What is the goal of reliable design? (Part 3 of 5)

Frank Federico, RPh, IHI Executive Director

Welcome to part three of our five-part series on reliable design. The goal of reliable design is to have processes that are at least at 95 percent level of reliability. Of course we want 100 percent for all of our patients, but remember we are working with non-catastrophic processes so that we have identified even if you don’t reach 100 percent, many times you are already delivering that excellent care that you want patients to get. Sometimes that 95 to 100 percent, that last 5 percent, is very labor intensive, resource intensive to get to that point. Again, I don’t say we shouldn’t reach to 100 percent, but our methodology has indicated that if you reach at least 95 percent, you are providing reliable care for your patients.

The process also needs to be capable and reliable because you can develop a reliable process that is not capable of getting you the results that you want. You could have a process that reliably somebody follows, but you always get a bad cup of coffee at Starbucks. That’s a reliable process, but it’s not capable. Likewise in health care, we want to have a process that’s reliable that ensures patients get the care, and it’s linked to the outcomes that we are getting. Ultimately, you should only be working on processes that are linked to outcomes because if you work on other processes, they might all be well intentioned, but if they don’t help you achieve the outcome that you want, then you are not doing the work you should be doing for your patients.

Change concepts that you should apply include simplification. That is, are there steps in the system, are there things, that can be eliminated because they really don’t bring value or can be done in some other way. The other [change concept] is standardization. That is, what is the best way known to achieve those outcomes that we want to achieve? Those best laid plans may change because your patient population may change. Treatment plans may change. You may have new knowledge about how to treat patients, and therefore you always have to be aware that what you have developed as a standard operating procedure today may change tomorrow based on new knowledge that you’ve gained.

So why should you standardize? Standardization makes it easy to fix a defect when one occurs because if everyone is doing it in a different way, how do you know which is the defect or the process that’s not actually working, and how do you fix it because you can only fix it for one person at that time?

Standardization reduces variation, and variation is one of the major issues why we don’t have good outcomes that we want. It makes it easier to train people when you have a standardized process because everybody is learning it the same way. It supports what we want to deliver for our patients. It ensures that we’re providing the safe, evidence-based care that our patients should get. It also, once you have standardization in place, it makes it easier to assess competency because then you can assess whether people are doing the work the way it was designed: yes or no.

Now, how do you standardize? First, you have to determine what to standardize. Ask people who do the work for their ideas. They can tell you what works and what doesn’t. You may want to steal ideas from others. That is, ask someone if you don’t know what to do — there are others who maybe have tackled that same problem. Remember, you then have to test that idea in your environment because it might not work the same way.

You still need to do plenty of testing. You still need to do plenty of measurement. And if the idea is just not working, don’t be afraid to give up and try something else because sometimes we spend a lot of time trying to tweak something to make it work, when in reality, it’s probably not the right process to begin with; we should be looking at something else.