Making the case for QI

Undertaking quality improvement projects is more difficult than ever, but certain strategies can help ensure success.


Undertaking quality improvement (QI) projects in the hospital is more difficult than ever, but certain strategies can help ensure one's project is not only approved but successful, according to speakers at a session on “The Business Case for QI” at Hospital Medicine 2011.

“The current state of QI is very reactive and compliance-oriented. We do what we have to do and what is mandated, and we can barely keep up with that,” said Janet Nagamine, ACP Member, a hospitalist at Kaiser Permanente in Santa Clara, Calif.

Unexpected allies for quality improvement projects can be found in departments like nutrition services Photo by Thinkstock
Unexpected allies for quality improvement projects can be found in departments like nutrition services. Photo by Thinkstock.

As such, it's important to be focused when undertaking a QI project, she said. At the outset, one should consider these key questions: What are the problems and gaps in quality at my facility, and what can we do about it? Who cares most about the problem(s) among stakeholders? How can we fix the problem(s)? Why should we fix the problem(s)—i.e., how will the fix(es) help the organization, department and/or patients?

After these questions have been considered, and one has narrowed down the problem to be addressed, it's time to think more strategically about getting buy-in from key stakeholders. The first step is to make sure the project one wants to work on is on the radar of senior leaders. Know the organization's strategic priorities for the year, and think about whether the potential project is related to them, Dr. Nagamine said.

“If your project doesn't fit into these priorities, frame the problem or tweak it so that it is related to something higher on their radar,” Dr. Nagamine said. “Everyone cares about patient satisfaction, so how can you frame the project in that way?”

After the problem has been framed in the most compelling light, focus on building a convincing case for tackling it, she said. First obtain data that quantify the frequency or magnitude of the problem. The hospital's risk management, quality and finance departments can be useful in acquiring hard facts Published literature can also provide more information on costs, she said. “You might find in the literature that, for example, adverse drug events in hospitals occur, on average, in one-fifth of patients, cost an average of $2,600 per case, and result in an increased length of stay of 1.5 days,” Dr. Nagamine said. “The finance department might then help with specific data at your hospital.”

The next step is to speak with the stakeholders who have a key interest in fixing the problem. Find out how they would frame the problem and what they'd like to see happen, and whether they would be willing to devote a staff person to help. Include the service line, quality and risk departments, nursing and pharmacy staff, patients, and other less obvious departments.

“You can find unexpected staff allies in departments like housekeeping, which is key for throughput, or nutrition services, which is key for glycemic control,” Dr. Nagamine said.

Next, identify mutual goals and outcomes for the project, to determine the collective organizational gain. Factors include direct money saved; effects on staff time, inefficiency and duplication of efforts, and how that influences costs; and effects on throughput, staff turnover, patient satisfaction and hospital reputation, all of which can be translated into dollars, Dr. Nagamine said.

When determining the return on investment for the project, consider both “hard” and “soft” costs and savings, advised co-presenter Lakshmi Halasyamani, ACP Member, a hospitalist at St. Joseph Mercy Hospital in Ann Arbor, Mich.

“In terms of hard dollars, are there potential savings in fixed costs like heating and carpet maintenance, or variable costs associated with factors like length of stay, medications, tests ordered and bed capacity?” Dr. Halasyamani said. “Soft dollars refer to care improvement...in things like patient and employee satisfaction, and hospital ratings.”

The final step, of course, is to draft and present the project proposal in a way that convinces the C suite of the need to improve something, and the expected return. In a nutshell, the proposal should include the background or context of the problem; a statement of the problem, including a quantification; the proposed solution, including a description of the partners involved, the intervention, the pilot unit, the time period, and how the project will be undertaken; and the desired outcomes, using metrics and dollar amounts, Dr. Nagamine said.

Don't make your analysis of the financial aspects too intricate or detailed, though, warned Dr. Halasyamani. “The folks you are trying to convince are concerned about money, but you should get to a certain sum [of savings] and stop there. Don't make it too complicated or their eyes will glaze over.”

Once there is agreement to move forward, make sure there is also agreement on what your role will be, the resources to be committed, and the timeframe, she said.

“Don't accept a project without a management partner to help create action plans, follow up on them, and keep everyone on task,” Dr. Nagamine said. “Make sure you don't get stuck doing all the work between 10 p.m. and 2 a.m.!”