Quality Improvement in the Healthcare Workplace

Quality Improvement in the Healthcare Workplace: Educate Yourself and Engage Your Colleagues

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Quality improvement (QI) has emerged as a powerful buzzword in healthcare, and for good reason. The quality of care is becoming increasingly tied to reimbursement practices, which raises the bar for providers at all levels to become competent with the language and skillset necessary to participate in QI initiatives in the workplace. At the core, QI aims to eliminate medical errors, which have been alarming the American public ever since the 1999 Institute of Medicine report, To Err is Human, found that up to 98,000 people each year die as a consequence of preventable medical errors. Underscoring the complexity of this mission, we recognize that suboptimal care is an unfortunate byproduct of our highly fragmented medical system, and that flawed systems, rather than flawed providers, are the true culprits. As a direct extension of that logic, the organizational culture of a hospital or practice is the single most important determinant of whether QI initiatives will succeed. As a healthcare provider, you have the potential to either contribute or detract from a culture that encourages the delivery of care that is 1) Safe, 2) Effective, 3) Patient-Centered, 4) Timely, 5) Efficient, and 6) Equitable. These are the six aims for improvement outlined in the Institute of Medicine’s follow-up brief in 2001, Crossing the Quality Chasm.

It has been over a decade since these aims were articulated, yet all of us have born witness to care that violates one of these fundamental principles. At one point, many of us had the unfortunate opportunity to become intimately familiar with a case that did not go well, for myriad reasons, perhaps, but many of which could have been prevented. We may have become inured to inefficiencies such as long waiting times at Emergency Departments, and the culture of the staff (Overworked? Underpaid? Low morale?) combined with the culture of the patients (Uninsured? In custody? Non-English speaking?) may have precluded the delivery of care that was genuinely equitable or truly patient-centered. For some of us who are employed at safety-net hospitals and other centers that cater to underserved populations, this discordance between the ideal and the reality has become the norm, and improvement may seem like a dismal uphill battle.

On an optimistic note, innumerable hospitals across the country (not to mention throughout the world, including remote hospitals in resource-poor nations) have witnessed a transformation due to dedicated and inspired employees that launched QI projects and fostered a culture amenable to change. The rest of this entry will focus on ways that you can empower yourself and your colleagues to become active participants in QI, and hopefully improve the lives of your patients as a result.

Step 1. The most important first step, for you, as a novice QI practitioner, is to identify an issue in your practice setting that requires improvement. Preferably, select an issue that you feel strongly about and are prepared to dedicate time and effort to resolving.  Perhaps there is a bottleneck whenever a common procedure is performed in the clinical setting, or you have noticed that your workflow is routinely interrupted due to an inconvenience, large or small (why does the discharge paperwork always hold up patient transport?). Your unit may have a higher rate of hospital-acquired infections, or a patient may have even experienced a “Never Event” – a serious adverse event that is harmful and preventable, such as a medication error. Better yet, brainstorm ideas with friends or colleagues in the workplace; generating a group consensus on the most pertinent quality issues to tackle in your organization will position you well for Step #2 and Step #3.

Step 2. Educate yourself on QI. An exhaustive overview of QI methodology is beyond the scope of this blog post, but there are plenty of resources available to healthcare providers aspiring to become well versed in the arena. The Institute for Healthcare Improvement offers online courses through the Open School available to healthcare workers, which are free for trainees and students but may involve a subscription fee for professionals. Coursera offers a free healthcare-tailored QI course as well. You can learn the fundamental of techniques such as Root Cause Analysis, employed by many healthcare organizations to determine the key players and underlying reasons for medical errors after an adverse event, and the Plan-Do-Study-Act cycle that is invaluable for instituting change in your organization. Lean and Six Sigma certification are more formal options typically offered at colleges and universities that focus on process improvement skills applicable to a variety of sectors, instead of just health care.

Step 3. Involve your colleagues on the frontlines. Nurses are estimated to comprise the largest group of healthcare providers in the U.S., and it is unsurprising that many QI initiatives consist of “bundles” or checklists that are implemented by nursing staff. Adoption of any change in the workplace must achieve “buy-in” from your nursing and other clinician colleagues, or else your meticulous planning and QI efforts may go to waste. Attaining lasting change is a concerted process that occurs at various hierarchical and organizational levels within your institution, and collecting concrete data (as you will learn in Step 2) to emphasize the need for improvement will promote interest in your QI project and adherence to your proposed change. To generate enthusiasm and increase participation, many organizational units at hospitals have a visible reward system to indicate their nurse and physician “champions” for specific initiatives. Recognizing employees who go above and beyond to set examples for colleagues and prioritize QI initiatives can help revamp organizational culture.

As a corollary, bolster your QI efforts by expanding your reach beyond your immediate circle and tapping into trainees at your institution, if present. Academic medical centers may possess an advantage due to the Graduate Medical Education requirement for residents and fellows to engage in QI work. This generates a pool of interested trainees who are willing to investigate the link between clinical practices and patient outcomes and instigate tests of change to address the gaps. However, trainees may lack formal QI training and adequate mentorship, experience time constraints, and face other logistical barriers to implementing a QI project independently. Therefore, approaching residents and fellows as a QI-savvy collaborator on a project may facilitate the success of your project and promote “buy-in” from your physician colleagues.

Step 4. Engage every stakeholder possible in the culture of QI in your institution – including the patients. Whether your organization implements daily bedside rounds that update patients and families on the plan for the day and solicits patient input, or targets another arena (such as mobile phone technology) to facilitate information exchange or promote shared medical decision-making, it is imperative that the needs of the patient must be at the forefront of your proposed QI project. Invite patients and families to participate in hospital committees that explore ideas for QI projects and share the perspective of the broader community in order to select high-value projects for all stakeholders.

As your knowledge, competence, and confidence in QI continues to grow, so will the benefits reaped by your coworkers, healthcare institution, and patients. As the old saying goes, help others to help yourself (but feel free to improve on that).