5- Framing Improvement Interventions and Project Teams

MODULE 10 | Section 5 of 11

Framing Improvement Interventions and Project Teams

FRAMEWORK OVERVIEW

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!

“COST” FRAMEWORK FOR HIGH–VALUE CARE INTERVENTIONS

Interventions

Description

Example

Predisposing Factors(Barriers or Assets) in Your Local Clinical Environment

Potential Strategies to Apply in Your Local Clinical Environment

C CULTURE
Valuing cost-consciousness and resource stewardship as practiced standards of medical professionalism at the individual and team level
Hospital-wide campaign led by peer-champions to raise awareness regarding overuse of lab tests

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O OVERSIGHT
Requiring accountability for cost-conscious decision-making at both a peer and organizational level
Requiring an attending to review the labs that residents order to promote better stewardship

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S SYSTEMS CHANGE

Creating supportive systems to make cost-conscious decisions using institutional policy, decision-support tools, and evidenced-based clinical guidelines.
Electronic health record displays costs of lab tests next to order for specific tests

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T TRAINING
Providing the knowledge, skills, and tools clinicians need to make cost-conscious decisions in their clinical environments
Lecture or workshop on ordering of lab tests

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Costs of Care is a mutli-institutional organization of doctors founded by Neel Shah, MD. Its mission is to promote value-based health care globally. This organization has proposed for helping to identify barriers and assets to project implementation. Identifying the barriers and assets to your project will help you to identify the people whose approval or support you will need to help your intervention gain traction or those who will take an active role in intervention delivery. To succeed, you will need to convince these individuals your intervention is worthwhile and engage them in the process.

THE COST FRAMEWORK FOR VALUE IMPROVEMENT PROJECTS

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.

THE COST FRAMEWORK FOR VALUE IMPROVEMENT PROJECTS

This article explores utilization of the COST framework to discontinue use of the Neutropenic diet once it was found to be an unnecessary medical practice. Read to learn more.
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Source: Gupta A, Brown TJ, Singh S, et al. The American Journal of Medicine. 2018: in press.

STAKEHOLDER ENGAGEMENT

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.

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GETTING EVERYONE ON THE SAME PAGE

A3 STRATEGY FORM

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.

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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

ADDITIONAL RESOURCES

Read more about A3 projects and tools at the Lean Healthcare Exchange

Learn More

ARTICLE

Take a look at this Johns-Hopkins-produced tool for developing a project with your institution.
Johns Hopkins Medicine

ARTICLE

Read about the process of strategy deployment from Theda Care using the PDSA model and A3 strategy forms.
Theda Care: Center for Healthcare Value
BLOG POST
This 60-hour certification course will take you through your own patient safety and quality improvement project and certify you in important concepts.
University of Toronto

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