management strategy. There is often more focus on the technical or clinical aspects of the problem than on how the solution will be received by the front line. It is important to remember that all improvement is a change, and change is going to have a significant effect on the professionals in the front line. Change management is often an afterthought, with the main focus being on designing, testing, and deploying the solution that addresses the needs of the project. Managing the effects of change is often reactive, and implemented without a clear plan. Communication and engagement with the front lines is not given sufficient emphasis leaving the project team unable to implement the much‐needed solution.
Too many competing initiatives. In healthcare, there are too many competing initiatives that result in improvement fatigue. Healthcare providers face a constant barrage of mandates to change practice from external stakeholders, including accrediting organizations, regulatory bodies, third‐party payers, and professional associations. Front lines often become overwhelmed by the number of changes that occur in their work routines. There is a lack of leadership with proper selection, stratification, and improvement focus at the front line.
Excessive focus on the methodology rather than the improvement opportunity. In the late 1980s, healthcare organizations began incorporating industrial quality‐management methodologies including Lean, Six Sigma, and Lean Six Sigma in their strategies to improve delivery of care. The Lean Six Sigma approach attempts to address the non‐value‐added activities, inefficient workflows, and disorganized work environments that interfere with clinicians’ ability to provide safe, high‐quality patient care. It merges the customer‐orientation and waste‐reduction techniques of Lean (time‐driven focus) with the more statistical and data‐driven systematic error reduction strategies of Six Sigma (quality‐driven focus). When implemented as an overarching management system and organizational philosophy, Lean Six Sigma process improvement methodology has been shown to improve patients’ experience, staff and providers’ work environment, and the quality of patient care (Nicolay 2012). Not all QI projects have been successful using Lean Six Sigma. Some teams have had disappointing results. For these teams, Lean Six Sigma lacked some of the critical elements they needed for success. When applied to medicine, industrial quality management methodologies have several problems:Heavy use of technical and business terminology. These improvement methodologies are derived from the manufacturing sector and often carry with them an overemphasis on improvement jargon that seems complex, counterintuitive, and far removed from the clinician’s front line.Improvement is often carried out by small teams of certified Lean Six Sigma practitioners who make up their own distinct department. These SMEs lead improvement efforts in a “top‐down” approach but often fail to create the conditions for the front line stakeholders to engage. Changes are pushed through without the front line professionals’ involvement in developing, revising, or monitoring the performance of key processes.
Physicians have a limited understanding of these improvement methodologies and in general regard them as something outside of the scope of medicine, showing little interest in learning them. Most industries make great products with average employees working with brilliant processes. Healthcare does great work with brilliant employees working with mediocre processes.
WHAT IS THE PHYSICIAN’S ROLE IN PROCESS IMPROVEMENT?
It is widely accepted that physician engagement is an essential requirement for any successful quality improvement project, and yet we have not seen the full engagement of clinicians. Physicians have a pivotal role within the organization. However, they are often not involved in healthcare organization improvement efforts, either because of the constraints of their overbooked clinical schedules or because of the perception that they are not directly responsible for the improvement of the operational aspects of delivering care.
Physicians express a strong support for QI projects, but often have a different view of what this entails. Although this is probably not you (the reader!), physicians in general
View improvement projects as taking time away from patient care, interfering with their schedule, and adding complexity to their workflow, even when that very workflow is the cause of the problem. This unfavorable view of QI projects is further perpetuated when their improvement efforts are not recognized with professional advancement or other incentives.
Are often reluctant to participate in QI projects because they believe the improvement initiative will be ineffective.
View quality assessment as an integral element of the practice of medicine and resist any improvement initiative that challenges this view.
View clinical guidelines and pathways as hampering individual provider’s freedom.
Have a lack of expertise in project management, team dynamics, and communication.
Physicians have historically been responsible for the quality of clinical care by virtue of their credentials. This has resulted in their implicit expectation that the burden of operational improvement should be left to staff and hospital administration, a tenet described by Kornacki as “The Physician Compact” (Kornacki 2012): “The Physician Compact is an implicit psychological contract that defines the actions physicians believe are expected of them and the response they expect in return from their employers.”
According to this compact, physicians believe their role is to treat patients, provide quality care (as defined by the physician), advance research, and support medical education. In return, they expect to be given clinical autonomy, protection from market forces, and the resources needed to resolve operational problems. In contrast, hospitals and healthcare organization need standardization, improved efficiencies, lower costs, and physician engagement in operational challenges. There is an internal incongruence between physicians’ expectations and hospital needs that results in resentment, misunderstandings, and a lack of physician engagement in operational improvement (Kornacki 2015). Efficiency and standardization are often perceived by physicians as a restriction to their ability to integrate their knowledge, experience, and assessment skills in their clinical practice. Ironically, it is often the physicians who initially identify processes that are dysfunctional and are open to becoming engaged in “their project” when there is adequate facilitation and coordination by another staff member.
REFERENCES
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4 4. Kohn LT. (2000). To Err Is Human: Building a Safer Health System. Institute of Medicine Committee on Quality of Health Care in America. National Academies Press.
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6 6. Kornacki MJ. (2012). Leading Physicians through Change. ACPE.
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