Evan Howell, MBA, MMSc, LSSBB, PA-C, serves as Chief Clinical Operations Officer and Chief Advanced Practice Clinician at ApolloMD, functioning as an internal consultant on all clinically based process and performance improvement initiatives nationwide. This includes complete service line assessments, flow analysis, patient experience programs, and data analytics. Mr. Howell recently presented at the Ohio Hospital Association Annual Meeting where he discussed a variety of approaches to address organizational change and how these methodologies can be applied to health care delivery.
Here is a summary review of that discussion.
My objectives here are to highlight several of the drivers for continuous quality improvement in health care, to give an overview of prominent process-improvement methodologies, and to provide some key considerations for leaders of health care organizations who are preparing to engage in process improvement initiatives. This is simply an overview and intended to provide fundamental understanding of the origin, focus, and key tenants of each of these continuous improvement methodologies.
Continuous improvement requires a mindset and approach that engages workers in understanding their organization, processes, and customers. It revolves around empowering all stakeholders and relies on teamwork and collaboration to identify or create solutions.
CONTINUOUS IMPROVEMENT IN HEALTH CARE
Over the last 20 years, continuous improvement in U.S. health care has become a priority for a variety of reasons, including lower quality, efficiency, access and overall performance scores, the health care spending trajectory, and cracks in the foundation of our system. Those cracks make our whole care-delivery system vulnerable, and the stressors are only going to get worse as the population ages, chronic disease cases increase, health care financing sources decrease, and provider and nursing shortages continue. For all these reasons, the time to implement continuous improvement measures is now!
While opportunities for continuous quality improvement in health care abound, some key areas at the forefront include health care access, care delivery models, telehealth, staffing matrices, affordability, data analysis, and technology. In health care, every stakeholder – from patients to health care workers to pharmaceutical companies to government and third-party payers – will be forced to the table at some point as the health care landscape continues to rapidly evolve. It’s very important for hospital leadership to remember that they are tasked with coordinating and managing the improvement efforts across their organization and therefore, must maintain the ”10,000 ft view” and not lose their overarching perspective by focusing too much on a single project or opportunity.
Before you begin any continuous quality improvement project in health care, it is critical to make sure all your stakeholders are approaching the opportunity with the right frame of mind. I am a firm believer in the Dr. Carol Dweck’s “Growth Mindset,” and I discuss its tenets with each stakeholder group at the onset of every project. Dr. Dweck detailed, “in a strong growth mindset, people believe that while we’re born with certain skills and intelligence, our basic abilities can be developed through dedication and hard work, and by trying new strategies and seeking input from others when stuck. The Growth Mindset fosters tenacity by viewing challenges as opportunities, encouraging healthy risk-taking, and embracing imperfection. We must become comfortable with ambiguity. We can’t hold up projects and solutions waiting for clarity, because many times the clarity comes from engaging in the process.” Additionally, a Growth Mindset serves as the underlying foundation for all the continuous improvement methodologies I discuss below.
The first methodology I want to discuss is Total Quality Management (TQM), which is an organization-wide philosophy with a core value centered on continually improving the quality of products, services, and processes. Everyone from top management to the employees plays a role in fact-based decision-making. The TQM process is represented by the PDCA cycle – plan, document, check, act – which relies on continuous improvement to elevate standards over time:
PLAN — Analyze how current issues with products and services can be improved, map out methods to achieve those improvements, and try to predict the new outcomes.
DOCUMENT — Test variables, record every step, and evaluate what works.
CHECK — Measure the outcomes of trials, monitoring results and improvements.
ACT — Implement improvements and then synthesize that new knowledge.
The next methodology, Six Sigma, is a statistical-based, data-driven methodology for eliminating defects in a product, process, or service. Six Sigma is all about reducing variation in the system and increasing predictability. As with TQM, Six Sigma focuses on satisfying the needs of the customer by incrementally improving processes. But again, the primary focus is on reducing variation.
The Sigma represents the population standard deviation, which is a measure of the variation in the dataset collected about any process. A Six Sigma process has a mean of six standard deviations from the nearest specification limit. Once the current performance of the process is measured, the goal is to continually improve the Sigma levels, striving toward the ultimate goal of Six Sigma. This is accomplished by utilizing the DMAIC cycle:
- Define — What is the problem? What are the goals and deliverables?
- Measure — Establish baseline and KPI; collect data.
- Analyze — Look at cause/effect relationship between the inputs and outputs to identify root causes.
- Improve — Implement solutions to eliminate or control those root causes.
- Control — Develop standards and controls to sustain long-lasting results.
LEAN methodology places a critical focus on streamlining processes by removing waste from the system – whether that waste be time and talent, inventory and logistics, or defects and quality control. The five LEAN Principles are also very similar to the other methodologies mentioned, but with emphasis on reducing waste:
- Define Value—Understand the value customers ascribe to products or services.
- Value Stream—Examine the sum of the product’s entire life cycle to determine the value it adds, and eliminate processes, features, and materials that don’t contribute to overall value.
- Flow—Strive to keep each process entirely in sync with every other one.
- Pull—Ensure nothing is made before it is needed, which can push work and inventory out of sync.
- Pursue Perfection—Lean practitioners exercise relentless pursuit of perfection, revisiting completed projects to evaluate future improvement.
The final methodology I’ll discuss is my personal favorite, Design Thinking, which best accounts for what I call the “dual-human variable” of health care delivery. When tackling health care process problems, we not only have to factor in those who provide the care and services, but also the patients/customers whose lives depend on the quality, efficiency, and efficacies of those services. Health care delivery is not assembling widgets by machines on a conveyor belt, so accounting for the innate variability of human health care workers and the human patients they are caring for can be daunting and often frustrating for any project team.
Design Thinking offers a human-centered methodology to solve problems by bringing together what is desirable from the human point of view, as well as what’s technologically feasible and economically viable. From the health care standpoint, all patients approach their illness, injury, or disease in different ways, so considering their feelings and behaviors via the Design-Thinking approach is particularly helpful in creating solutions. The Design Thinking framework involves:
- Understanding human needs.
- Reframing and defining problems in human-centric ways.
- Brainstorming multiple ideas & solutions.
- Prototyping, testing, and re-testing those ideas & solutions for efficacy.
- Implementing that solution and reconnecting with patients or providers to iterate the process.
As we all know, there are strengths and limitations to each of these methodologies in the health care setting. They all originate from industries that don’t necessarily regard the complexity of health care delivery and the “dual-human variable.” Using a blended model for each project allows organizations to incorporate the most pertinent elements of multiple process improvement methodologies as guided by the scope of the project, the people involved, and the potential impact of the outcome. I personally have not led a project over the last 10 years that did not include elements from at least 2 of the methodologies I discussed. Deciding on the right blend for a given project may be challenging initially, but the best approach usually becomes clear after some collaboration sessions with the stakeholders around the opportunity being addressed.
Fundamentally, the solutions to complex challenges in health care rely upon engaging and empowering the individuals doing the work. That starts with leadership. If the leaders aren’t on board, all the stakeholders will not be on board. Focus on changing the organizational approach to problems, and then instill that culture in the project team members. The team members are the most effective instruments of change.
As health care leaders, we must look at the value created for patients, health care providers, organizations, and the larger communities served. That’s a lot of responsibility, so strip it down to the basics for initiating a continuous improvement project in your organization:
- Observe and engage. When you become aware of a problem, immerse yourself in that area to gain a baseline understanding of the opportunities that are there.
- Ensure you have access to the pertinent data around the opportunity and confirm that your organization has the analytics capabilities to adequately measure that data before, during, and after the project.
- Start with low-hanging fruit. Success breeds success. Start with some easier problems to address and celebrate the success of the solutions implemented and the stakeholders involved in the project. That helps create a positive culture around continuous improvement and build the necessary excitement and momentum to fix the larger, more complex problems your organization faces.
Many of you have probably read just about every leadership book out there but remember that your project champions and participants likely have not. This is a short list of books that are good reads for any novice who will be participating in a continuous improvement project: