Читать книгу The Quality Improvement Challenge - Richard J. Banchs - Страница 17

Efforts to improve the quality of care have focused on performance metrics, complex incentive formulas, and increased scrutiny from regulatory agencies. These and other measures have not addressed the real problem and, for the most part, have not significantly improved the quality of care. Patients continue to be disappointed with the healthcare experience, and staff and providers are getting increasingly burned out from the overwhelming day‐to‐day administrative burden. There is a generalized frustration among providers working in a system that is inefficient, overcomplicated, and seemingly at odds with the mission of providing high‐quality care. Despite significant efforts to improve, we have not achieved our goals. Accountability based on metrics developed by outsiders has failed to engage physicians, and too much of the efforts of healthcare organizations is spent on submitting reports, preparing for accreditation surveys, and ensuring adherence to regulatory mandates. Meeting the objectives of specific organizational metrics has become an all‐consuming activity, rather than developing a strategic and comprehensive improvement agenda. There is no question that the work involved to ensure survey readiness and regulation compliance is important, but too much effort is directed at achieving core measure targets and not enough on system redesign. By prioritizing improvement initiatives that address the underlying processes related to the regulatory compliance and core measure targets, we could address both regulatory mandates and improve the healthcare experience.

Quotable quote: “We are faced with a series of great opportunities brilliantly disguised as insoluble problems.” John W Gardner

Healthcare organizations continue to invest resources to improve the delivery of care but face unique challenges that impact the effectiveness of the improvement efforts they pursue. Process improvement is not easy, and it requires a clear understanding of the barriers:

 The culture. The primary role of a healthcare organization is to provide care to patients, a high‐stakes undertaking that may exacerbate patients’ clinical conditions if errors occur. As a result, healthcare professionals are risk averse, conservative, and hesitant to try new things compared to other industries. When quality improvement (QI) teams and organizations try to implement changes, they often encounter a resistant culture that labors to maintain the status quo. Incongruously, providers and staff often resist the adoption of standards and other evidence‐based guidelines that support improved patient outcomes in favor of time‐honored, and sometimes outdated, traditional approaches to patient care.

 Silos. Improvement initiatives are difficult in healthcare organizations unaccustomed to leveraging teamwork across silos to accomplish their goals. Silos not only exist within the clinical specialties but also exist between the clinical and the operational areas in healthcare organizations. These silos often cut from the top of the organization down to the front line staff members. They impact the effectiveness of any improvement initiative, ultimately leading to a fragmented operational approach that focuses only on individual tasks and departments without considering the entire patient experience. Coordination and collaboration give way to “suboptimization,” where every unit pursues its own “targets” independent of the needs and aims of the organization as a whole.

 A lack of IT support. Improvement initiatives depend on and should be guided by data. But QI teams often find it difficult to get their basic needs fulfilled, having to allocate additional team resources, or rely on manual data collection to obtain the data they need. It is difficult to understand why staff and providers have to struggle to get a report of the same data they just entered into the hospital’s electronic medical record.

 A lack of active participation of senior hospital leaders. The role of the leader is to legitimize improvement projects and facilitate the work of the improvement team. The leader establishes priorities for competing initiatives; provides resources for the team; resolves cross‐functional issues, and removes roadblocks that impede the success of the project. Senior leaders in healthcare are often not visible, active, or engaged in QI projects. When leaders are not present, projects flounder, have difficulty reaching their objectives, and often fail. Leaders are vital in building a coalition of key sponsors to achieve project success and facilitating change.

 A lack of improvement experience. Healthcare professionals often lack the experience and formal training needed to address the complex performance problems of the healthcare delivery system. Postgraduate healthcare education continues to be almost exclusively focused on the acquisition of scientific and clinical facts, and has not included the knowledge and skills that define competency in improvement work. QI competency needs to be developed with rigor, heightened focus, and consistency like any other discipline. Because they lack experience, often staff and providers rely on their subject‐matter expertise to complete a QI project. They fail to follow the required structured systematic approach and cannot achieve the goals of the improvement initiative. Improvement knowledge does not come as a natural evolution of clinical expertise. Improvement capability is not a natural ability!

 The team dynamics. QI teams in healthcare are often multidisciplinary in nature and are convened in an ad‐hoc manner, from different areas or departments. There is usually very little time to ensure cohesive functioning of the team members to avoid “silo” mentality. Physicians, nurses, staff, and administrators are brought together and expected to work as a team, even if they have never done so in the clinical arena.

 A top‐down approach to improvement. With multiple competing clinical priorities, improvement projects are often left in the hands of leaders and small teams of specialized subject‐matter experts (SMEs). This traditional model is no longer effective and cannot achieve the operational improvements in the large scale that are needed in today’s healthcare organizations. Engagement of the front line is critical to succeed and, yet, is not always present. This traditional approach to QI perpetuates the belief that process improvement is the responsibility of a small number of individuals in the organization and it does not have the same critical nature as the “clinical side” of care. Even when the front line is engaged, organizations don’t provide sufficient time, resources, or support. It becomes challenging to convene regular meetings with key stakeholders who must juggle their clinical and nonclinical responsibilities with project activities.

 Lack of a robust change management strategy. There is often more focus on the technical or clinical aspects of the problem than on how the solution will be received by the front line. It is important to remember that all improvement is a change, and change is going to have a significant effect on the professionals in the front line. Change management is often an afterthought, with the main focus being on designing, testing, and deploying the solution that addresses the needs of the project. Managing the effects of change is often reactive, and implemented without a clear plan. Communication and engagement with the front lines is not given sufficient emphasis leaving the project team unable to implement the much‐needed solution.

 Too many competing initiatives. In healthcare, there are too many competing initiatives that result in improvement fatigue. Healthcare providers face a constant barrage of mandates to change practice from external stakeholders, including accrediting organizations, regulatory bodies, third‐party payers, and professional associations. Front lines often become overwhelmed by the number of changes that occur in their work routines. There is a lack of leadership with proper selection, stratification, and improvement focus at the front line.

 Excessive focus on the methodology rather than the improvement opportunity. In the late 1980s, healthcare organizations began incorporating industrial quality‐management methodologies including Lean, Six Sigma, and Lean Six Sigma in their strategies to improve delivery of care. The Lean Six Sigma approach attempts to address the non‐value‐added activities, inefficient workflows, and disorganized work environments that interfere with clinicians’ ability to provide safe, high‐quality patient care. It merges the customer‐orientation and waste‐reduction techniques of Lean (time‐driven focus) with the more statistical and data‐driven systematic error reduction strategies of Six Sigma (quality‐driven focus). When implemented as an overarching management system and organizational philosophy, Lean Six Sigma process improvement methodology has been shown to improve patients’ experience, staff and providers’ work environment, and the quality of patient care (Nicolay 2012). Not all QI projects have been successful using Lean Six Sigma. Some teams have had disappointing results. For these teams, Lean Six Sigma lacked some of the critical elements they needed for success. When applied to medicine, industrial quality management methodologies have several problems:Heavy use of technical and business terminology. These improvement methodologies are derived from the manufacturing sector and often carry with them an overemphasis on improvement jargon that seems complex, counterintuitive, and far removed from the clinician’s front line.Improvement is often carried out by small teams of certified Lean Six Sigma practitioners who make up their own distinct department. These SMEs lead improvement efforts in a “top‐down” approach but often fail to create the conditions for the front line stakeholders to engage. Changes are pushed through without the front line professionals’ involvement in developing, revising, or monitoring the performance of key processes.

Physicians have a limited understanding of these improvement methodologies and in general regard them as something outside of the scope of medicine, showing little interest in learning them. Most industries make great products with average employees working with brilliant processes. Healthcare does great work with brilliant employees working with mediocre processes.