Is there a simple formula for sustainable quality improvement?

Answer: no! Almost any process in health care can be improved but sustained improvement is much more elusive. Part of the problem is the prevalence of discontinuous and non-integrated quality initiatives attempting to tackle, for example, safety, value, staff satisfaction, and culture change.

A recent report from IHI published in NEJM Catalyst (March 6, 2019) argues that what’s missing for sustainability is not care model redesign, incentive payments, IT systems, or policy change but management structure and practice that changes the organisational culture.

Under IHI’s guidance a High-Performance Management System has been tested since 2015 over a number of years, in various settings, including outpatient surgery centers in the U.S. and hospitals in Scotland.Core elements of the system are standardization, accountability, visual management, problem-solving, integration, and escalation. These management practices, derived from systematic approaches to quality improvement and Lean principles, are reported in the article to result in sustained new levels of organizational performance and reduced costs.

In US surgery centers where this initiative has been implemented, important practical steps have included introduction of visual management tools and a weekly value management huddle:

• Weekly collection and reporting of operational measures (e.g. time of discharge), capacity measures (e.g. time spent in direct face-to-face patient care), and financial measures (e.g. agency nursing cost. The weekly report covers all teams in the center, including preoperative and postoperative care, the sterilization unit, the business office, and the operating room. Each team has its own huddle system and huddle board. Every week, the teams report whether they conducted the huddle, whether they updated their measures, and any challenges that occurred during the huddle and require follow-up.
• Visual management includes a focus on cost through the use of a “box score” (a concise performance dashboard in the form of a spreadsheet updated weekly) and a visual management board (a physical bulletin board that outlined analyses and improvement projects linked to a small set of performance measures). Simple visual management boards display these measures, with examples of standard work and tracking of problems that surface during the huddles.
• Participating surgery centers introduced new practices such as surgical time-outs, safety concern escalation behaviors, and improved processes e.g. updated guidelines for equipment processing and sterilization. A daily huddle that focused on a small set of specific actions (such as review of safety risks for the patients on the current day’s surgery list) and safety measures (such as the number of days since the last adverse event). The site’s quality manager routinely observes the team huddles, provided coaching, and worked closely with an administrative manager to monitor progress and provide the teams with feedback and encouragement.

Hospitals in the Scottish NHS introduced very similar changes, including standard work and huddles, visual management tools, a focus on problem-solving and continuous improvement, and the involvement of multiple levels of management.

Results

• Improvements have been seen in cost management, productivity, safety, teamwork and accountability.
• Frontline staff appear to feel more empowered and engaged; participation in the performance huddles identifies emerging leaders who subsequently receive recognition and promotion.
• Improvements in communication, and collegiality have been shown; a survey tool asked staff to respond to the following 4 statements:
  • People support one another in my unit.
  • We have enough staff to handle the workload.
  • When a lot of work needs to be done quickly, we work together as a team to get it done.
  • In this unit, people treat each other with respect.
• In Year 1, 86% of staff either “strongly agreed” or “agreed” on a metric that combined the responses to the four statements above into a composite measure, increasing to 92.5% a year later.
• The management system was spread to additional hospital-based teams; as a result, endoscopy team reduced late starts; a medical unit in a community hospital reduced patient falls; a cardiac intensive care unit reduced its cost per admitted patient by 7%; 9 of 14 teams have shown at least 1 statistically significant improvement in terms of quality and/or cost, and some have shown >1 such improvement; all surveyed hospital teams have had either stable or improving culture scores.
• Improved use of nurse capacity increased face-to-face patient time, and improved discharge preparation. In one unit productivity increased by 32.8% since the start of the project, with the number of patients seen in the unit increasing from 58 to 77 per week. A lower readmissions rate of 12% to 10%, was seen, representing a statistically significant change.

Management behaviors reinforce the “integration” component of the High-Performance Management System. Middle-level managers attend huddles, ask questions, and provide encouragement. An assigned physician helps to address challenges in engaging physicians, particularly specialists and those without significant quality improvement experience. Hospital executive teams are involved in key decisions, including the selection of teams, the pacing of spread, and investment in improvement priorities.

The article notes 3 common factors across teams that showed the most impressive results:

1. Improvement capability: Successful teams used basic quality improvement methods with ease: e.g. annotated run charts, detailed cause-and-effect and Pareto analyses, and Plan-Do-Study-Act (PDSA) cycles – all part of what is termed “problem-solving” in the overall management model.
2. Standard work: Standard work means not only using checklists and other tools, but also defining aspects of standard work for different roles to achieve smooth execution. e.g. patient discharge which requires assigned tasks across many different roles: a nurse assistant to arrange the patient’s belongings and family transportation; nurses to lead teach-back activities, communicate with the physician regarding discharge orders, and review safety bundles; and a charge nurse to adjust staffing to ensure that others can complete their tasks.
3. Leadership: Successful teams have support from several levels of leadership, including senior executives who attend huddles, remove barriers, coach unit leaders, and celebrate success. Senior executives have their own measures and visual boards as well as a role in solving problems and executing improvement. Physicians attend huddles and lead their own PDSA cycles helps to drive improvement and engagement. Teams have administrative support from a service manager or quality improvement coordinator accountable for issues such as physician scheduling and ensuring accountability for the frontline team leader.

Conclusion

According to the authors, the High-Performance Management System takes time to introduce and evolve but teams can start with a small number of pilot huddles, and the system should evolve to include huddles, visual management, standard work, and other elements at each level of management.

What would it take to introduce similar management behaviours and practices to private and public hospitals in South Africa? Would our design look different? Can we afford this type of intervention, or, more realistically, can we afford not to?