SHM's Center for Quality Improvement

Engaging leaders and peers in quality and patient safety initiatives is a key component to ensuring successful outcomes. To obtain support, you will need to:

• Clearly explain how your efforts may enhance quality and safety
• Improve processes and patient satisfaction
• Impact the hospital’s bottom line
• Develop a direct communication line to a senior administrative officer, either by a direct reporting structure or by involving a senior administrator on the team

One suggested approach is enlisting an “executive sponsor” (e.g., CEO, CMO, CNO) or administrative champion of the project. This sponsor should receive regular updates on the project (or ideally attend committee meetings) and be an advocate for the project to hospital leadership.

An executive sponsor is invaluable in helping the team focus on critical issues. However, it is equally important that the team understands where it fits in the overall quality improvement structure and priority for the organization. Teams are frequently assembled during a crisis but need a plan that keeps them connected so that improvements made are sustainable and regularly reviewed. It is useful to ask the executive sponsor to review progress and outline barriers.

Peer engagement is equally important and requires building buy-in from colleagues who can support your initiative at a grassroots level and influence others to do the same. 

A critical component of success is engaging your leaders and peers in conducting a readiness assessment to determine whether your institution has the infrastructure and support needed to embark upon a new initiative.

Assessment Survey on Patient Safety

Healthcare organizations can use this survey tool to:

• Raise staff awareness about patient safety
• Diagnose and assess the status of patient safety culture
• Identify strengths and areas for patient safety culture improvement
• Examine trends in patient safety culture change over time
• Evaluate the cultural impact of patient safety initiatives and interventions
• Conduct internal and external comparisons

It is essential to include individuals who are invested in and see the value standardizing the process. Also, consider including patients/families as content experts on your team, as they have a perspective that is unique and critical to all the efforts of your team.

View the Tool to Identify Key Stakeholders. 

At your very first team meeting, it is key to establish the team “rules” and ensure that everyone explicitly agrees with them.

• All team members should formally sign a document agreeing to these rules to communicate and stress their importance.
• The facilitator is usually given the task of gaining consensus and enforcing the team rules.
• Download the team rules task sheet as a starting point.
• The team should modify the rules as needed and then officially record and acknowledge them. Breakdowns commonly occur when these basic rules are ignored or violated.
• Everyone on the team must be encouraged to speak up, and all views must be respected. Traditional concepts of rank must go “out the window.”

In addition to these rules, it should be made very clear that potential members should notify the leader immediately if they cannot devote the requisite time and effort so that a suitable replacement can be found. Timely minutes as well as a quick turnaround for comments/corrections should be the rule.

Establishing substantive goals is essential for maintaining focus and motivating the team.

Your aims should be specific, measurable and time-defined and should specify the population or populations for whom you want to improve care. A "stretch" goal should be established that should be aggressive enough to mandate a change in the design of your current process to achieve it. Until you have reliable metrics and a baseline evaluation, however, team-supported general aims or goals can be important for galvanizing action and establishing clarity of purpose.

• Be sure to define the scope of your efforts.
  • Do you want to focus on just one ward or service? Critical care patients, ward patients or both?
  • It may be reasonable to start small and then spread your improvement methods to other areas.
  • While you should not take on more than what is achievable, testing and learning on a small scale can make even very large projects more manageable.

Examples of General Aims:

1. General Aim 1: Reduce adverse drug events in critical care by 75 percent within one year.
2. General Aim 2: Improve medication reconciliation at transition points by 75 percent within one year.
3. General Aim 3: Transfer every patient from the inpatient facility to a long-term care facility within 24 hours after the patient is deemed ready to transfer.
4. General Aim 4: Reduce waiting time to see a urologist by 50 percent within nine months.

As your team develops, your challenge will be to define many of the terms in your general aim, which will entail developing defined metrics and more mature, specific, time-defined aims. For example, what aspects of the process or issue do you want to improve first? What are the factors that lead to lower quality or an unsafe condition? How can you educate caregivers about these issues?

Data collection, analysis and presentation are essential to the success of any quality improvement program. Measurement is a critical part of testing and implementing changes.

Use a balanced set of measures for all improvement efforts: outcomes measures, process measures, and balancing measures.

Outcome Measures

How does the system impact the values of patients, their health and wellbeing? What are impacts on other stakeholders such as payers, employees, or the community?

Examples:

• For diabetes: Average hemoglobin A1c level for population of patients with diabetes
• For access: Number of days to third next available appointment
• For critical care: Intensive Care Unit (ICU) percent unadjusted mortality
• For medication systems: Adverse drug events per 1,000 doses

Process Measures

Are the parts/steps in the system performing as planned? Are you on track in your efforts to improve the system?

Examples:

• For diabetes: Percentage of patients whose hemoglobin A1c level was measured twice in the past year
• For access: Average daily clinician hours available for appointments
• For critical care: Percent of patients with intentional rounding completed on schedule.

Balancing Measures

Looking at a system from different directions/dimensions

Are changes designed to improve one part of the system causing new problems in other parts of the system?

Examples:

• For reducing time patients spend on a ventilator after surgery: Make sure reintubation rates are not increasing.
• For reducing patients' length of stay in the hospital: Make sure readmission rates are not increasing.

When defining interventions to improve quality, it is critical to reduce variation in the way care processes are implemented. The key concept is routine. Doing a complex activity the same way each time is the best way to make sure nothing is left out. 

The following is a review of some principles for effective implementation of interventions:

1. Principle 1
   
   Keep it simple for the end user. There will inevitably be trade-offs between the depth of detail of guidance you want to give providers and the simplicity of the forms and the processes the end users must go through. Most of the time, simpler is better. Minimize calculations the end user should make or automate that process for them.
   
   
2. Principle 2
   
   You cannot interrupt the work flow. Do not become shortsighted about the importance of this particular intervention. Remember that this issue may not be the focus of members of a caregiving team, and they are likely to be attending to dozens of other tasks per patient. Involve frontline workers to make sure your plans are feasible and that your processes/order sets/protocols are easy to use. Check boxes and prewritten scales can encourage rapid acceptance because they make the work easier. Get their input on how to make implementation go smoothly. Clinicians should want to use the new processes if they are constructed properly.
   
   
3. Principle 3
   
   Design reliability into the process. Human beings are incapable of doing anything reliably 100 percent of the time in the complicated health care setting.
   
   
• High-Reliability Strategies
• Desired action is the default action (not doing the desired action requires opting out).
• Desired action is prompted by a reminder or a decision aid.
• Desired actions are standardized into a process (take advantage of work habits or patterns of behavior so that deviation feels odd).
• Desired action is scheduled to occur at known intervals.
• Responsibilities for desired action are redundant.
  
  
4.  Principle 4
   
   Pilot your interventions on a small scale before attempting wide implementation. Inevitably there will be some glitches with your initial order set and/or algorithm. It's best to "fail faster" by piloting on a small scale, so that you can get the glitches out of the way before you implement the process more broadly.
   
   
5. Principle 5 
   
   Monitor the implementation of the new intervention: expect variation and learn from it. Reduce variation over time. Rolling out the intervention is only a beginning. You need to learn from variations in your process. The idea is to squeeze variability out of the process while retaining variation based on tailoring to accommodate the patient.

For educational modules about quality improvement, visit the SHM Learning Portal under “Hospital Quality and Patient Safety.” Topics include:

• Quality Measurement and Stakeholder Interest
• Teamwork and Communication
• Organizational Knowledge and Leadership Skills
• Patient Safety Principles

SHM members can also share questions, challenges and successes with other hospital-based caregivers across the country through the Hospital Medicine Exchange (HMX) online forum.

Contact SHM with any further question or inquiries you may have.