who deliver care and experience the problems of the system are the key; we need to bring them along in the improvement process because they are the ones who understand the system and hold the key to the solution. Healthcare professionals see and understand the challenges our patients face. Their understanding of the process and proximity to the patients makes them uniquely suited to identify and deliver potential solutions that can improve the healthcare experience. To improve, we must engage providers and staff. They have a pivotal role and are the linchpin that makes possible the success of the improvement efforts. Front line stakeholders have valuable insights into their processes and the barriers they face in delivering high‐quality patient care, but they often have minimal opportunity to share that proficiency in modifying their workflows. In most organizations, there is an enormous reservoir of “energy, ideas, and engagement that is never tapped into because of management practices that reduce intrinsic motivation and hinder joy and creativity in work” (Rena Awdish 2018).3 Be willing to try, fail, and try again. Improvement in healthcare is complicated. Improvement is an imperfect process that requires our willingness to design and test solutions, and when they fail, to learn from our mistakes. In a risk‐averse culture such as healthcare, improvement is difficult. We just need to make sure that our failures do not harm our patients. Engaging in the right kind of testing produces the right kind of failures from which we can learn. Quotable quote: “Fall seven times. Stand up eight.” Japanese proverb
4 To improve, sometimes we must think “out of the box.” The traditional formula of continuous incremental improvements sometimes delivers disappointing results when it comes to the operational side of healthcare. We may not achieve the dramatic results we expected, largely because we may have been trying to improve the “old way” of doing things. Sometimes we have to stop focusing on improving what appears to be outdated models that were successful in the past but have outlasted the circumstances that created the need for them. For these processes, improvements cannot address what is fundamentally wrong with them. They have underlying deficiencies in their conceptualization, structure, job design, workflows, and control mechanisms because they were designed to address the needs of a different time. Improvement cannot succeed when it relies on an obsolete paradigm. When this is the case, we must redesign our processes using our knowledge, and a clear understanding of the needs of our patients.
5 Consider all improvement a change. All improvement is a change, and change is always met with varying degrees of resistance. For change to occur, QI teams must create a space where growth can develop, giving the frontline professionals the opportunity to understand the problem, discuss barriers to success, and engage in the co‐creation and implementation of solutions. The effectiveness of our improvement effort results not only from the quality of the solution but also from the engagement and buy‐in of the frontline professionals. If staff and providers do not accept the change, it is very unlikely that improvement will succeed. We must understand what drives change at the front line, and then design strategies to overcome the natural resistance that so often derails our improvements efforts. Change cannot succeed without the commitment of the people that it will affect.
THE FIVE “RS” OF EVERY QI PROJECT
All projects need a structured approach that moves through several distinctive phases. To achieve the goals of any QI project, an improvement team needs to successfully transition through five phases (see Figure 2‐3). These phases define a logical flow to problem solving that starts with understanding the problem and continue through dissecting the process to identify root causes of defects and breakdowns, and creating solutions that address the needs of the people that experience the problem.
FIGURE 2‐3 The five “Rs” of all successful QI projects.
Each phase follows the Project Roadmap, drawing from a set of steps and tools to help reach the final destination (see Figure 2‐4).
FIGURE 2‐4 The Project Roadmap.
The first “R”: The Right Project. First, identify project opportunities. Once you have selected your project, ask yourself: Is this the right project? Is this project feasible? Can the project goals be achieved? Confirm feasibility, jot down some ideas, and write the first draft of your Problem Statement. Then create your Project Charter. The Problem Statement and Project Charter will help you and your team focus on the right project.
The second “R”: The Right People. All projects must have the “right people on the bus” (Bossidy 2002). Projects need a senior leader (primary sponsor) to legitimize the project, provide resources, and resolve cross‐functional issues. The primary sponsor must be present and active throughout the lifecycle of the project. Project teams need a competent leader and team members from the front line with subject‐matter expertise and the appropriate mix of skills.
The third “R”: The Right Problem. We must “walk in the shoes” of the customers or end users to understand the problem; learn about their experiences and understand their expectations. Collect the voice of the people that “do the work.” Understand their needs. What are their challenges? What barriers prevent them from meeting the customers’ expectations? Summarize the resulting insights into a clear explanation of the problem you are trying to address. This phase will help your team focus on the right issues.
The fourth “R”: The Right Cause. The first step in finding the cause is to “go see.” Understand how work is really done. “Walk the process” to identify areas of improvement. Eliminate waste where you can see it. Once you understand the process, select the measurements that matter. Define your metrics and collect baseline data. What is our baseline performance? Can we meet our customers’ needs? Are we meeting our customers’ needs? How often are we meeting these needs? Organize and stratify your data and use your process knowledge to discover the most likely cause of the problem. Then test your assumptions and confirm the cause‐and‐effect relationship.
The fifth “R”: The Right Solution. Use tools to energize your creative thinking. Generate a list of improvement ideas. Evaluate your options and prioritize the best solution. Create low‐fidelity mock‐ups and work with the end users and frontline stakeholders to test your ideas. Make this process iterative. Modify and refine the original idea as needed by uncovering performance gaps that need to be addressed. Learn from your testing. Once you have a winner, roll it out with the support of the key stakeholder who will be implementing it over the long term.
These five phases may be iterative and overlapping, require the completion of several steps, and end with project deliverables as shown on the Project Checklist (See Table 2‐1). Starting after the second phase and continuing throughout the project, the QI team should meet with the Primary Sponsor for a tollgate review (see Chapter 24). A tollgate review is a go/no‐go decision point where project activities and deliverables are reviewed to assure that the project is on track. Likewise, after each step, the QI team should plan for communication with the frontline stakeholders. Effective communication is a critical aspect of any quality improvement project and is recognized as a key component of behavior change in any change management effort (see Chapter
