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In Whole System Quality: A Unified Approach to Building Responsive, Resilient Health Care Systems, the Institute for Healthcare Improvement (IHI) proposes a holistic approach to quality management — whole system quality — that enables organizations to close the gap between the quality that customers are currently receiving and the quality that they could be receiving. Developing a whole system quality approach might seem like an overwhelming undertaking. The white paper excerpt below proposes activities that health care organizations can implement to build a foundation for the transition to whole system quality.
Organizations that are the most advanced in establishing whole system quality infrastructures and processes have spent more than 10 years making quality the center of their missions and visions and building the necessary systems and capabilities to do so. Health care organizations need to consider two dimensions when assessing their approach to whole system quality:
- Penetration: Quality Improvement (QI), Quality Control (QC), and Quality Planning (QP) skills and activities exist throughout the organization.
- Cohesion: QI, QC, and QP work together as a cohesive system rather than independent, siloed activities. Many organizations develop pockets of excellence in quality control, quality planning, and quality improvement, but fail to effectively link the disparate efforts and thus the quality activities do not penetrate the organization.
Below we share the experiences of Intermountain Healthcare, Cleveland Clinic, IOV, East London NHS Foundation Trust, Kaiser Permanente, and Fairview Health as just some examples from which other health care organizations may learn as they seek to establish whole system quality.
Organizations like Intermountain Healthcare and Cleveland Clinic have followed a particular trajectory in building their quality management systems. They often start with a focus on finite improvement work (e.g., a focus on improvement tools and methods, or improvement projects in a particular clinical or administrative area), then transition to a focus on management and quality control (e.g., the introduction of Lean management systems) to sustain improvement, and finally integrate a focus on quality planning and increased customer focus once this infrastructure is in place (at this point, the quality plan is actionable at scale). Organizations like East London NHS Foundation Trust start their journey by reducing quality assurance activities to create space for targeted quality planning, improvement, and control activities.
In many ways, this trajectory makes sense. Given years of investment, teaching quality improvement methods and tools relies on many widely available resources and approaches. Establishing management interventions to sustain improvement proves challenging but is still feasible and often builds on existing management systems such as huddle practices or similar communication methods. Further, tools like Lean management huddle boards can be introduced using improvement methods (e.g., PDSA cycles), so use of these tools logically follows the introduction of quality improvement, and the capacity to apply improvement methods enables staff to act on problems surfaced in daily work.
Engaging senior leaders is often the most difficult element, and thus it’s logical that quality planning is often the last area of focus. Yet, organizations that fail to prioritize senior leader engagement early in their transition to whole system quality often find it difficult to sustain early gains in building the system itself. Just as Lean management practices provide the “glue” that sustains improvement at the microsystem level, senior executive engagement proves the effective ingredient for sustaining the system as a whole. While we acknowledge the paucity of high-quality literature studying Lean management and total quality management, most existing reviews cite leadership engagement as one of the most critical success factors informing the viability of such efforts.
In developing and rolling out its quality management model, Kaiser Permanente adopted Kotter’s 8-Step Process for Leading Change. According to this model, Kaiser’s approach included, among other steps, building an internal national quality committee, selecting a set of system-level quality measures, benchmarking performance against exemplars such Baldrige award winners (quality planning), building data transparency for selected measures (quality planning and control), and creating an organization-wide infrastructure to drive quality (quality control and improvement). They used, in part, the continued “quality chasm” highlighted at the beginning of the whole system quality white paper as part of their platform for change to create a sense of urgency, in addition to their own results compared to top-performing health systems.
At Fairview Health and IOV, organizational mergers created an opportunity and a sense of urgency to realign each organization around a new set of values, ways of working, and organizational structure to drive sustained quality. Fairview Health used 10 organizational commitments (e.g., “set and hold standards”) to organize and inform their quality transformation work, connecting all management interventions (e.g., introduction of tiered, escalating huddles) to these 10 commitments, which enabled the health system to more broadly communicate their vision and build the foundation for a new way of working. IOV in Brazil used its merger as an opportunity to spread practices that had been introduced incrementally and build a robust Lean management system.
To learn more, download the free Whole System Quality: A Unified Approach to Building Responsive, Resilient Health Care Systems white paper.
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