When I was working in the emergency department (ED), I thought I understood improvement. I’d make changes to enhance patient flow. I’d try new ways to improve the patient experience. After 15 years as nurse, I figured I knew what it took to make systems run more effectively and efficiently.
Then I started to learn about quality improvement (QI). Over time, I realized that there were similarities between the clinical skills my colleagues and I used and the fundamentals of the Model for Improvement.
The Model for improvement has the three parts: an aim, measures, and changes. As a nurse, in many instances, the aim for patients was clear: to ease breathing, decrease pain, or increase mobility, for example. The aim helped guide the actions of the entire multidisciplinary team. The aim was our goal post.
In support of the aim, the clinicians used measures that we evaluated on a regular basis. These included blood pressure, heart rate or oxygen saturation or more qualitative measures like pain. The measures helped us determine if the therapies we provided were helpful.
We then tested changes — a treatment or medication, for example — that we evaluated using the set of measures. Sometimes these changes were successful. In some cases, they were abandoned for new ideas.
Every clinician has basic improvement skills because we know how to provide care. But how do you turn experience focused on change for individuals into systems improvement for every patient, every time? The challenge is to learn how to apply improvement skills to systems problems that cause frustration, harm patients, or otherwise lead to less than optimal outcomes.
Tips for Leading QI
Many things get in the way of system-wide improvement. Often, the biggest obstacle is the idea that the way we do things is how they’ve always worked and always will. Just thinking about change can be daunting, but there are some keys to successfully transition from making individual changes to leading improvement:
Don’t do it alone — It’s essential to understand that you don’t have to take on change alone. Working with a multidisciplinary team — ideally including a patient and with strong support from senior leadership — will help you see beyond individual changes to systems improvement. It’s hard to think about improving systems on your own and doing it with others helps make the big hill you’re trying to take more manageable.
Understand your data — Any health care system generates a million streams of data and leaders are responsible for deeply understanding all of it. That’s a big piece of what we at IHI call continuous learning. You have quality data, safety data, patient satisfaction data, and employee data. The idea is to use all this information to identify the most critical areas that need your scarce improvement resources. QI helps us avoid overreacting to normal variation and helps us understand where best to focus our improvement efforts.
Build the QI skills of your team — Not every organization has a lot of staff trained in QI, but the reality is that the need for improvement in just about any organization is bigger than the number of people with “quality” in their titles. If you build improvement skills across your organization, you can direct all those resources to improve outcomes for patients, for employees, and for the organization as a whole. There’s power in getting formalized training, especially if you’re moving from a staff nurse or other staff position to one of middle management.
Clinicians already have many of the skills they need to be improvement leaders but learning specifically about QI is critical. It can help us learn the most effective ways to convene teams, understand data over time, and make meaningful systemic improvement and not just isolated changes. As more health care organizations invest in leadership training for middle managers, I’d argue that learning how to lead QI is as important as any other professional development for health care professionals of all disciplines.
Jennifer Lenoci-Edwards, RN, MPH, CPPS, is Executive Director for Safety at the Institute for Healthcare Improvement.
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