number of mothers who were breastfeeding. As work began the team discovered there was an issue with documentation: nurses were inputting information in 10 different places due to the design of the EHR. This variation in practice meant there were no reliable baseline data about breastfeeding—and no good foundation for outcomes improvement.

The permanent group, clinicians from several states who were passionate about breastfeeding, set aside their original plan and focused first on developing a comprehensive “quick chart” that allowed nurses to document all the information related to breastfeeding in one place in the EHR. The entire process, from identifying the issue to implementing the finished quick chart system-wide, took just two-and-a-half months. The flexibility built into the system enabled the team to quickly pivot and address this unforeseen issue. Once accurate data was loaded in to the EHR, the team was able to focus on the original initiative: increasing the number of mothers who breastfeed.

All Three Systems are Critical to Success

Having all three systems in place – best practice, analytics, and adoption –is critical for creating sustainable clinical process improvements.

The adoption system is often the most difficult to implement as it can’t be purchased in the same way as order sets or analytics technologies. It requires real, ongoing commitment from leadership and the cross-functional team to ensure success. Without investing in a adoption system it is impossible to drive and sustain true clinical process improvement.

What has your experience been? How has your adoption mechanism been set up? Did it include multi-level as well as multi-functional teams? What were your keys to success? And how does what we shared here align with your organization’s approach?

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