How to Sustain Healthcare Quality Improvement in 3 Critical Steps

Finding ways to improve care quality while reducing costs is essential in today’s healthcare environment. It is also an enormous challenge. The good news is that many organizations are making strides in this area. But once they’ve achieved a cost or quality gain, they discover a whole new challenge: sustaining the gain.

I recently read an article by Ronald D. Snee, a fellow with the American Society for Quality. He articulates that organizations don’t hold quality and cost gains because they don’t make improvement the backbone of their organization. Rather, they approach improvement as a series of initiatives.

He states, “Many organizations focus on sustaining the gains only after improvement has been achieved. Intuitively, that may seem the correct sequence, but it is in fact backwards. The time to focus on sustaining improvement gains is well before the initiative is launched.”

I couldn’t agree more with that statement. Sustaining clinical and financial gains requires alignment of organizational resources from the outset in a manner that drives a culture of improvement. This must be part of an organization’s improvement strategy and not an afterthought.

The Three-system Approach to Healthcare Transformation

Aligning organizational resources to drive continuous improvement is what I refer to as an adoption system. The importance of this adoption system and the way it works best will be the subject of this commentary.

First, however, I want to introduce you to the other two systems of this three-system approach to healthcare transformation. In addition to the adoption system, establishing a culture of improvement requires:

  • An analytics system
  • A best practice system

The analytics system includes the technology, such as an enterprise data warehouse (EDW), and the know-how to gather data, make sense of it, and standardize measurements. The best practice system involves applying evidence-based practice to your clinical work processes.

All three of these systems work together, but the adoption system is essential to sustaining gains. An effective adoption system is the engine of cultural transformation. Why? Because the adoption system establishes the roles and team structures that ensure the improved clinical work processes become the standard workflow and that the measurement system is leveraged to check and adjust the process to drive ongoing improvement.

The Application of Key Principles for Driving Sustainable Healthcare Transformation

Why doesn’t sustainability occur when you just focus on it after launching the initiative? Let’s face it: after a launch, a certain amount of momentum simply gets lost. I call it initiative fatigue. Everyone works intensely to get to that launch point, and then the reaction tends to be, “We made it! Now we can ease up on our pace a bit.”

If you don’t have the structure and processes already in place to sustain, the stakeholders involved in the initiative tend to disengage or are pulled to other projects. Many factors are involved in this loss of momentum and focus, but the most important are:

  • Teams are temporarily assigned to the improvement project
  • A lack of clear accountability and decision pathways
  • Limited or no access to analytic resources
  • The inability to create broad buy-in for the change

The alignment of organizational resources I outline below addresses these issues. It establishes permanent teams, clearly designates accountability, includes analytic and clinical resources, and involves every level of the organization to ensure broad understanding and support for the change.

The three basic tiers of this structure are:

1. The Clinical Implementation Team (CIT)

Once a clinical work process (for example, pregnancy) has been prioritized for improvement, the clinical implementation team is assembled.  The team includes individuals who represent every major step in the care process (for example, fertility; prenatal; L&D; postpartum). This is a broad sampling of stakeholder groups who will be affected by a data-driven improvement initiative. The clinical implementation team is led by a physician, a nurse subject matter expert, and a clinical operations leader; what I call the “leadership triad.”

Involving a physician, a nurse, and someone in operations on the CIT is very important. A physician could propose a plan that optimizes a process for physicians without realizing that it doesn’t fit the nurses’ workflow. Or a nurse could suggest a change that raises red flags for the operations team member. Engaging the entire triad ensures that an improvement works for the entire care team, not just one or two groups. This leadership triad extends beyond the CIT and, in fact, should flow through the entire structure of organizational improvement.

Each CIT member represents a group of peers who fill the same role in the workflow. The team member communicates planned improvement targets to this larger “constituency” in regular staff meetings and relates their concerns and suggestions to the clinical implementation team. In this way, every stakeholder affected by a change is aware of it and has the opportunity to provide feedback. I call this process fingerprinting.

The result of this iterative process is the establishment of a shared baseline—the agreed-upon protocol or standard for how clinicians and other staff will execute any particular clinical process.

2. The Clinical Workgroup

Once the clinical implementation team leadership triad has been selected, a small workgroup is formed. The workgroup is comprised of the leadership triad and best practices, analytic, and technical experts. This small, smart group does the legwork for the larger team by assembling and analyzing data and drafting tools like order sets, treatment protocols, and value stream maps. Additionally, the workgroup has primary accountability for studying the impact of the improvement effort and bringing forward that information to the CIT. The clinical implementation team will use that information to adjust the tools and process to foster ongoing improvement.

The team hears the workgroup’s findings and makes recommendations about which ideas to prioritize and how to roll out a best practice. This kind of participation and feedback cements each participant’s investment in quality improvement decisions and ensures that all participants understand the implications of any initiative on their clinical workflow.

3. Hospital Senior Executive Leadership

Of course, this structure and improvement methodology requires executive sponsorship. Understanding of a need for a different approach and being willing to make the necessary cultural changes must start at the top. It is difficult to surmount the challenge of involving clinicians on the frontlines of care in the process of improvement if executives aren’t completely on board with the approach. Executives who don’t embrace cultural change management may still drive some improvement by implementing analytics technology, but they will not achieve what they might have with a structure for continuous improvement.

The adoption structure for sustaining clinical improvements is shown below:

Sustain Healthcare Quality Improvement

The Clinical Implementation Team is Permanent and Accountable

An incredibly important point to keep in mind about these teams is that they are permanent. They do not disband at the launch of the initiative, nor do they stop collaborating six months in. Rather, they are tasked with and accountable for continuing to monitor and maintain the improved process.

The principal burden of accountability lies with the clinical implementation team. The workgroup continues to do the legwork—using analytics applications more frequently to see whether the shared baseline is being met. The workgroup brings this information back to the clinical implementation team to provide a status report on how the shared baseline has been adopted.

It is at this point that the clinical implementation team makes a decision about what should be done to improve adoption, refine the protocol or otherwise reduce the incidence of outliers. The team has been delegated the authority to make these decisions and will be supported by the executive team. This empowers the team to drive continuous improvement.

Sustaining Clinical Improvements is Difficult but Possible

No one has ever claimed that cultural change is easy. However, the structure I outlined here is a straightforward, proven method for successfully rolling out and sustaining clinical improvement. It is possible to start small. All you need is executive support, the right analytics technology, and a single workgroup. An experienced analytics vendor can provide guidance and tools so you can learn how to structure yourself to become an improvement organization.

Has your organization succeeded at sustaining improvement gains? If so, what organizational structure have you implemented? What are the main challenges you face when attempting to standardize a best practice throughout your organization?


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