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Why Improvement Needs Nurturing

By Kathy Duncan | Friday, January 10, 2020

Why Improvement Needs Nurturing

The idea of nurturing quality improvement work didn’t come to me until later in my career. Over time, I realized that — just as we need to nurture a child or a pet or even a plant — we also need to nurture improvement. This means supporting improvement teams instead of just demanding, telling, or assigning.

To nurture also means to protect and to encourage. We wouldn’t expect a child, pet, or plant to thrive on its own. We shouldn’t expect improvement to either.

How Leaders Can Help (or Hinder) Improvement

Leaders can either neglect or get in the way of improvement. We often get too focused on outcomes. It’s easy to be distracted by the need to complete a project by a certain date and forget to check in on a team member who may be doing a test of change.

Another way that leaders sometimes hinder improvement is by thinking we know all the answers. We need to let the people who are doing the work design the work, decide what’s important and what’s not important, and let them do the testing. The people who are doing the work will test their way through to the best, most efficient way to get something done.

Leaders also need to realize that — when we’re asking a team to work on an improvement project — we’re asking a team to do something new. Even a small change from their regular work can be hard for some people, especially when they have spent years perfecting their current skills or how they do certain tasks. To ask them to improve something may sound like saying, “You’ve been doing it incorrectly all this time.”

Those of us who have done a lot of improvement work sometimes forget that for staff participating in a test, the possibility of it not working — failing — may feel terrible, even if we give permission to fail at a small a test. The people doing the testing need consistent encouragement and reminders that we expect that most tests will not work. We need to be clear that the point is to learn and continuously improve.

Tips on How to Nurture Without Micromanaging

If managers only spend time on a unit once a month or once every six weeks, our presence can feel like an inspection instead of nurturing. Rare visits — or worse, only being there when something is wrong — can cause unnecessary tension and stress.

We don’t want people to be anxious when we come to a unit or department. We want them to say, “She’s here because she values our work.”

Here are some other tips for nurturing improvement:

  • Schedule time for nurturing. I used my calendar to set aside time to support the improvement teams. At the end of my hospital career, I was responsible for seven units. I scheduled at least 30 minutes on each unit to check in every week. Investing time — whether it’s 20 minutes or two hours — shows we value the work and the process being improved.
  • Go to the site of the improvement work. Go where the work is happening. Make it a point to be there often when the team is running tests. If a team is testing a central line bundle, for example, ask them to give you a call when a line is being placed so you can see what the process looks like for them. Observing their environment may help you understand the barriers to improvement. It also means a lot to teams if you go to them instead of always expecting the team to come to you.
  • Give teams what they need. If they want sticky notes, index cards, or envelopes to do a small test of change, get them. If they need a colored marker, tape, or some other office supply or tool to do their testing, bringing them what they need shows your support.
  • Make good use of your check-ins. As you’re testing a process, it’s important to huddle or meet quickly once a week and ask, “How did last week’s test go? What worked? What didn’t work? What do we want to do next? What does our data look like? What did we miss?” Especially as PDSAs get going, the discussion could be 10 minutes standing in the hall on the unit. When you do them weekly, they can be quick. Gather up two or three team members and don’t take them away from their work for too long. As we earn a team’s trust and their confidence builds, we spend more time listening to how things are going, asking clarifying questions, and offering guidance when needed. Teams may need some ideas about the next PDSA cycle. They may need advice on how to make a test small enough. They may need encouragement to try something new.

Leaders often direct people — which is part of any leadership role — but with improvement, we also need to nurture. When we invest time and support the people doing the work of improvement, we get much better results than if we just tell people what to do and expect them to work miracles.

Kathy D. Duncan, RN, is faculty for IHI’s Leading Quality Improvement: Essentials for Managers virtual program that starts on February 11, 2020.

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