Quality improvement (QI) is about system change for the entire organization. In a session at HM14, Michelle Mourad, MD, and Nasim Afsar, MD, SFHM, outlined QI principles and a systematic step-wise process that can create and sustain change successfully in our hospitals.

QI principles include creating a sense of urgency, implementation, and sustainability. The seven steps for a successful QI project are as follows: understand the problem, convince others there is a problem, identify areas of improvement, prioritize a small test of change, devise a measurement strategy, measure change, and sustain change.

Understanding the problem includes creating a fishbone diagram that helps you identify the causes of your problem. Convincing others requires presentation of inspiring data and telling your story.

Dr. Mourad encouraged the audience to use personal anecdotes and focus on the ‘why,’ not the ‘what’ or ‘how’ to relate to others on a personal level. Identifying areas of improvement requires creation of a process map to identify obstacles that can be removed. “Your goal is to make systems work for people,” said Dr. Mourad. Ask people to tell you how the process will work better for them.

Prioritizing small tests of change requires identifying low-effort, high-impact tasks that will lead to easy wins. “Don’t do the thankless tasks that are high-effort with low impact,” said Dr. Afsar. She further encouraged physicians to perform small tests of change to help understand if their ideas are worthy of large scale implementation.

Plan-Do-Study-Act (PDSA) and A3 methodology are two methods by which a QI project can be organized for implementation. Devising a measurement strategy requires collecting data from appropriate sources in the hospital to ensure improved outcomes as a result of interventions performed. Outcomes, structure, and process are the areas in which results can be measured.

Coaching your team is an important part of motivating your team for continued progress. Change can be concretely measured and plotted over time via statistical process control charts (download SPC macros in Excel to plot graphs).

Lastly, sustaining change requires celebrating success. Dr. Afsar cautioned the audience to set appropriate expectations and goals to sustain system change. Further, once the change is set in motion, put the process ownership into the group (not on you). Creating data that is readily accessible and visible to the group helps them understand progress over time. Design the process to fit into natural workflow to make the process an easy transition that is sustainable long-term.

Key Points

• QI is a four legged stool: education, data audit and feedback, systems change, and culture change;

• Create a fishbone diagram to understand the cause and the effect;

• Create a sense of urgency by sharing inspirational data and finding your story and focusing on the why;

• Use process maps to identify areas of improvement;

• Prioritize those areas and implement small tests of change;

• Measure all outcomes and use statistical process control charts to demonstrate change;

• Motivate and coach people throughout the process change;

• Make data easily accessible to all members of the group to track progress; and

• Sustain change by setting realistic expectations and celebrating success.

Dr. Kanikkannan is Hospitalist Medical Director and Assistant Professor of Medicine at Rowan University School of Osteopathic Medicine and is a member of Team Hospitalist.