After you’ve worked on a sufficient number of projects, it’s easy to identify differences between those that deliver sustainable successful outcomes and those that deliver, shall we say, less-than-stellar results. From my experience, I can offer seven tips for quality improvement projects in healthcare. Here they are and what makes them tick:
1. Outcomes Versus Accountability Focus
Most outcomes improvement project teams operate under one of two precepts: measure for accountability or measure for improvement.
Projects that measure for accountability primarily focus on rewarding or punishing based on whether or not individuals adhere to certain processes and procedures. A classic example would be paying an individual physician a bonus (or charging a penalty) based on his or her compliance with some clinical initiative at a facility. The focus of those being measured quickly shifts to whether or not a specific data point is accurate for a particular individual. The project becomes mired in a slurry of minutia. When this happens, individuals worry about the negative spotlight and the ensuing punishment. With this approach, there is no rising tide that lifts all boats. Sure, some of the outliers at the bottom may improve, but personal interest takes priority instead of examining the process and focusing on interventions that will help move the overall mean. Outcome improvement is delayed or never reaches its full potential. Don’t get me wrong, measuring for accountability has its place, however it is important to evaluate if your project demands it or if it should instead focus on measuring for improvement.
Ok, so what does measuring for improvement really mean? It’s the concept that we focus on the process and not on individuals. It’s the concept that interventions to improve outcomes focus on the inliers and not on the bad outliers. It’s the idea that in looking to improve the process, we don’t waste time getting every data point 100 percent correct, but get the information and level of accuracy of information needed to move forward and evaluate if interventions are working or not. Instead of punishing the three individuals who have the worst outcomes for a particular surgery by denying them privileges to perform that surgery, focus on what causes the bad outcomes in the process and implement actions to ensure those outcomes don’t occur for all providers. It should be no surprise that the project that actually measures for improvement, improves the targeted outcomes much more quickly and more dramatically because all participants know the focus is on the system and the process rather than on people. Fear is removed from the project, which is one of Deming’s 14 Points for Management, “Drive out fear, so that everyone may work effectively for the company.” Productivity rises when individuals can assume positive intent during every interaction. The environment becomes collaborative instead of combative (in most cases) and more creative solutions come forward when the focus is on the process.
The Joint Commission published a journal on quality improvement article titled “The three faces of performance measurement: improvement, accountability, research.” In it, the authors make this statement: “We are increasingly realizing not only how critical measurement is to the quality improvement we seek but also how counterproductive it can be to mix measurement for accountability or research with measurement for improvement.” Although this article is almost 20 years old, you can see how it is still relevant to illustrating the concept that we need to measure differently for accountability than we do for improvement.
2. Define Your Goal and Aim Statements Early and Stick to Them
Who hasn’t been part of a project where the scope increases dramatically over time? It usually starts innocently enough. For example, a group comes together initially to improve asthma outcomes, but then sees that patients are being referred outside of their group practice. The focus then shifts to this leakage, and so on, and so forth. Before you know it, the original goal of improving asthma treatment disappears, is severely delayed, or gets lost in a dashboard that now is the “one dashboard to rule them all.”
To keep the project moving forward, the project team should define the SMART (Specific, Measureable, Attainable, Relevant, Time-Bound) goal up front. I’ve found that defining this in the first or second workgroup meeting is usually the best timing. Establishing these parameters puts everybody to work on efforts that will return the best bang for the buck. It becomes clear when work is heading down a sidetrack and, therefore, not beneficial.
At Health Catalyst, we encourage a focus on a clear goal that the team expects to make from its improvement efforts. Then we outline our aim statements, the tactics to achieve this goal. Aim statements are written, measurable, and time-sensitive descriptions of the goal. They represent important quality topics that can stimulate enthusiastic team support. Aim statements:
Aim statements are a great tool for project managers to rally discussion and get a lot accomplished. Without them, projects become bloated, are less agile, and end up floundering instead of delivering value quickly. This isn’t an indictment against project flexibility. Aim statements, and even goals, can morph as data is excavated, but as a guiding principle, it is best to focus on one goal and between two and four aim statements for the initial scope of a project.
3. Assign a Knowledge Manager of the Analytics (Report or Application) Up Front
One of the best experiences I’ve had on an outcomes improvement project was largely due to a stellar Knowledge Manager being assigned. We implemented our Key Process Analysis (KPA) tool to help the physicians identify areas of highest variation and resource consumption in their practice. We then targeted these areas for our improvement efforts with great success. Three factors made her participation a critical success factor to the project overall. First, she was assigned up front. This way, she knew everything going on with the project from start to finish. She was able to champion the project as the permanent owner and coordinator of the team after the initial round of outcomes improvement. All the key stakeholders in the project knew her and trusted her as a result of her participation throughout the project. Second, she was not purely technical, but instead had a bit of technical background and was a subject matter expert in the process and clinical environment. Too often a purely technical resource is assigned, which risks making the project “another IT project” that gets little adoption. By having someone who could relate to both the technical and the clinical side, the Knowledge Manager was able to translate clinical concerns to the technical team and technical challenges to the clinical side. Third, she was someone they knew, trusted, and was an innovator. Choose the right Knowledge Manager and you’ll be well on your way to a successful project. If the Knowledge Manager doesn’t have the three attributes mentioned above, then the probability of long-term success decreases.
4. Get End Users Involved In the Process
Outcomes improvement projects aren’t science experiments developed in a lab with “eureka!” moments. End users need to be involved in the process. A successful outcomes improvement team cannot be just executives or individuals who aren’t on the front line. When choosing the end users to participate, it is important to think long term. Which end users do the rest of the staff trust? Which end users will be able to champion the outcomes improvement project? Often these individuals are quite busy. Successful projects choose these individuals to participate and make time in their schedules to help iterate through the application and drive adoption of the outcomes improvement project. Amazing projects get their buy in and support before even kicking off the project.
Practice iterative development of the visualizations so end users can modify the analytics to suit their needs, to something that they will actually use. Involving end users creates project buy-in and develops trust in the data because the champions have been validating it throughout implementation.
Finally, an inclusive mentality creates adoption in that you’re generating built-in super users and champions.
5. Design to Make Doing the Right Thing Easy
First of all, the analytics tools must be simple and easy to use.
For example, I work with one healthcare system that used to run reports by pressing a figurative “start button,” then would return from lunch to see the output. That is, unless the computer crashed while they were out enjoying their chicken lettuce wraps. The mechanism wasn’t easy to use and—you guessed it—reports were minimally accessed and adoption dropped dramatically in the ensuing months. Ensure a basic level of usability. Remove barriers to accessing the information needed to make improvements. Otherwise, it gets costly to create workarounds to simplify the process.
The second design element in making the right thing easy to do involves interventions that are built into the workflow. Interventions that require more work (for example, requiring handwashing documentation every time a caregiver enters the room) are often unsuccessful. The burden is too great. If physicians are required to place three new orders (e.g., flu shot, a lab, and a script) that require five extra minutes with a patient, then this is an intervention that won’t be successful, unless there is serious buy-in.
Contrast this with example projects that focus on ways to make doing the right thing easy:
6. Don’t Underestimate the Power of One-on-One Training
Outcome improvements only happen when analytics and interventions are adopted. I’ve seen many projects flounder because key stakeholders didn’t know enough or had forgotten their training on how to access reports and analytics related to the outcomes improvement project. It’s so key that I’ll mention it again: these champions and super users need to be the subject matter experts, those who know the process well, who others trust, and who, optimally, are early adopters. Where possible, train super users and key champions one-on-one for 20 minutes on the analytics tools. This has proven to be so much more effective in getting adoption than group sessions. This isn’t to say that group training doesn’t work, but there is something magical about sitting down one-on-one with key stakeholders. It’s a safer environment to ask questions, it builds the relationship should questions come up, it often results in insights absent from the group situation, and it shows the importance of the project, particularly if the organization doesn’t do a lot of one-on-one training. Adoption improves when this happens.
7. Get the Champion Involved
I’ve walked into project kickoff meetings and had the group ask wonderful questions as to why we are working on this project. Nobody knew why we chose this particular project and the sponsor of the project was not even in attendance. Indeed, the group questioned if there even was a problem to solve because their current systems were giving them what they needed. Needless to say, those projects went nowhere.
None of the other features of highly successful outcomes improvement projects compensate for a project missing a leader who is expert in the subject area and who has bought in. The most successful projects I’ve been part of have a champion who articulates that problem AND its impact on individuals and organization. The champion needs to convey the “why” of the project to the group and ensure that these reasons resonate with those involved at all levels. The best champions intrinsically motivate the workgroup and others to work toward the common goal. This is what gets everyone onboard to solving the problem and creating improvement. The champion regularly shares the vision, encourages and celebrates with all participants and stakeholders, and ensures the outcome improvement project progresses.
Doctors, nurses, executives, IT professionals, analysts, administrators—anyone reading this—are all incredibly busy people with full plates. Quality improvement projects are typically additional responsibilities to all of us who live and breathe healthcare. But let’s face it, improving and delivering quality, whether it’s clinical care or operations, is why we do what we do. When everything clicks and you can measurably say that this project saved lives by decreasing infection rates, or prevented over a dozen amputations for diabetic patients this year, or improved the patient experience by decreasing wait time – what a great experience to be a part of that! Those assigned to outcomes improvement teams need the security of positive intent. They need clearly defined goals and aim statements. The team needs an owner, a champion, end users, and super users involved every step of the way with one-on-one training to aid adoption. Finally, the tools and interventions must be designed so it’s easy to do the right thing. Outcomes improvement works when permanent teams continuously focus on the improvements and keep them going over time. When all of these elements fall into place, then you know you’ve gotten into the habit of a highly effective outcomes improvement project team.
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