Getting Started with Quality Improvement

We often think of QI as a very complicated process involving teams, clinical decision support, which is a fancy word for electronic tools, and sophisticated data models. But the reality is that even the simplest actions can actually be a form of QI.

So what is quality improvement in health care? Quality improvement in health care refers to systematic approaches to enhance delivery of care, patient outcomes, and operational efficiency.

Consider these examples. Standardized note templates, improving the onboarding process for new providers, standardized order sets for sepsis. Those things all enable clinical teams to provide the best care to patients, whether they’re in the ICU or anywhere else in the hospital.

I’m sure you can think of some examples, checklists for the OR, protocols for answering phone calls, care pathways, making sure patient instructions are written at a fifth grade level. These are all examples of practical and powerful quality improvement tools.

So that sounds great. But how do I get started? Well, you have to think about anything like this systematically.

So number one, start with education. It’s likely that your unknown unknowns box is much larger than your known knowns box. Learning what process improvement and quality improvement tools exist is just a springboard.

Number two, find local experts. Ask different people in different roles, areas, or functions what their problems are. You’ll often find that while their specific problems may be different, they are usually unified by a common thread. This is often a great target for quality improvement, because it allows you to use tools like the five whys to identify root causes for problems and begin to attack those.

Figuring out what to do often revolves around asking the boots on the ground, a.k.a. the people who actually know what’s happening, what’s going on. Number three, ask for help. The QPSI is an amazing resource and can connect you with the right people to get you on your way.

At its core, QI is about creating measurable, sustainable improvements based on evidence and data.

To begin QI work, one must start with the most important task of all, identifying a problem that requires improvement. Starting a project can be challenging, but here are some best practices that can help get you off the ground.

Number 1, keep your eyes and ears open. The best opportunities for quality improvement are all around you.

Number 2, define a clear and concise, also measurable problem statement.

Number 3, try to make SMART goals. SMART stands for Specific, Measurable, Achievable, Relevant, and Time-bound.

Number 4, don’t go it alone. QI projects are more successful when you have a group of people with broad and multidisciplinary expertise working together.

Number 5, understand the current state. Often, people are so excited about moving forward on a QI project that they don’t bother understanding what’s happening in their clinical context. In QI parlance, this is called the current state.

Once you’ve identified your project goals, team, and metrics, you need to finish your project. Here’s some helpful tips to help you succeed.

Number one, start with structure. When planning your project, use a structured methodology. Lots of these exist. For example, plan, do, study, act, often referred to as PDSA, Six Sigma methodology, and lean methodology.

Having someone on your team with a background in process improvement will significantly increase the chances of success.

Number two, start small, move fast. Using small scale, iterative improvement is usually better than broad scale change, both from the standpoint of institutional resistance and from the standpoint of not having unintended consequences creep up on you.

Number three, document, document, document. People in healthcare are really bad at this, but remember, just like a clinical note, if it wasn’t written down, it didn’t happen.

Others will need to learn not just the results of your project, but the methodology and how you got there. How else are they going to have a toolkit to recreate your success?

Number four, observe broadly. Remember, there may be a series of secondary and tertiary consequences of your project. Chance favors the prepared mind. Be observant and you may realize your project has uncovered other efficiencies or problems that will benefit other parties.

Number five, communicate. People want to be in the know. Finding a balance between sharing too little and too much is often a challenge. But remember, when you empower people with knowledge, you might find collaborators who can help facilitate your goals.

Once you’ve completed your project, you want to make sure the positive energy doesn’t die off. In order to do this, you have to keep the project going, a.k.a. sustaining the project.

Here are some tips.

Number 1, education and training. These are often overlooked, but all of the workflow mapping, documentation, charts, graphs, and project posters don’t really do a lot of good unless there is a plan to make sure that new and old hires are able to understand and act on the information. And more importantly, integrate these into their workdays and workflows.

Number 2, standardize. Be like Spotify. Introduce new concepts along with well-liked and familiar concepts. This makes the new concept seem much more palatable because they seem familiar.

Number 3, celebrate. People are rarely rewarded for their work in meaningful ways. Days since last fall charts in nursing units are a great example. By celebrating quality, people find that they are surrounded by positivity and rates of falls decrease.

Number 4, governance. For better or worse, quality has to be a top down priority. Governance helps by encompassing multiple concepts including privacy, security, ethics, legal, compliance, and a whole host of other things you never learned in medical school.

Number 5, automate continuous monitoring. People are conditioned to alerts and reminders. Figure out a way to provide these.

Number 6, periodically reassess your progress. It may turn out that the ideal state two years ago is no longer the ideal state today. It doesn’t mean that you should throw out the baby with the bathwater, but it’s important to have a plan to reevaluate what you’ve done at an interval that is planned and automated.

Automated being the key.