Integrate QI changes to make them last
Integrate QI changes to make them last
Measurement and feedback shouldn’t stop
Sometimes, quality improvement seems too easy. You focus on a goal, such as increased preventive services, and suddenly the cholesterol screenings and flu shots increase. But once you turn your attention to something else, will that improvement disappear?
Short-lived gain caused simply by bringing a problem to light is called the "Hawthorne effect." To make lasting improvements, medical groups must make outcomes measurement and feed-back an integral part of their business, says Lloyd Provost, MS, statistician with Associates in Process Improvement in Austin, TX.
That begins with the design of the improvement efforts, which should include a testing phase to allow input from the staff and physicians, says Provost, who works with the Boston-based Institute for Healthcare Improvement on its quality improvement collaboratives.
"In a lot of new collaboratives, we show [QI] teams some of our change ideas," he says. "They’ll say, We already do that or we already tried that.’ Someone sent a memo out to doctors that said, Start using this procedure.’ Nobody’s really using it; nobody really tried it."
Careful design of the QI project and ongoing measurement can make the difference between failure and success, he says.
Test out ideas first
Provost believes in quick quality improvement cycles. He teaches the stages of Plan-Do-Study-Act, in which teams develop, test, and implement change. They can go through these steps in a week.
But the teams are not rushing toward permanent change. They’re looking for evidence that the new processes work and asking for feedback. They generally run several cycles before finding something that works.
"Unless we give organizations a chance to test and adapt and modify the changes they’re supposed to implement, then the implementation will be shallow," Provost says.
For example, a quality improvement team might ask several physicians to reduce the number of appointment types in their schedules for a week as part of an effort to improvement access. The scheduling change occurs manually; the regular computer codes stay the same for everyone else.
In the "act" stage of the test, participants decide if they need yet more tests. "Do we abandon the change? Do we modify it to make it work better? Do we run another cycle?" asks Provost.
By the time the team decides to adopt a change, "we’ll have people who are seriously planning on implementing it instead of conforming to whatever it is, and after the pressure is off, going back to what they want to do," he says. "It’s a commitment rather than just compliance to what the rules are."
Teams continue to meet
Sustaining change is a constant issue for Lovelace Health System in Albuquerque, NM, which began a disease management/quality improvement project in 1993 with multidisciplinary teams studying different conditions. Six years later, 10 of the "Episodes of Care" programs have been fully implemented and about 10 more are being developed. The teams still meet, though less frequently, and physicians receive regular reports showing their key indicators compared with their peers.
"Right now, we’re re-appraising each of those efforts and seeing where we want to go," says Maggie Gunter, PhD, vice president and executive director of the Lovelace Clinic Foundation, a research institute affiliated with the health system. "How do we maintain measurement and feedback at some level to make sure we don’t lose the gains? Which additional ones do we want to include? Which are of strategic importance to our membership and employers?"
Gunter says she found computer-based records help provide "ongoing reinforcement." Software was designed in-house that allows physicians to call up notes and lab results for a patient, as well as care guidelines and reminders.
"We are always thinking, How do we make it easier for the physician to change?’" says Gunter. "It’s that integration into the daily workflow of the physicians that makes their life easier."
How do you make change a part of the "infrastructure" of the practice?
First, during implementation, you need to consider every process that is affected, says Provost. For example, you may need to rewrite job descriptions, change forms, or set up new procedures.
When you begin to train your staff and physicians, be sure you integrate the information into new employee training, as well. "If you don’t change any training program, then a lot of changes that are people-focused . . . are likely to disappear," he says. "A question to ask, as you set up measures and process documentation, is How easy would it be to backslide?’"
Make key measures a part of your review of your business, just as you look at financial information. In an effort to improve access, some practices began measuring their daily demand for appointments, based on the number of patients who called to schedule a visit.
"That’s a fundamental change in thinking," says Provost. "Once people see the insights they get from that, they make that measure a permanent part of their business."
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