Richard J. Banchs - The Quality Improvement Challenge

The second “R”: The Right People. All projects must have the “right people on the bus” (Bossidy 2002). Projects need a senior leader (primary sponsor) to legitimize the project, provide resources, and resolve cross‐functional issues. The primary sponsor must be present and active throughout the lifecycle of the project. Project teams need a competent leader and team members from the front line with subject‐matter expertise and the appropriate mix of skills.

The third “R”: The Right Problem. We must “walk in the shoes” of the customers or end users to understand the problem; learn about their experiences and understand their expectations. Collect the voice of the people that “do the work.” Understand their needs. What are their challenges? What barriers prevent them from meeting the customers’ expectations? Summarize the resulting insights into a clear explanation of the problem you are trying to address. This phase will help your team focus on the right issues.

The fourth “R”: The Right Cause. The first step in finding the cause is to “go see.” Understand how work is really done. “Walk the process” to identify areas of improvement. Eliminate waste where you can see it. Once you understand the process, select the measurements that matter. Define your metrics and collect baseline data. What is our baseline performance? Can we meet our customers’ needs? Are we meeting our customers’ needs? How often are we meeting these needs? Organize and stratify your data and use your process knowledge to discover the most likely cause of the problem. Then test your assumptions and confirm the cause‐and‐effect relationship.

The fifth “R”: The Right Solution. Use tools to energize your creative thinking. Generate a list of improvement ideas. Evaluate your options and prioritize the best solution. Create low‐fidelity mock‐ups and work with the end users and frontline stakeholders to test your ideas. Make this process iterative. Modify and refine the original idea as needed by uncovering performance gaps that need to be addressed. Learn from your testing. Once you have a winner, roll it out with the support of the key stakeholder who will be implementing it over the long term.

These five phases may be iterative and overlapping, require the completion of several steps, and end with project deliverables as shown on the Project Checklist(See Table 2‐1). Starting after the second phase and continuing throughout the project, the QI team should meet with the Primary Sponsor for a tollgate review(see Chapter 24). A tollgate review is a go/no‐go decision point where project activities and deliverables are reviewed to assure that the project is on track. Likewise, after each step, the QI team should plan for communicationwith the frontline stakeholders. Effective communication is a critical aspect of any quality improvement project and is recognized as a key component of behavior change in any change management effort (see Chapter 25).

TABLE 2‐1THE QI PROJECT STEPS CHECKLIST

A QI project is always a change project. Change rolled out “top down” often fails because it is rarely embraced, and results in doubt, pushback, and even open resistance. To be embraced, change must be socially constructed(Hamel 2016). Successful change requires an engaged front line. Engagement

happens when the front line is given the opportunity to be involved in the improvement process, and;

requires participation in the search for causes and the creation of possible solutions. Quotable quote: “In times of change the learners will inherit the earth, while the knowers will find themselves beautifully equipped to deal with a world that no longer exists.” Eric Hoffer

Frontline professionals must share responsibility for change needs. All successful projects need a change space, or framework, that engages frontline professionals in a shared vision of the problem and the co‐creation of solutions. The role of the improvement team is not to find solutions and implement changes but to create the conditions and provide the tools that enable the front line to find solutions.

1 1. Awdish R. (2018). Keynote Speaker. Institute for Healthcare Improvement National Forum.

2 2. Bossidy L. (2002). Execution: the discipline of getting things done. Random House.

3 3. Hamel G. (2016). Build a change platform, not a change program. McKinsey & Company.

4 4. Pennington R. (2017). The Pennington Group. www.penningtongroup.com.

Improvement projects are launched to address patients’ expectations for quality and service; frontline staff and providers’ workflow issues; a department’s strategic initiatives; or disappointing performance and undesirable outcomes. If you clearly know what problem you are going to address, then you are ready to move to the next steps. But if you are not sure where to focus your efforts, start with the right questions.