Keywords

Introduction

Anyone working in healthcare – from executives to mid-level managers to frontline staff – knows that organizations today invest heavily in process improvement efforts. But frequently, these efforts fail to deliver on their objectives. In my 20 plus years in healthcare, I have encountered many detailed processes that appeared sound, but, in reality, they were flawed and ineffective. The problem often lies in developing and implementing processes without involving all parts of the organization. Sure, if you are a medical professional, a physician, a nurse, or a researcher, quality improvement (QI) principles have been a regular part of your training and experience, and you are likely skilled in assessing processes and making improvements to them along the way. However, as support services professionals know well, healthcare institutions do not consist solely of medical personnel or administrative staff with advanced degrees.

Critical to any operation is the staff in areas such as housekeeping, food and nutrition, and security. Medical and nursing staff in the operating room (OR), in intensive care units (ICUs), or the emergency department (ED) may be skilled in evaluating and improving processes for their units, but what about the necessary processes that support medical and nursing staff? For instance, hauling waste out of the facility, or effectively cleaning and turning over rooms when a patient is discharged, or expediting food delivery to a patient in an inpatient unit? Who is responsible for improving these processes, and how do they go about it? Is the expectation that everyone understands statistical analysis or is six sigma black belt certified? One thing is certain: all processes, regardless of the department or work unit in a healthcare organization, can and should be improved. This obligation – to improve processes for our patients, families, guests, and employees – is shared by executives, management teams, and staff, alike, across an organization. I know that patients and families deserve it!

The fact that processes often are interrelated is another reason that we must consider nonmedical teams in our QI efforts. Waste and inefficiencies in one area have the potential to effect another in a significant way. Think of the patient discharge process as an example. We know that for a hospital to make room for a newly admitted patient, it must first complete the timely discharge of another patient. For timely discharge to occur, the medical team must write an order that is then implemented by the nursing team. In pediatric institutions, we often find that if discharges occur around mealtime, patients and families want to leave after the meal is served. The food and nutrition department becomes part of the process, and they must deliver the meal on time, if not early, so that the discharge is not delayed. Once the patient or family is discharged, housekeeping staff must respond quickly to clean the room and make it available for the next patient. These individual teams’ processes are interconnected, and a gap or delay in one area has a negative impact on others downstream.

Any process is only as good as its weakest link. Medical and nursing teams may have efficient, tight processes, but once they rely on other departments to fulfill certain tasks, their hard work may be for naught. How do you get all processes to function smoothly? Your organization might be eager to educate all employees, including support services staff on statistical probabilities, central lines, upper and lower limits, tack times, and identifying kaizens. That may work well for some staff. But formal training programs may not be effective for many employees whose postsecondary education has focused on vocational, technical, or occupational training. Instead of delivering more training, one will need to take this complicated information and make it relevant to your audience.

We know from research that quality improvement is fundamental to an organization’s overall success. We also know that in order to have a real impact and change the culture at all levels, we must focus holistically on every aspect of the business while engaging all employees in the effort. It is the only way you can change the culture to one that will always put quality and safety first to achieve the best possible outcomes for our patients.

In this chapter, we will explore this question: What is the best way to instill a quality improvement culture across all disciplines in a health system focusing on clinical support services?

The Journey

I learned about the importance of quality improvement in my first healthcare job as a clinical nutritionist working in the Lower East Side of Manhattan. I had just joined Rivington House, the nation’s largest inpatient facility dedicated to the treatment of HIV/AIDS patients. It was 1997, and HIV/AIDS was still ravaging lives across the country. Patients, both male and female, often were admitted to Rivington House with a body mass index as low as 13 and an extremely poor prognosis – anything below 18.5 is considered underweight. I vividly remember one female patient, Liz, who was about 5 feet 6 inches tall and weighed only 60 pounds. She had lost so much muscle mass that she was severely contracted. In my role as a dietitian, I had to work closely with the nursing team, the physician, and the pharmacist on Liz’s treatment plan. I was responsible for calculating the formulas for both intravenous nutrition and tube feedings and communicating that information to the rest of the clinical team. There needed to be a way that the clinical staff could supply nutrition to patients when the dietitians were off duty or busy with other patients. Liz had to receive nutrition as quickly as possible, and each patient had different needs. The pharmacist and I worked collaboratively to create a form that could be used to determine the exact recipe of nutrients that the nurses would supply to patients. It was a matter of plugging in the right information, and the formula could be calculated easily. We trained the clinical staff at Rivington House on how to use the form, which soon became an essential part of our operations. This new process demonstrated to the staff how one small change could make a big difference in care and outcomes.

As you consider how to instill a quality improvement culture in your organization, you will need to begin your journey by imparting a few concepts to your teams. The question is not whether to educate the staff on these critical topics, but how to go about it. No matter our level of education, most of us value knowledge, especially when we believe it will benefit us, produce better results, or make our work a little easier. How we acquire that knowledge can vary. For some, it requires the right environment – one that is supportive, nonjudgmental, and free of blame. It is worth spending the extra time and effort to create an environment that is conducive to your team’s learning.

To help staff understand and use these concepts in their day-to-day tasks, you will want to provide clear and straightforward explanations. The staff will want to understand the reasons for the process, its components, and how to monitor it effectively to know that it is yielding the right results. One way to do that is to display progress measures prominently on QI boards in staff lounges and corridors (Fig. 13.1). These techniques will help you raise awareness and understanding of the concepts and give employees a greater sense of responsibility and accountability for QI. It is how you create an appetite for change to transform the culture. Healthcare leaders frequently believe that cultural transformation is a top-down initiative. It may start at the top, with the CEO or senior leadership team’s vision, but culture takes shape at the frontline, where the employees interact with each other and with patients, families, and guests.

Fig. 13.1
figure 1

Quality improvement board from the environmental services lounge at Children’s National

Full size image

Determine Baseline Knowledge

What is the best approach for teaching these concepts to housekeepers, food service staff, plumbers, electricians, and security officers? First, ensure the staff understands key terms. Team members must speak the same language. You need to perform a needs assessment to gauge a group’s level of understanding. This can be done by asking questions at team huddles, meeting with union or group leaders, and meeting one-on-one with individuals. I would gather these responses and chart them on a whiteboard in my office. Despite a lack of training or formal education, the staff may be familiar with some of the concepts. Your assessment can help you determine how to tailor any instruction, where to provide general information, and where to give in-depth instruction.

Don’t underestimate the staff – they will surprise you. One day last year, I was speaking with the housekeeping team about our organization’s retirement plan. I was pleasantly surprised to learn that most of the staff had a good knowledge of investment terms, such as risk, future value, and compounding interest. This surprised me because the majority was not contributing to the plan. Although the knowledge was there and they understood the benefits, contributing to the plan was too difficult for many of them. After covering monthly bills and feeding their families, they had little left to save for retirement. This chat with them showed me that you should never assume you know what others know. This was also evident when we assessed the group’s understanding of quality improvement theories and terms. As predicted, the group’s knowledge followed a bell curve, with some staff well versed in the terminology, many others slightly familiar, and a smaller group that was new to the concepts.

Create a Lesson Plan

The next step is to develop a lesson plan to structure learning. Your plan should be clear and concise and not overwhelmed with jargon. As much as possible, it should include the use of colorful visuals and you can share by projector or LED monitor. Graphs, charts, photos, and illustrations are all helpful. Long verbal explanations of concepts and text-heavy slides are not. I have found that the best way to get a point across is to tell a story, especially when you make it relevant to the group’s experience.

To explain to my staff why it was so important for the hospital to admit patients quickly, I relied on my own experience as a parent. We work in a children’s hospital, and the majority of my staff are parents or grandparents. Some had used the hospital’s services for their kids. It was apparent to me that this connection had to be leveraged. “Imagine that the patient who needs to be admitted is your child or grandchild,” I began. “How would you feel about waiting forever in the emergency room or waiting room?”

Then I shared my personal account with the team. My son suffered from severe eczema when he was younger. During one bad flare-up, when we felt we had lost control of his care and treatment, we rushed him to the hospital where I was working at the time as the leader of support services. This is a highly respected institution in the community, and families travel from other parts of the state to bring their children there for care. I knew and trusted the caregivers there. My son’s skin had become infected with staph, and as soon as the clinical team laid eyes on him, they told us he needed to be admitted for steroidal and antibiotic treatment. However, there were no inpatient beds available. So, we had to wait in the crowded emergency department for almost half the day.

When we finally arrived at the room and saw the admitting physician, she explained the treatment plan. Within 24 hours, he was doing much better and on his way to recovery. The wait had added to our anxiety. Housekeeping would come to my son’s room twice daily, first in the morning to clean and then again in the afternoon to empty the waste bin and asked if we need any additional services. Everyone was very polite, but I knew that the processes were fragmented because whenever we asked for something, the time it took to respond to our request was inconsistent. An explanation was always given, but service varied depending on the time of day and service required. Food and nutrition responded promptly, but facilities took a while, or vice versa. A process cannot be effective if it is applied inconsistently.

I provided my feedback to the unit and emergency department nursing directors, both of whom I considered to be friends. Although I was nervous about sharing the feedback, I discovered that they actively listened to what I had to say without being defensive. They genuinely wanted constructive feedback.

I was careful, however, to begin with the positive parts of my experience. I had learned about the importance of starting with the positive from coaching exercises in the many different leadership development programs I had attended, including some facilitated by the Arbinger Group, Studer Group, Disney Institute, and the Ritz Carlton Customer Service Training. It was easy to share favorable feedback because the majority of our experience was excellent – for example, my son loved the food! While he wouldn’t eat waffles at home, he gobbled up the ancient grain waffles they served. He adored the nurses and housekeepers, who were friendly, respectful, and very considerate of our privacy. They would always knock at the door and ask permission to enter. The physicians, nurses, and nurse assistants, alike, were patient and caring, and I knew they always had my son’s well-being in mind. With all that was going right at the hospital, they needed to fix a few processes to ensure these inconsistencies would not overshadow the team’s great work.

Sharing stories with my staff helped as I use my stories to illustrate the point that the right processes can reduce the variability within an organization. The story brought the concepts home for the staff. They understood that it may be challenging when we are always asking them to make improvements – it’s something our leadership focuses on constantly. The team now realizes that if we incorporate quality improvement and process improvement methodologies in everything we do, it will become part of our everyday work. When process improvement becomes a habit, a regular part of our work, it will be much easier to achieve our goals. When we get to zero surgical site infections, zero pressure injuries, zero readmissions, zero late trays, zero faulty lights, and zero soiled linen, we will know we have succeeded. All these zeros may one day translate to 100% patient satisfaction.

Patient satisfaction scores are receiving even more attention lately because of the way hospitals are reimbursed for care and now rewards or penalties are given to healthcare institutions based on their patient experience scores. Thus, improving patient satisfaction now also means improving an organization’s reimbursement and its bottom line.

Educate in Real Time

Now that you have performed a needs assessment, identified gaps in knowledge, and established a plan, it’s time to teach the material. You will want to present your content in a way that is interesting and easily understood.

Initially, you may have some short in-person sessions, but traditional classroom training does not work well for support services staff. Instead, seize on opportunities to explain QI concepts as they present themselves. Housekeeping staff who disinfect rooms every day know that despite a strong track record of properly cleaning rooms, there are occasional gaps. A patient may find breadcrumbs on a chair or debris in the shower drain. How were these things missed? I once posed this question to my staff: “How would you like to visit a hotel or a hospital and discover these items in your room when you arrived?” They agreed unanimously that they would be upset. So I asked, “How do we ensure that this does not happen here?” Someone in the group mentioned having a list of all the items that are supposed to be cleaned in the room. It was a great observation. “Is there such list, and if not, who will put it together?” Management? Not necessarily. Management can lead the conversation, but it’s employees on the frontline who must provide input into the development of the checklist and any tool they will be using. They know patient rooms like the back of their hand and interact with patients and families daily. If you are a support services leader, your critical step here is not convincing your leader that you want staff input, it’s persuading your frontline managers that the opinions of the staff are not just nice to have – they are essential. Your job is to get mid-level managers and supervisors on board and sharing in the belief that staff input and feedback is key. The wisdom of the crowd is far superior to the arrogance of one individual; I often solicit input from my managers and frontline employees, and they continue to exceed anything I could have conjured up by sitting behind a screen on my desk.

Another critical component of educating in real time is making sure your approach is inclusive of all staff – from all backgrounds, perspectives, and abilities. I once had the pleasure of working with a young man with special needs named Jonathan, who was part of our food and nutrition team, working with the dish cleaning crew. His responsibilities included testing the pH levels of cleaning solutions to ensure dishes were properly disinfected, and he needed to document the testing. Despite his developmental challenges, Jonathan was able to make the testing and documentation part of his regular routine because of the approach the team used to impart the concepts to him in real time. With Jonathan, we relied on systematic verbal reinforcement from department leaders and peers, as well as one-on-one conversations with his supervisor, Maria, with whom Jonathan had a special bond. She had taken him under her wing from his first day, and he trusted her. After about a month of message reinforcement, Jonathan had incorporated the pH testing and documenting into his routine. So when The Joint Commission reviewed our handwritten records, they asked to interview the employee whose name was on the logs. Jonathan shined, during the interview explaining in clear terms to the Joint Commission the importance of what he was testing and what he was documenting.

Checklists

Checklists are a great QI tool when designed carefully with input from staff and guidance from management. Once created, a checklist should be reassessed periodically to ensure it is still accurate. Processes change over time. Let’s say, for example, if you add a new ultraviolet disinfection treatment to your room cleaning process, you’ll need to add that step to your checklist. A checklist needs to be customized for a particular unit or area. Something that was designed for an inpatient unit might not work in cardiac care or perioperative areas.

Checklists are valuable as long as they are used. You can create the best list imaginable, but it won’t matter if it’s never operationalized. If the checklist isn’t practical, it won’t be used. Ultimately, staff is less likely to use a checklist they have not helped create. The more time you spend involving team members in a checklist’s development, the more likely they’ll put it to good use.

Make tools, like checklists, easily accessible. The language you use should be simple, and the tools should be shared at huddles, posted on boards, and made available electronically. When staff is on duty, helping patients on the floors, digital access is not always possible, so have laminated copies available. You can post laminated checklists in the kitchen, breakrooms, and on safety and quality boards. You can also place them on housekeeping carts. Consider color-coding items to make it easier to identify types of tasks at a glance. When it’s a long checklist, with numerous steps, label critical steps in red and any optional or infrequently used steps in black.

Early in my career, I worked for a management firm that used checklists at every opportunity to conduct its business. That was great for those of us who were new to the company, but these same checklists became cumbersome for people who had been with the company a while. Their checklists were comprehensive, but often too long, and hampered efficiency. One organization I worked for had a nightly checklist for supervisors that included more than 40 items. Just completing the checklist occupied most of the shift, leaving little time for engaging with and supporting the staff. Evaluate your checklist frequently. Identify critical steps and eliminate duplications or unnecessary items. Your checklist should be a valuable tool, one that can even save lives – but it doesn’t have to be onerous nor lengthy.

As the saying goes, a picture is worth a thousand words. Try to summarize your checklist steps using simple images instead of text. You’ll notice, for example, that instructions for properly donning and doffing personal protective equipment invariably include images. During the COVID-19 pandemic, hospitals developed instructions with both still images and videos to ensure the procedures were clear to everyone. You can incorporate visuals into your checklists using icons.

Plan-Do-Study-Act

Another helpful device is the use of plan-do-study-act (PDSA) cycles. PDSA cycles allow you to try out (or practice) a chance to see how it will work (study it), should it be implemented broadly. Through the cycles, you can quickly learn about the likely success or potential failures of a planned change and use the process to modify your plan as needed. In our environmental services department, we struggled to get staff to return soiled microfiber mops for reprocessing. At the end of the day, soiled mops are deposited at a central location where our vendor would pick up the bins full of used mops, take them to a cleaning facility, and return them to our facility the following day. Thus, if 1000 mops were delivered that day, it stands to reason that 1000 mops would be returned the next. However, that never happened for us, and our inventory of clean mops diminished over time.

We decided to conduct a relatively easy PDSA cycle and followed our protocol of asking frontline staff (PLAN) for input. The employees appreciated being involved in the process. They identified a number of reasons why microfiber mops were not being returned. When the mops are distributed to staff at the beginning of the shift, they are dry and lightweight. Conversely, at the end of the day, the soiled mops are wet and heavy, not to mention messy. Unless we provided them with a simple, efficient way to return the mops to the point of collection, the staff found the task overly burdensome.

They asked if they could return soiled mop heads to a designated location on the floor where they worked instead of hauling them to the central location. Why couldn’t we create a return point on every floor? There was only one way to find out if such a strategy could work: to add a collection bin at an agreed-upon location on each floor and have staff drop off their soiled mops at the end of each shift (DO). Collection bins were relocated, and staff instructed to bring soiled mops to the gathering point on the floor. Very quickly, we realized that staff were indeed bringing the mops to the new location, but rather than placing soiled mops in the bins, mops were discovered around the bins and on the floor (STUDY). We discovered that the collection bins had a small slot on top where mops were to be placed; the rest of the bin was locked. When we asked staff why the mops were not placed inside the bin properly, we discovered something interesting; soiled mops were collected in plastic bags, and the entire bag was brought to the soiled bin collection location. The bag full of mops did not fit through the slot. Frustrated and tired employees at the end of their shift, staff did not want to take the mops out one by one and place them in the bins. We could hardly blame them for not wanting the extra tasks that meant handling soiled mops again at the end of the shift. Moreover, this step likely constituted an infection control issue. The smart thing to do was to drop the entire bag of soiled mop heads next to the return bin.

We knew we had to improve the proposed process, which brings me to the last step (ACT). We continued to place the soiled return bins on the floors, but now we unlocked and opened the top of the bins, so the opening was more expansive, making it easier to drop the bags into the bins. This was a simple PDSA cycle that allowed us to plan, execute, assess, revise, and implement a new procedure in 48 hours. We could very quickly see if the new process worked, and if not, what additional changes needed to be made to help it succeed. The critical step here is timely feedback. There is no need to observe the process for days on end. Make some prompt observations, ask for quick suggestions from frontline staff, and proceed accordingly while continuing to observe and plan and implement the next steps.

Make Your Data Visible

Another step to successful QI is making the data available and visible to all. From the CEO to the housekeeper who cleans the nursing units, we all need access to the same data. Graphs and tables are prominently posted in our environmental services lounge. Data on bed turnaround minutes, hand hygiene, total operating expenses, supply costs, and patient and employee engagement scores are all posted in the department’s QI board. The goal is for every member of the team to be able to understand the graphs and speak about the data. Not all employees can elaborate on every detail, but most are comfortable speaking about key points. All team members working in the inpatient nursing units, as well as our discharge team, can talk about the bed board and improvements we have made in turnaround times. Our storeroom clerk can speak about the steps taken to better control supplies and inventory. Other members that are regularly audited by infection control staff feel comfortable talking about hand hygiene or PPE utilization and processes.

It is critical that you also share the data and any metrics related to your team’s progress with your leadership structure. Invite them to see the performance board displayed in the department and to share in your successes and setbacks. Better yet, have one of your frontline managers or staff discuss the team’s latest efforts with them. These types of interactions provide an opportunity to not only impress your leaders but also promote and advance your staff. Successful organizations are the ones that can find and develop talent from within.

The QI message boards proved extremely useful during the COVID-19 pandemic . With social distancing measures in place, we could not conduct in-person huddles with the staff the way we had become accustomed to. The inability to not meet in person hindered the flow of information. Our education coordinator thought we could use the boards in the department to communicate COVID-19-related updates regularly. Any updates or news we wanted to share on COVID-19 data, processes, or procedures would be posted on the same board in the lounge. It became a one-stop shop for staff messages ranging from CEO announcements, to details on free Uber rides to work, to resources for mental health services. All this information was shared through the COVID-19 communication board and it became a permanent, invaluable tool.

Specialized Software

At Children’s National Hospital, leaders have the opportunity to participate in a quality improvement program called QuILT (Quality Improvement Leadership Training ). During the program, they learn about several useful QI tools and how to develop and track QI projects. They quickly discover that to track and improve processes, you must have good data. Without accurate and reliable data, you can’t effectively track your progress, much less show an impact. As was mentioned earlier, the use of data is critical for QI tools, like PDSA cycles.

Tracking and analyzing trends such as patient throughput are essential for our department and especially support services departments. An analysis of throughput can show you how quickly patients are admitted, transferred, or discharged within the hospital. With so many patients admitted every day, and with a finite number of beds, it’s vital that the process to admit and track new patients and patient flow be as smooth as possible. It can have an impact on your organization’s reputation and financial performance. At Children’s National, we tend to be at or close to capacity most of the year, which is usually a good problem for a healthcare system to have. This requires accurate, timely, and easily accessible data. Bed tracking applications can help, but not every organization has the luxury of investing in this type of software. For those that have it, the software provides a plethora of data, though some customization may be required to get to the specific information you need.

Good data can inform your decision of where to focus your efforts. After reviewing the data, our environmental services team identified that we needed to do a better job ensuring hospital rooms were cleaned soon after patients were discharged. It showed us we were not achieving national benchmarks. We launched a project to improve our room turnaround rate. The project required a process map and an intervention using LEAN principles . Process mapping was critical to understanding the sequence of events that occur from the time a patient is discharged to when the room is cleaned. As with any QI effort, there is a need for reliable data at each point in the process. We developed a process map to understand the flow of patients and resources and to uncover any gaps in the process. After a careful gap analysis and educating the team on the areas of concern, we were able to increase the percentage time that we responded to a vacated room within 60 minutes, from less than 50% to over 80% in 12 months. We eventually increased the goal to over 90%. Without access to reliable data, the project would never have gotten off the ground; we relied on input from frontline staff to uncover pain points and identify the reasons for delays in the process. Don’t forget to use this opportunity to share your efforts and results not only with your direct leader but also with colleagues and leaders of other divisions, including the medical staff. After all, these improvements have organization-wide implications.

Pareto Charts

If you are undertaking an important process improvement project, you will need an executive sponsor. Typically, this happens early in the project’s development. Without executive support, many projects fail, so it is an important consideration. If they approve of your proposals and plans, executive sponsors will champion your efforts with their peers, giving your project a greater chance for success. The use of data is one way to garner support from your executive sponsor and broader leadership team. Leaders use data to inform their vision and drive sustainable outcomes. Pareto charts can be very useful in bolstering your position or argument.

Looking at a multitude of numbers can be confusing for anyone trying to decipher meaning and develop insights. That’s why it is important to take the time to create graphs and charts that make your point for you in a clear, visual way. Once you see a graph or some other visual representation of data, you often realize that the truth of the data is staring straight at you. I’ve often had epiphanies when seeing data displayed in a Pareto Chart.

A Pareto chart is a type of graph that includes both lines and bars that allows you to examine the frequency of events. Pareto charts are a simple way for a project to identify the most frequent defect, complaint, or another factor that can be categorized and quantified. At Children’s National, we regularly use Pareto charts (Fig. 13.2) to illustrate relationships between variables and identify the “culprit” or problem area (i.e., where we should be focusing our attention). Pareto charts allow you to quickly show these relationships, and they are very effective when you are trying to steer a discussion or persuade leadership to approve a decision.

Fig. 13.2
figure 2

Slips, trips, and falls Pareto chart

Full size image

In one recent example, the senior leaders at Children’s National were discussing employee injuries and the costs associated with them. They asked our team to research the problem and find some solutions. We knew that we needed to conduct a thorough analysis and provide accurate data. We also recognized it was essential to present the information to leadership in a way that helped them draw the right conclusions and make good decisions.

The problem centered on a recent uptick in the DART rate at Children’s National. The DART (Days Away/Restricted or Job Transfer) rate is a calculation that describes the number of recordable employee incidents that resulted in days lost, restricted days, or transfers due to work-related injuries or illnesses. The first question here was “why was this happening?” and then “what can we do to address the problem?”

We needed data to learn more about the issue. With the help of a Pareto chart, we could determine where the defects might have occurred most often and where the organization should focus its resources. The data showed that the uptick in the DART rate was partially due to an increase in the number of employee slips, trips, and falls. We presented the data on the Pareto chart, showing the cost implications of the lost productivity, and we effectively convinced leadership that something had to be done.

We investigated further, digging deeper into the data to explore how the employee falls were taking place. Using a second Pareto chart, we showed that most slips, trips, and falls that resulted in lost productivity were due to wet floors (as opposed to objects in the pathways or staircases). This data point was crucial to our work because it told us precisely where to focus. Over the course of a year, our entire team made this our quality improvement initiative, and protecting others from wet floors became our obsession. The result of this intense focus was that, after 18 months, we had decreased the overall rate of slips, trips, and falls by 34%, but more importantly, we had reduced the rate of falls due to wet surfaces by 80%. Our work, along with other parallel efforts, cut the DART rates by almost 50% (Fig. 13.3).

Fig. 13.3
figure 3

Slips, trips, and falls Pareto chart showing progress

Full size image

Five Whys

As you develop a process map, another technique is quite useful, called The Five Whys. In assessing a process more generally, you’ll want to explore the purpose behind the actions – you’ll want to simply ask why. Why does this specific step need to occur? This questioning strategy is a way of performing a deep dive to understand the progression of steps fully and can help you develop the best possible solutions. By asking why, you can identify gaps, eliminate waste, and streamline your map. Not everyone is trained or able to perform a full LEAN process map, with its specific methodology that includes identifying kaizens and calculating tack times. Furthermore, in the teams I have led, everyone understands how to answer “why” and the importance of this line of questioning. However, asking “why” requires no formal training in a methodology. It can reveal where a process is broken or not function as intended. Questioning why must not be superficial. Don’t just identify the first “why” that comes to mind; it might not lead to a solution. Instead, the team needs to continue asking “why” until a breakthrough in understanding is achieved. Management will not have all the solutions frontline employees hold the key. Involve them right away and carefully listen to their ideas and their complaints because within their pain points lies the potential opportunities to improve. You can pursue the “why” when conducting short PDSA cycles, but if you still haven’t found your solution, don’t despair. Keep trying a new PDSA cycle until you see results.

Low-Hanging Fruit

Sometimes you will find that improving your process can be costly. For example, we noticed that staff often complain that there are not enough housekeeping carts to do their jobs. The easy answer might seem to be to buy more carts. But what would happen if you don’t have the resources (space, financial, etc.) to do that? How do you go about fixing the problem? Many times, the most straightforward intervention is the one that has the most significant impact. There are often many possible interventions available to you. First, try those that require limited or no resources but have a lesser ask or requirement – the so-called low-hanging fruit – and implement those solutions first. If more intervention is needed, then your next step might be an action that requires some investment. The last possible interventions are those that have the highest ask or require a significant amount of resources. Those should be left to the end, and for those steps, you’ll likely need executive sponsorship. Incremental improvements, which can have a very positive impact, can be achieved by going after the low-hanging fruit first.

Stop and Ask a Colleague

There are times your frontline staff, including supervisors, might be met with a challenge they have not experienced before or that rarely occurs. Are there any just-in-time QI tools that can be used to support a positive outcome in these situations? The answer is yes. Whether it is related to an operating room team performing an operation, an emergency room team treating a trauma patient, or a food and nutrition team delivering a tray, team members will inevitably experience situations that they might not have encountered frequently in their careers. Or, it might be a situation in which there is uncertainty about how to proceed. What then? How do we prepare our teams to deal with the unexpected? These are the times where I instruct my team to pause and think critically about the situation or reach out to a colleague. When you are in doubt about your next steps, or experiencing a unique situation, ask a colleague and verify possible solutions before moving forward. Regardless of the situation, someone in your department or your organization likely has experienced something similar before. Reach out and ask for advice and confirm that your thinking on the matter is correct. Taking the time to pause and consult peers or other leaders is crucial here and a simple tool that can be beneficial not only in clinical settings but in hospital operations.

Conclusion

QI provides valuable tools to help support services teams make more reliable decisions on complex issues in healthcare. Simple QI tools can be used outside the clinical realm; however, it is important to remember that not everyone in healthcare is well versed in terminology or learns well in a highly academic setting. As healthcare professionals, we have the responsibility and obligation to teach all employees in our environment and provide them with the best tools so they can improve steps in any process, clinical or otherwise. As middle or frontline managers, we have an obligation to listen to our staff and hear their ideas, perspectives, and grievances. As executives, we should also listen, but expect in-depth analyses and thorough reviews and assessment. We should ask to see the data and require our management teams to use evidence to make improvements. Finally, we should trust and support our directors and managers to deliver results.

Processes can be complex, but leaders can simplify the concepts. In a healthy environment and under the right circumstances, leaders can teach all their support services staff simple QI concepts that can be used in everyday situations. Tools, such as PDSA cycles, QI boards with easy-to-understand data, asking The Five Whys, using Pareto charts, and pausing to ask a colleague for advice, can all help achieve the desired aim. Remember that all of our employees deserve continuous education that helps them improve. In fact, they are hungry for it. We owe it to them and to our patients and the community to keep learning and growing and to share our knowledge. A visit to your healthcare institution should be as smooth and safe as humanly possible, and that means preventing anything that can lead to hospital-acquired conditions and, at the same time, giving the patient the best possible experience. A focus on quality improvement can improve outcomes, enhance the patient experience, and reduce waste, thereby lowering healthcare costs. To achieve these results, however, QI must be embraced by all parts of the organization and at the higher levels of leadership. Then and only then will you see a profound impact on the entire healthcare system. It begins with the involvement of support services teams.