Has your organization tried to implement quality initiatives to enhance productivity or to cut costs? Did anything significantly change as a result? Is it surprising that, despite management’s best intentions, people perceived the changes as the "flavor of the month"? What was missing from these initiatives that needs to be present for the program to succeed?
The only way to significantly improve your organization is to reduce variation by applying statistical thinking. Statistician W. Edward Deming and others developed this approach to modern quality improvement in the 1940s as a way for organizations to deal with complex challenges that they confronted. The approach to improvement they developed was built on the premise that quality improvement is really about process management.
The fundamental ideas of statistical thinking are these:
“In God we trust; all other must bring data.”|
text-align: right;>W. Edward Deming (Balestracci & Barlow, 1996)</div>
Organizations develop projects and teams to improve quality, but it's unclear where people are supposed to find the time for these improvements given that they are already working at capacity. Ultimately, improvement cannot be an addition to people's everyday jobs; it must become everyone’s job.
Joseph Juran, an electrical engineer and lawyer, saw the approach to quality improvement as two separate journeys:
Participants in the diagnostic journey need to use data to identify the most significant opportunities for improvement in a process. This journey will require positing theories about root causes, studying work in progress, analysis, and resulting action. It depends largely on the expertise that all involved in the process have about the process. Next, they need to develop a potentially viable solution and test and evaluate it on a pilot scale to determine feasibility.
In the remedial phase, the team knows the solution and must implement it. This requires change management principles given people's natural resistance to changing the status quo. The Nudge Theory is just one example of change management methods.
<figure><img src="https://sophialearning.s3.amazonaws.com/markup_pictures/10875/file/29be5ad6f51bf92a4875639f84a2df50.png" title="The Nudge TheorySource: www.process.st/change-management-models/" style="" class="markup-right"></img><figcaption><b>The Nudge Theory</b><br />Source: <a href="https://www.process.st/change&#45;management&#45;models/&quot; target="_blank">www.process.st/change-management-models/</a></figcaption></figure>
Several quality management models contain elements of quantitative measurements and concepts like these:
Deming and Juran’s theories and methods will be discussed further as we delve into process improvement methods in a later section.
Determining where to start with quality improvement efforts is one of the biggest challenges that leaders face. The healthcare system includes so many opportunities to improve processes and eliminate waste, it can be difficult to know where to start. It is essential to eliminate guesswork and drive decisions with quality data to ensure you are using limited resources wisely. Data can provide an objective view of a situation, removing destructive emotions that sometimes lead to inappropriate actions. The transformation from a crisis-driven to a data-driven organization can meet obstacles if people follow first instincts that do not agree with the data.
One way to stay on this track is to use the Key Process Analysis (KPA), which identifies which clinical processes have the highest variation and consume the most resources. This analysis combines clinical, billing, and cost data and correlates it with ICD-9 codes and all patient refined DRGs. The result is the sorting of each patient encounter into a hierarchy, as follows:
Organizations can either contract with a vendor to conduct a KPA or use these concepts to determine the key factor on their own. In the latter case, the organization would run their own comparative analysis using the Pareto Chart to identify which 20 percent of processes are using 80 percent of the resources. This will allow the organization to begin strategic quality-improvement planning by focusing on the highest priority process.
The images below show a KPA using a bubble chart or Pareto chart.
<figure><img src="https://sophialearning.s3.amazonaws.com/markup_pictures/10984/file/ae02e6cb302b92811f868f4dea62e4c4.png" title="Key Process Analysis using Bubble ChartThis bubble chart shows the clinical work processes plotted against the variable direct cost (X-axis) and variation (Y-axis). Note the green septicemia bubble in the upper right quadrant. It represents an area with potential opportunity for improvement and standardization.Source: www.healthcatalyst.com/clinical-quality-improvement-in-healthcare" style="" class="markup-right"></img><figcaption>Key Process Analysis using Bubble Chart<br />This bubble chart shows the clinical work processes plotted against the variable direct cost (X-axis) and variation (Y-axis). Note the green septicemia bubble in the upper right quadrant. It represents an area with potential opportunity for improvement and standardization.<br />Source: <a href="https://www.healthcatalyst.com/clinical&#45;quality&#45;improvement&#45;in&#45;healthcare&quot; target="_blank">www.healthcatalyst.com/clinical-quality-improvement-in-healthcare</a></figcaption></figure>
<figure><img src="https://sophialearning.s3.amazonaws.com/markup_pictures/10983/file/7a4566f048e18523943fd3589f54503e.png" title="Key Process Analysis using the Pareto PrinciplesThis graph is an example of a Pareto chart generated in Health Catalyst KPA application. It shows the variable direct cost by each care process family.Source: www.healthcatalyst.com/clinical-quality-improvement-in-healthcare " style="" class="markup-right"></img><figcaption>Key Process Analysis using the Pareto Principles<br />This graph is an example of a Pareto chart generated in Health Catalyst KPA application. It shows the variable direct cost by each care process family.<br />Source: <a href="https://www.healthcatalyst.com/clinical&#45;quality&#45;improvement&#45;in&#45;healthcare&quot; target="_blank">www.healthcatalyst.com/clinical-quality-improvement-in-healthcare</a> &lt;/b&gt;</figcaption></figure>
To fulfill a given quality-improvement strategy, each organization will need to transform the system. As Deming indicated, the organization will need to align management practices and structures with work processes. This alignment is crucial and must be accomplished through a well-understood, broadly communicated strategy that is essential to change management. Resources need to be allocated accordingly, and the initiatives should be displayed on a visual management board where executives can review weekly progress. Strong leadership commitment with a clear vision and strategy is essential to creating reliable processes and systems. This is not for the weak of heart. It is hard work but is a journey worth taking to achieve high reliability and safe, efficient, and reliable care.