6 Steps for Implementing Successful Performance Improvement Initiatives in Healthcare
front-line staff who understand the processes targeted for improvement. Their role is to define workgroup outputs and lead the implementation of process improvements. Whenever possible, these teams should represent a broad range of departments, clinics, hospitals, and regions to help disseminate knowledge across the organization. These teams generally create work groups to perform the detailed work.
Work groups. Work groups are generally led by a physician and nurse subject matter expert and include best practices, analytics, and technical experts. These teams meet frequently to analyze processes and data and to look for trends and improvements. Their role is to develop Aim Statements, identify interventions, draft knowledge assets (e.g., order sets, patient safety protocols, etc.,), define the analytic system and provide ongoing feedback of the status of the care process improvement initiatives.
Step 5: Use a best practice system to define program outcomes and define interventions
Sample Work Group Aim Statements: Heart Failure
By developing Aim Statements for a performance improvement initiative, an organization can ensure that all stakeholders understand the initiative’s goals. The following sample Aim Statements might be developed for a performance improvement initiative focused on improving performance in treatment of patients with heart failure.
Aim Statement 1: Data quality. By [date], establish a baseline for all-cause 30-day readmission rates for patients found in the heart failure cohort, and reconcile and validate against the previous year’s baseline heart failure readmission rates by [date].
Aim Statement 2: Risk stratification. By [date], identify high-risk patients with heart failure and establish a baseline for 30-day readmissions for those patients. Develop a risk stratification model to predict the likelihood of all-cause 30-day readmission rates for all patients with heart failure.
Aim Statement 3: Intervention. By [date], the heart failure team will develop one evidence-based process metric (such as number of medication reconciliation reviews or number of follow-up appointments) and one balance metric (such as ED admissions or observation days) that will have an effect (X) on all-cause 30-day readmission rates for high-risk patients.
AIM Statement 4: Cost. Reduce the value-based penalty by 0.2 percent for heart failure and improve hospital payments by $75,000 for next fiscal year.
Workgroups are responsible for developing Aim Statements, part of the best practice system, that establish clear clinical improvement goals and integrate evidence-based practices to standardize care. For examples of Aim Statements that relate to heart failure, and are based on evidence-based practice, see Sample Work Group
Aim Statements: Heart Failure.
The focus of performance improvement initiatives for many organizations tends to be on low-performance outliers—that is, on identifying instances where costs are much higher and outcomes substantially poorer than averages among caregivers. However, a more effective approach is to identify those practices that consistently lead to the best outcomes and promote them, with evidence-based guidelines, to improve outcomes across the board, as illustrated in Figure 6.
The analytics platform described early in this paper also can be used to identify and eliminate waste that can be an outgrowth of non-adherence to evidence-based practices. This type of waste tends to fall in three categories:
Ordering waste. This waste results from providers ordering tests, care, and supplies that do not add value. An example of such waste might be the ordering of unnecessary chest X-rays for patients with asthma because of a faulty order set, something Texas Children’s Hospital discovered and addressed in their process improvement programs.
Workflow waste. This waste results from inefficiencies in delivering tests, care, and procedures. As an example, some healthcare organizations are still manually having charge nurses fax a nightly list of patients with urinary catheters and central lines to their infection preventionist team, an untenable manual process as agencies, such as the Centers for Medicare and Medicaid Services (CMS) expands surveillance activities to an enterprise-wide, versus critical care, focus.
Several hospitals have been able to reduce their catheter-associated urinary tract infection (CAUTI) and central-line associated bloodstream infections (CLABSI) surveillance activities by as much as 50 to 90 percent through the use of an analytic platform that automatically identifies the patient population and integrates of an electronic surveillance algorithm, allowing nurses to focus more on infection prevention versus manual reporting.
Defect waste. If delivery of tests, care, and procedures is defective, the resulting waste could lead not only to higher costs but also to patient harm. Inpatient fall prevention is an example of a defect, deemed to be avoidable. Falls can cause injury (ies) to the patient and incur additional costs to treat the injury (ies) and may require the patient to have an increased LOS.
Step 6: Estimate the ROI
As the guidance team sets priorities for performance improvement, the team also should take time to estimate the potential ROI for each initiative based on available information. The team can start by identifying organizational costs and estimating benefits using tools such as industry benchmarks for similar projects, vendor case studies, and internal estimates. Most organizations will need to educate their clinicians, operations and finance departments on the value of sharing data and working together on inter-disciplinary teams, rather than keeping everything in silos.
Next, the team should identify direct benefits and savings (either from enhanced efficiency and productivity) or from clinical improvement and waste reduction. Then, the team can identify indirect benefits, such as a reduction in future infections or an improvement in patient satisfaction.
The team also should consider revenue opportunities such as higher market share and patient volume, an increase in contract compliance, or a reduction of bad debt. A revenue opportunity example might be a payer who is willing to pay an organization a bonus for reducing unnecessary pre-term deliveries. Another revenue opportunity example is reducing the number of referrals outside of the healthcare network.
Building the Framework
Creating a foundation for sustainable improvement and prioritizing initiatives does not have to be overwhelming. By following these steps and establishing a framework for performance improvement based on analytics, the right teams, and evidence-based practices, an organization can obtain the right tools to achieve and sustain performance improvement gains into the future.
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