Process and tools critical to improvement process in healthcare

Barb ClearyFocusing on outcomes without examining the “how” and “why” of those outcomes is like addressing an epidemic of obesity by putting a scale in every home. The goal of reducing rates of obesity may be reached, but without any understanding of whether the reductions derive from good nutritional practices or from illnesses, such as eating disorders. The scale may indicate progress, but can’t by itself contribute to that progress. With no guidance about how to reduce patterns of obesity, or why unwanted weight gains occur, anything goes, in a kind of end-justifies-means approach.

Although conformity to standards may sometimes seem to reflect this same approach (“Do anything that shows that we’ve met this standard”), the burgeoning interest in providing quality in healthcare seems to suggest that healthcare professionals are increasingly focusing on the “hows” and “whys” of improvement in performance, examining strategies that not only will improve performance for specific assessment instruments but will also contribute to improved patient well-being that underlies that performance.

With this focus comes an understanding of improvement as a system, rather than as only a snapshot revealed in a test or reflected in conformance to standards. Of course, healthcare professionals have always been good at reflecting on the ways that they can help their patients improve, so seeing these efforts as part of a larger pattern—a system made up of critical processes—gives support to specific strategies and validates them in the larger approach to good health. At the same time, understanding system improvement will assure conformance to standards outlined by the Joint Commission and other accrediting agencies.

What is known as the Plan-Do-Study-Act (PDSA) system, popularized by organizational management expert W. Edwards Deming, represents a way to see the improvement process and to understand that healthcare is really about continuous improvement—a term that was popularized in the manufacturing industry but is increasingly applied to not only this environment, but to healthcare and other service environments as well.

Simply put, the PDSA system involves the following steps:

  1. Plan: Define the system to be improved and plan for that improvement. This involves thinking of ways that a problem or limitation can be addressed, or considering ways that success can become part of standard performance. It also includes collecting data on the current way of doing things, so that improvements can be measured and success demonstrated.
  2. Do: Try out a theory of improvement. If a team believes that packaging prescriptions differently in order to assure correct delivery to patients, this theory should be tried.
  3. Study: Data collected after the new theory has been implemented can be compared or contrasted with the “before” data to indicate whether it is really working. A variety of charts and diagrams render this comparison visually accessible.
  4. Act: This step involves not only putting a successful theory into practice, but thinking further about ways to improve the process. Again, this includes collecting data and studying its meaning.

For each of these steps, specific strategies or tools will advance that step. These tools not only bring improvements to a process (such as accurate delivery of prescriptions), but also serve to help those who “own” the process take responsibility for its improvement, evaluate progress, and reflect on outcomes.

Among the tools are strategies derived from mind-mapping traditions as well as engineering practices and other outside-the-hospital sources. Let’s look at a few of them and notice the ways in which they support the larger system of improvement, as well as how they contribute to demonstrating proof of conformity to standards.

Brainstorming—that old standby for generating ideas—takes on a new life when it addresses ways to examine a problem or improve a process. In response to a topic or a question—“How can we improve the rate of infections in our facility?”—staff members can offer suggestions, one at a time, without judgment or evaluation by others. The process encourages creativity, teamwork, and reflection, and if the responses are given serious consideration, it encourages those who are involved to consider alternative ideas.

Affinity diagrams have a natural tie to the brainstorming process, since they offer opportunities for participants to write down their ideas—again, one at a time, but this time on sticky notes—about a given topic. When they are finished writing, they are invited to post their ideas on a central board. As participants put ideas up, they are also asked to group them with others’ suggestions that are related (have an affinity to) theirs. To respond to a question about what we need to know about lab reports, participants can consider origin, content, distribution, and recording. Looking at their own ideas posted for everyone to see gives a sense of empowerment, since every idea is considered.

Flow charts offer a way of visually organizing steps in a process. Each step in the flow chart is part of a process, contributing to a system. A flow chart—derived as it is from the world of engineering and process control—has specific symbols to indicate start and finish for a process, for example, or to designate points at which decisions must be made. Creating flow charts involves breaking down a process to its constituent parts, an activity that stimulates analytical thinking. If one were to create a flow chart of the process of filling prescriptions from the hospital pharmacy, steps may move from ordering a medication through to delivery to patient.

Check sheets help to keep track of data related to a process. Check sheets are infinitely useful in gathering data that will be used in the improvement process, or in disaggregating (breaking apart) data to clarify it. In the PDSA cycle, check sheets help to define the system as it is, so that improvements can be made. Recognizing and recording infections by type will give information that will be useful to further investigation of infection rates and reductions in these rates.

Pareto analysis can go hand-in-hand with check sheets to support the improvement process. Using the example of hospital infection rates, understanding that staph infections represent the most common occurrence helps those charged with reducing infections to begin to identify causes and ultimately address approaches to improvement.

If, as John Quincy Adams asserted in establishing the Smithsonian, “To furnish the means of acquiring knowledge is…the greatest benefit that can be conferred upon mankind,” then providing these tools for acquiring knowledge of systems for teams intent on improvement of processes is indeed a lofty task

Barb Cleary

Barb Cleary