Dear IHI –
My unit has done great improvement work to reduce pressure ulcers, and we’ve held the gains for several months. Do we have to keep measuring our processes forever, even though we’re doing well and no longer trying to improve? Would we be better off spending our time and resources measuring and improving something else? – READY TO STOP MEASURING
Dear READY –
Congrats on your great work! Reducing pressure ulcers for even one week is no small feat. Holding the gains for a few months means you’ve succeeded beyond what most people achieve.
A lot of times at this phase of your improvement journey, you end up measuring interventions that are happening almost 100 percent of the time as a result of your changes. For example, many teams measure how consistently their staff are completing the Braden Scale to assess risk for pressure ulcers. Another process measure might be related to turning patients during regular rounds. You might occasionally see dips in your turns, but it’s a lot of work to monitor each of these steps for all of your patients.
So should you “measure this forever,” as you said? The answer is no. You are at a great place in your improvement journey. In fact, Dr. Don Berwick recently called for a stop to excessive measurement in JAMA. Now, you can methodically review your process measures and make a plan for spot checking the processes in the future. I’d suggest a couple ways to do this:
- Use an all-or-none measure methodology. As Tom Nolan and Don Berwick write in this piece, all-or-none measures raise the bar for performance, and they’re an important milestone in your improvement journey. They better reflect the interests of patients than many measures, give you a true system-level view, and give you greater sensitivity to drops in performance.
- Spot check all patients one day a week. For example, next Tuesday you could look at the all the patients that are on the unit, review the EMR for the day before, and check "yes" or "no" for each of your processes. You may find that only one of the processes isn’t reliable (i.e. turns). This method will help you see whether you’re holding the gains in your process improvements or you have an area to keep your focus on.
One more piece of advice. Now is a great time to celebrate with your team. Hopefully, the staff on your unit already feel proud of the difference they’ve made for patients. Take a moment to recognize this work, maybe even highlighting or hearing from patients who benefitted. It’s a great moment to promote joy in work — not just because you helped your patients, but also because your staff will be able to take some of this time-consuming measurement off their plates.
Kathy D. Duncan, RN, IHI Faculty
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