Improving at quality improvement

When choosing a QI project, it's important to think before you act.

Quality improvement (QI) may be a big thing in medicine, but that doesn't mean that QI projects need to be large, experts said during an Internal Medicine Meeting 2018 session on “Sustaining Your Quality Improvement Project.”

“We hold ourselves back thinking we need to do a randomized controlled trial for it to count, and it just needs to be a little small thing,” said Lawrence Ward, MD, MPH, FACP, associate professor and vice chair for clinical practice and quality at Thomas Jefferson University in Philadelphia. “Don't overthink it.”

Dr Ratner speaking with moderator Sima Suhas Pendharkar MD MPH FACP and panelist Dr Ward Photo by Kevin Berne
Dr. Ratner (speaking) with moderator Sima Suhas Pendharkar, MD, MPH, FACP, and panelist Dr. Ward. Photo by Kevin Berne

He and co-panelist Shana P. Ratner, MD, FACP, offered many tips for physicians thinking of leading QI, from the steps to take before a project launches to how to ensure improvements are sustainable over the long term.

Choosing a project

Beginning with the very first step in the QI process—choosing a project—it's important to think before you act, the experts said. The target should be something that definitely needs improvement, with baseline data to prove it. “It's fascinating how most of us... we don't know actually how we're performing,” said Dr. Ward. “You have to obviously have something where there's a gap between where you hope to be and where you currently are.”

The project should also be aligned with the goals of the institution. “It's great to do something that you love and you're interested in and you're passionate about, but if the organization couldn't care less about it, you have a problem with getting everybody behind it,” said Dr. Ward.

The panelists offered additional tips to get the necessary support from administration, clinicians, and staff. “People will change with their hearts, not with their minds. One of the most powerful ways to get buy-in from the beginning when you're working on a project is to use the power of story,” said Dr. Ratner, an assistant professor at the University of North Carolina School of Medicine in Chapel Hill.

Patient anecdotes, ideally dramatic ones, are effective motivators, the experts agreed. “It helps to have the wow factor. Something that is interesting, something that is going to really excite people is always good,” said Dr. Ward.

Even before making a public case for change, some behind-the-scenes conversations may be helpful. Dr. Ward identified four categories of colleagues: the charismatics, the thinkers, the skeptics, and the quiet leaders.

“Your charismatics are your cheerleaders.... They're the ones you'd think you'd want to go to and get them on your side, and they definitely help, but they're not the key to your success,” he explained. Skeptics will be difficult to convince no matter what, but the thinkers can be won over by making a good case for your project, Dr. Ward added.

“The other ones to really focus on, I think are the quiet leaders,” he said. “They'll sit in the back, they won't say anything positive or negative, but they are the ones that when they talk, everybody knows.... If you can get them to be one of the people that comes out and says, ‘You know, this is a great idea,’ it has an enormous value across the rest of the group,” he said.

Physicians are helpful as project champions, but QI may actually be more effective the less it involves doctors, the experts said. “Yes, the doctors can torpedo you and a lot of times we focus on the doctors, and that's a mistake. We really need to focus on the people who are really going to be doing it at the point of care,” said Dr. Ward, noting that many practice changes are handled mostly by nurses, medical assistants, or office staff.

“If you get your project team from the start to include these folks and have them be the ones building the intervention, you're more likely to have a solution that works with their current jobs,” agreed Dr. Ratner.

Lean management philosophy includes a related concept called the gemba walk, Dr. Ward explained. “It's going and working or walking around the actual production line and talking to the people that are actually doing the stuff down on the floor,” he said. “You've got to go down and sit with the medical assistants and the front desk and everybody else, look through the [electronic health record] yourself, and actually do what they are doing to understand where you're going to succeed and where you're going to fail.”

Speaking of the electronic health record, QI should not make it any more of a burden, Dr. Ratner advised. “People change when you make it easier to do the right thing, not when you make it harder—the number of times that many of us have heard ‘It's just two more clicks,’” she said. “While we want to improve quality and safety for our patients, what we don't want to do is design something that's going to make the burnout epidemic worse.”

PDSA again and again

The best way to determine how a QI project affects practice is to try it out, using the Plan, Do, Study, Act (PDSA) cycle, the panelists said.

“Some people think of PDSAs as three months of plan, three months of do, three months of study, and three months of act,” said Dr. Ratner. “To me, PDSA cycles are really small things that you can do today or tomorrow. Can we test this with one patient, one nurse, one provider? And get some feedback from them and see what works.”

She offered an example from her institution's effort to switch from fecal occult blood testing to fecal immunochemical testing (FIT) for colorectal cancer screening. A medical student working on the QI project sat down early on with the nurse who prepared the testing kits, which included a return envelope that was stamped with the practice's address.

“She went to put the [address] stamp on the envelope and the envelope was shiny, so the address just wiped right off,” Dr. Ratner said. “It was an easy enough thing to solve. We got labels and stamped the labels and put them on there. It was no big deal, but imagine if we had done 100 of those and sent them out to patients and then found that they wiped away.”

Involved clinicians and staff might raise other concerns. “‘Are the patients OK with it? Is it going to be more costly for them?’ That was one of the first questions our providers asked us when we started talking about this,” said Dr. Ratner. Small PDSA cycles can be conducted to help answer such questions.

Along with incremental implementation, QI projects' effects should be measured in small batches, too, the experts said. “By day, by week,” said Dr. Ratner. “If you're measuring by month or by quarter, you're probably not picking up some of these sensitive changes that happen early during a project.”

Small successes can help build support, Dr. Ward noted. “If you can get that early win to show you know what, we're a little different from the other 50 projects you were a part of and we actually are going to be a change, that's a great way to get things going,” he said.

Negative results are not all bad, either. “In QI, I like to use the concept of fail faster. Go quickly, and if you fail, you're going to learn something from it. Celebrate these failures,” said Dr. Ratner, noting that after initial very high uptake, her program's use of FIT suddenly dropped because they had run out of the kits. From that experience, they learned the necessary frequency and quantity for future FIT kit ordering.

Both successes and failures should be publicized to project participants. Dr. Ward's example QI project was an effort to offer influenza vaccination to every patient. “We delivered these results every week,” he said. “When we had some practices that were not doing well, we would do them almost every day, and we'd give them patient-level data. ...We'd help them work through exactly where the holes were in their plan.”

Practices and even individual physicians who excelled were also identified. “We have a large quality dashboard,” said Dr. Ward. “We actually didn't have a quality bonus or anything like that at the time, but man, they fought to be at the top of the list.”

When compiling results, try to include both process and outcome measures, advised Dr. Ratner. “Sometimes in a quality improvement project, people just want to look at the outcome measure,” she said. “But if your process didn't improve, you can't take credit for the outcome improvement.”

Keeping it going

The QI process isn't over as soon as you've gotten some positive results, the experts noted. A third-year medical student and a faculty physician committed a specific amount of time to launch the FIT project, but the effort was meant to be ongoing, Dr. Ratner said.

“We had a project phase that was four months long, but it was never our intent that we're just going to do this for four months,” she said. “We want to build something during that four months and test something during that four months that would be sustained well after that medical student left and that faculty member was on to working on different things.”

To help ensure that a change is sustained, it should be hard-wired into existing systems. “If you have a standing order for something like this, are you updating it? Are your training materials getting updated?” asked Dr. Ratner.

Having involved front-line staff in the initial QI development process should make this easier. “The more you can involve staff that are going to be on that unit this week, and next week, and the week after that, and are not going to be rotating off back to their seven on/seven off or going to be leaving the residency program, the more likely you're going to be sustainable as a project,” Dr. Ward said.

Although sustainability might seem like the last step in the QI process, it should be considered from the start, according to Dr. Ratner. “Doing that during the project phase when we may have a little bit more energy or resources, we're going to set up something that's going to be more likely to be sustained in the long run,” she said. “Think about how are you going to check on this later on. You need to find a process owner.”

Especially if an improvement is applied across multiple services or practices, standardization can help with sustainability, suggested Dr. Ward. “How is it going to be the same every time at every practice? Standardize so everyone could do the same thing,” he said.

Once the standards are developed, document them, the experts advised. For example, Jefferson has a repository of QI projects, Dr. Ward noted. “People can look at what other practices have done and learn from it. ...It gives them an idea of the large scope they can do as well as the small scope, so it's a way of educating and spreading that information.”