CHAPTER 2 We Need to Improve the Way We Improve
WHAT’S THE GOAL OF A QI PROJECT?
First, Define Quality
The goal of healthcare is to provide quality care. The traditional quality paradigm was centered on the provider’s point of view and the notion that quality care was effective care. But expectations have changed, and the paradigm has evolved to one centered on the patient’s perspective, which includes not only the treatment but the healthcare experience. Quality is no longer just “effective” care. Quality is now defined as much by the therapeutic intervention as by how we meet patients’ expectations. In 2001, the Institute of Medicine defined quality along six dimensions: effective, efficient, timely, safe, patient‐centered, and equitable (IOM 2001). In this new paradigm, assessing quality requires us to evaluate “what” was provided i.e. effective and safe care, as well as “how” it was provided, i.e. efficient, timely, culturally sensitive, and equitable care (see Figure 2‐1).
FIGURE 2‐1 The new quality paradigm.
Patients remain at the center of our delivery system because they are the reason healthcare organizations exist. Clinicians provide care to patients and expert services to other providers. Leaders and ancillary staff support the providers’ clinical practice within a complex, multidimensional system. Together, their efforts yield the patient’s outcomes and experiences. Our aim is to provide care that is effective in addressing the disease process, and is delivered in an efficient, timely, safe, patient‐centered, and equitable manner. This paradigm shift has redefined not only quality but the role of the healthcare provider. It is no longer sufficient to provide treatment for a patient’s clinical condition; we must also improve the quality of the healthcare delivery system to address patients’ expectations of the holistic care experience.
Then, Define Improvement
Improving the quality care for our patients cannot be achieved just by increasing resources and cost in a wasteful manner. Improvement is centered on value. There are numerous definitions of value. For now, let’s consider value as the outcomes achieved (therapeutic intervention + patient experience), divided by resources used in achieving the outcomes. To improve, we need to focus on achieving quality care while optimizing the quantity of resources such as time, personnel, and money consumed in working to achieve it (see Figure 2‐2).
FIGURE 2‐2 The goal of improvement.
Quotable quote: “The biggest room is the room for improvement.” Chinese proverb
A BETTER IMPROVEMENT STRATEGY
The identified barriers and characteristics of currently used improvement practices have contributed in part to failed improvement projects and frustrated healthcare leaders and clinicians. Healthcare is a complex and dynamic system, and the pressure of the current healthcare marketplace requires “organic and continuous improvement initiated and sustained at all levels and areas of the organization” (Pennington 2017). We need to move beyond the small, dedicated teams of subject‐matter experts that lead and support specific priority initiatives. Healthcare professionals throughout the organization need to acquire the knowledge, behaviors, and skills that define competency in quality improvement work, and become the drivers of the healthcare transformation. Improvement needs to be embedded in the DNA of healthcare organizations. Rather than imposed from the “top‐down,” improvement must come from the “bottom‐up,” inspired by a vision that enlists professionals in a common cause. “Top‐down” and “bottom‐up” approaches have to converge.
Improvement needs a problem‐solving approach that engages frontline professionals in creating solutions through a focus on the needs and values of the patients the solutions will serve, and the staff and providers who will deliver them.
Frontline professionals will need to be involved in all aspects of QI. Their engagement is critical to develop, revise, and monitor the performance of core care processes. Engagement of the frontline professionals depends on three enablers:
1 Engaged leadership. Leaders need to be actively engaged in creating an improvement agenda and providing the needed resources. Leaders are key in assuring the success of a QI project. They provide guidance, resources, and can be instrumental in creating a network of middle‐level leaders to support the changes. Successful improvement initiatives must rely on the collective efforts of all leaders, both clinical and operational.
2 Shared knowledge. Improvement competency needs to be supported and shared throughout the organization. For a healthcare organization to be successful with its improvement agenda, a large portion of the front line must be trained in the knowledge and skills that define improvement competency. Improvement knowledge needs to be democratized. Improvement capability cannot just be in the hands of a small team of experts while the front line lacks the skillset to successfully complete a QI project. Outsourcing process improvement expertise (i.e., hiring a consultant) cannot be the only solution. Relying solely on expert consultants often results in short‐lived success and considerable expense. Investing in human capital and broadening the base of improvement experts within an organization is a more cost‐effective and permanent strategy. To that end, educating healthcare providers and staff to become the future leaders of improvement initiatives keeps the path moving toward an improved healthcare delivery system.
3 Physician driven. Physicians need to look at the practice of medicine through a new paradigm: knowledge of patient processes – how diseases affect physiology – is as important as the knowledge of system processes – how the system and its components affect the delivery of care. While therapeutic interventions improve the health of our patients, redesigning processes improves the health of the system in which care is delivered. Physicians need to be engaged and drive the improvement and change management initiatives. They have a pivotal role and are the linchpin that drives the success of improvement efforts. Today’s physicians have two roles: deliver outstanding clinical care and improve the quality of the healthcare delivery system.
GUIDING PRINCIPLES
These five guiding principles are the values that establish our framework for all improvement efforts in the healthcare environment:
1 Problems need to be approached using the lens of the customer. To understand a problem, we need to see the problem from the lens of the people who experience them; we need to “walk” in their shoes, understand their issues, and be willing to address their needs. Improvement is only realized when we place the end user’s needs and experiences at the heart of the process. Value is created by focusing the efforts of staff and providers on the needs and expectations of the patient or the end user. End users are the experts of their own experience, and are central to the process of creating a solution that delivers on their expectations.
2 Consider
