Rarely is an improvement project flat and one-dimensional. And in health care, processes are often more complex and multidimensional than the industrial environment from which many of the improvement methods we have covered are born. It is not enough to know which intervention you will use—we must identify and tackle potential barriers to these practices.
It is therefore helpful to use a framework to structure your intervention. Here we present one potential framework, but there are many others. You’re encouraged to find what works for you!
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S SYSTEMS CHANGE
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Despite over 150 years passing since Ignaz Semmelweis demonstrated that hand washing can save lives, there are campaigns at medical centers across the US aimed at improving hand-washing practices. As it turns out, changing behavior is incredibly challenging, even despite compelling evidence.
Strategies like 360-degree feedback, enhanced accountability (handwashing ‘audits’), and the omnipresent hand gel dispensers have made it easier to do the right thing and improve hand washing adherence. Learning from experiences like these, the group Costs of Care developed a “COST” framework for designing multidimensional strategies to prevent harm from overuse.
When thinking through the structure of your high-value intervention, it should encompass components of Culture, Oversight, Systems Change, and Training. Along each of these domains, barriers to the intervention and strategies to overcome those barriers are identified.
For example with our discharge process, a culture intervention may be the lead charge nurse on each floor explaining the importance of the time between discharge orders and discharge as a measure of their collective efficiency to all floor nurses as they rotate on staff. A potential systems change for this might be changing the electronic health record to make it easier for providers to track the time between a discharge order and actual discharge on each patient. The key is to think of interventions in each component of the COST framework.
While structuring your intervention, it is important to think about who is important to the success of your project. In other words, who are your key stakeholders? One quality improvement tool to help you prioritize different stakeholders is a power vs. interest grid.
Shown below for the early discharge example project, stakeholders are ranked on power to impact change and level of interest in the change. Roles are then assigned to each stakeholder based on these results, allowing you and your team to determine who your key players are. From this we can see we should focus on the interactions of residents, nurses, social work, and case managers.
Once you‘ve identified your stakeholders, it‘s time to synthesize the problem as you see it and your proposed solution so everyone knows the plan. While there are multiple tools to do this, including the project charter, let‘s take a look at A3.
A3 thinking is a Lean methodology for describing different aspects of improvement in a way that is simple enough to fit on one 11 by 7 inch piece of paper, also known as A3 paper. One A3 tool useful in project measurement and evaluation is the A3 Strategy form. Similar to a project charter, it is a tool used to succinctly describe an improvement project.
The ‘story’ of this form flows from top left to bottom right and should be able to tell the story of your intervention, including measurement and evaluation strategy in 5-10 minutes.
Reprinted with permission from the Lean Enterprise Academy Reprinted from Making Hospitals Work by Marc Baker and lan Taylor with Alan Mitchell ©2009 The Lean Enterprise Academy Ltd, Marc Baker and lan Taylor
Read more about A3 projects and tools at the Lean Healthcare Exchange
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