Richard J. Banchs - The Quality Improvement Challenge

Administrators, sponsors, and clinical leaders may require an estimated project duration to monitor the project and ascertain when they can expect project deliverables. Other project stakeholders and frontline employees may need to know the estimated project timeline to evaluate the feasibility of their participation in the project. All face multiple competing priorities every day. They may hesitate to become involved in your project if they fear the project is going to interfere with their other responsibilities. You should develop a project schedule based on realistic estimates of activity duration prior to engaging team members. The two most common scheduling practices are schedule set and PERT:

Schedule set. The QI team may receive the expected timeline for implementation of process improvements by senior leadership or the primary sponsor. Based on the expected date of project completion, you may have to work backward to determine the amount of time you can allocate for each activity to develop the project schedule. Schedule activity estimates can be a one‐point, best‐guess estimate based on your quality improvement experience in conducting similar process improvement projects, or historical information from the organization’s subject‐matter experts. These estimates can provide a general guide to a projected project timeline, initially with progressive specificity as the project activities unfold.

Program Evaluation and Review Technique (PERT). Another way to develop a schedule is to use the Program Evaluation and Review Technique, which relies on historical information or expert opinions to approximate optimistic, pessimistic, and most likely estimates of the duration of each activity, which are then combined to yield the project schedule. The formula for determining the activity duration using PERT is: (O + P + 4ML) / 6, where O is the optimistic estimate, P is the pessimistic estimate, and ML is the most likely estimate.

Regardless of the method of estimating that is used, the schedule will need to be updated when new information becomes available. You may need to align your project activities with the schedule, as the project team members, leaders, local sponsors, and frontline stakeholders usually have multiple conflicting priorities with restricted availability for project work. When the schedule gets off track, two schedule‐compression techniques may be employed in an attempt to restore the timeline:

Parallel processing involves performing two activities that are usually completed in a sequential manner in a parallel manner instead. This technique increases the risk of rework due to the change in the process.

Crashing involves using additional human resources to complete the activity faster. This technique impacts the cost of the project according to the type and number of resources used. It may also be performed to conduct a pilot to evaluate the effectiveness of the new process and justify additional resources.

By developing a tentative project schedule and updating it as new information becomes available, you will be able to estimate and manage project resources more efficiently and effectively.

“I think the problem is that we don’t have enough people in the morning shift to clean the rooms so we can keep patients moving,” said Martha Sanchez, the head of housekeeping. “If we are to decrease the time patients have to wait to be seen, we need to clean the rooms faster after the doctor sees the patient. I am going to speak to the director of the clinic; I said it many times: we need more staff!”

Describe the situation. How is the problem defined? Why is the way Martha Sanchez “sees the problem” a problem?

You should start every improvement effort by creating a clear and concise statement of: what problem you are trying to address, why you are launching a project, and what your overall objectives are.

The problem statement is a clear, concise, and specific explanation of the problem that does not include any causes of the problem.

What’s not working? What is wrong? How is performance falling short of customers’ expectations? What is the magnitude of the problem, and who does it affect? What’s the challenge? The problem statement frames the issues and is critical to the success of your improvement efforts.The time spent defining the problem is not a waste: it’s time well spent!

The primary purpose of a problem statement is to focus the efforts and attention of the QI team. A good problem statement should

Be clear.

Use precise language without unnecessary medical or technical jargon.

Describe the problem to the level where the root cause is not yet known.

Incorporate data, if any is available.

Include the undesirable results and outcomes from the patient, providers, or staff’s perspective.

Be agreed upon and fully supported by all core team members.

When people describe a problem, they often describe it in vague terms and use what they think is the cause to define it. Defining the problem by the cause creates a narrow‐minded focus that, at best, restricts creativity and, at worst, sets in motion a process that culminates in rolling‐out solutions that do not address the true nature of the problem. By simply and properly defining the problem, you will create a better solution. The most apparent problem is often the tip of the iceberg, which upon further investigation reveals a multitude of underlying problems that leads to what at first glance seems obvious.

To describe a problem, put yourself “in the shoes” of the customer and try and describe it from the perspective of the people affected by the problem. Properly defining a problem is the most commonly overlooked step for many QI teams, and yet it is the step that provides the greatest return on investment. Healthcare providers and QI teams often jump to searching for solutions without having clearly defined and agreed on the actual problem. Teams spend a great deal of time debating the “best” solution but seldomly ask themselves: do we clearly and fully understand the problem?

Quotable quote: “Without changing our patterns of thought, we will not be able to solve the problems that we created with our current patterns of thought.” Albert Einstein

Problem statement investigation efforts should include

The reasons why we should address the problem,

The consequences of not addressing the problem,

The “why now?” are we addressing the problem, and

How the project is linked to the organizational priorities.

Remember, the problem statement should not include any potential causes of the problem or possible solutions to resolve it. One way to create a problem statement is to divided it in three parts: define what we consider the “ideal state” (or standard); define the current state; and identify the gap between the current state and the ideal state. Write a short paragraph addressing each one while answering the relevant questions:

Ideal state. What would be the ideal performance? What would success look like? What is the standard?

Current state. What’s the failure? What is the rate of failure (how often is it happening)? How long has it been going on? What’s the background? Who does it affect? What is the patient or customer’s perspective? What is the stakeholder’s perspective? What metrics are currently used to measure the problem? Where is the data coming from? What is the current performance? What is the key output metric that needs to be improved?