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Every hospital in the country today is engaged in performance improvement programs in one form or another. But industry consultant Michelle Pelling, RN, MBA, president of the Propell Group in Portland, OR, warns that many quality improvement directors embark on these projects without first gaining the necessary support from physicians and staff and without having in place an effective infrastructure to bolster their efforts.
Pelling says the most effective way to secure physician and staff support is to follow a three-step process:
"Hospitals should not do performance improvement just to do it," Pelling cautions. "The results must be worth our time and effort."
According to Judy Homa-Lowry, RN, MS, CPHQ, president of Homa-Lowry Healthcare Consulting in Canton, MI, this also will promote an interdisciplinary approach to improve patient care processes and outcomes.
From a planning perspective, Pelling says, hospitals must first define the objectives behind their performance improvement initiatives, and that should begin with a basic operating philosophy that establishes the goals the hospital is seeking to fulfill.
"The first step is understanding why the organization has a performance improvement program in the first place and what they seek to accomplish through this process," says Pelling. Despite the pressure from regulatory and accreditation bodies, an organization’s primary focus should be defining its performance improvement outcomes relative to how the initiative will help the organization move forward in patient care, service, and operational efficiencies, she contends.
According to Homa-Lowry, individuals involved in the performance improvement process must be aware that they will have direct involvement in identifying, analyzing, and improving patient care outcomes. But she warns there most likely will be resistance if participants believe the major emphasis of the improvement program is to comply with external regulatory requirements.
Once a clearly defined operating philosophy is established, Pelling says the next step is to identify organizational priorities to help guide ongoing projects. For example, one hospital started by defining broad categories such as pain management and ambulatory care management and linked its overall objectives in those areas to its performance improvement policy. "Many of these priorities may seem very standard. But a surprising number of hospitals don’t have anything like this in place." Pelling says that establishing priorities gives hospitals a template they can use to assign responsibilities, initiate improvement projects, and establish communication structures.
Finally, Pelling says that performance improvement priorities should be linked to strategic priorities. For example, if a hospital is trying to expand its ambulatory care services, it makes sense to focus on improving overall performance in that service, she explains. That does not mean there must be a performance improvement measure for every strategic objective, she adds. But if an organization is attempting to expand services or achieve certain levels of patient satisfaction, then it should link those efforts to performance improvement activities.
According to Pelling, many hospitals establish a formal group called a performance improvement council that is responsible for guiding the organization’s initiatives in this area. But such councils often lack the infrastructure needed to support those initiatives, she adds. "Many organizations establish this type of council, but it quickly becomes a body that people report to as opposed to an active body that is continually assessing priorities." Instead, Pelling says these councils should coordinate with the teams that are working on projects and maintain a liaison with each team to help guide them along the various steps as they work through a process.
Pelling says hospitals can accomplish this either by using an incremental improvement process or a redesign process that will help lead them through the improvement effort.
According to Homa-Lowry, it is important that this process be well-defined. She says individuals responsible for the improvement efforts must be comfortable with the approach, and it should be consistent across the organization. This will foster an interdisciplinary approach to improving patient care processes and outcomes, she adds.
According to Pelling, the steps selected will depend on whether the group uses an incremental improvement approach or a redesign approach. She says each approach is appropriate for different situations:
• An incremental improvement approach should be used when the goal is to achieve a breakthrough in performance by making a few focused changes in an existing process. "This approach is best used when the current process is definable and conceptually sound," she explains.
• A design/redesign approach should be used when the goal is to develop a new process or completely redesign an existing process. Pelling says a change in the process is developed first and then followed by analysis to prevent potential problems. This approach is best used when a current process is nonexistent, severely deficient, or undergoing massive change, she explains.
"Every hospital thinks it has these methods in place," Pelling cautions. "But when you ask them specific questions about what they do first, second, and third when they initiate an improvement effort, people are often unclear." She adds that inconsistency often exists among groups and teams working in the same organization. "We often find that they don’t really understand and apply what the organization’s leadership believe they have established."
She adds that most organizations that develop an incremental methodology try to use it for everything. "That is a big mistake. It is not effective when you are designing a new process or significantly redesigning an existing process." In other cases, she says, councils have defined responsibilities and a performance improvement methodology. "But when you dig into it, you often find they are not really using it."
According to Pelling, hospitals also must establish effective mechanisms for communication in order for the medical staff and hospital managers to share information and prevent duplication of efforts. She says this is less of a reporting structure and more of a communication mechanism usually coordinated by someone who oversees the various performance improvement activities.
In addition, coordination of departmental quality improvement efforts and potential interdepartment performance improvement proposals will facilitate the sharing of what has been learned and appropriate involvement of stakeholders, adds Pelling. "What is critical to the ongoing success of performance improvement initiatives is the development of a framework for employee communication regarding departmental, interdisciplinary, and organizational improvement efforts and the methods managers can use to involve their staff," she concludes.