Why It Matters
Even organizations dedicated to improvement can find it hard to think of quality as a whole system instead of just a series of projects.
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Before and After Whole System Quality

By IHI Team | Monday, January 30, 2023
Before and After Whole System Quality Photo by Bankim Desai | Unsplash

At Children’s Healthcare of Atlanta, where I am chief quality officer, it was amazing to see how well our organization came together at the start of the COVID-19 pandemic. Even in the face of so much urgency and uncertainty, the hierarchies flattened, we made decisions efficiently, and perceived differences in authority disappeared.

However, I have since learned that expertise and comfort when in a crisis has a flipside. When not facing an emergency, it can be easy to fall back into old bureaucracies and inefficiencies. On the continuum between being a reactive organization and a proactive organization, we determined that we were more reactive. Once the leadership team at Children’s realized this, we called the Institute for Healthcare Improvement (IHI). We have had a strong focus on patient safety for many years, but we decided to get help with taking a step back and evaluating our program. The recognition that we needed to be more proactive provided the burning platform that compelled us to explore the whole system quality approach.

A Better Way to Prioritize

For me, whole system quality is a set of leadership and management behaviors that help us move away from judgment and toward the journey to becoming a learning system. Embracing whole system quality means connecting measures at the system level and cascading measures to the front line. Using this approach helps an organization follow a strategy that helps everyone row in the same direction.

The whole system quality approach focuses on quality planning, quality improvement, and quality control. We have always had a good quality planning process, but we started to understand that we were not looking at each quality project in enough detail. It became clear that we sometimes used anecdotes or emotion to decide on our areas of focus instead of clinical evidence and data.

Using the whole system quality approach, we categorized our improvement efforts. We did some things at the macrosystem level. Some projects focused on the local microsystem. Some work was to maintain quality control. Categorization has helped us organize our thinking and allocate the appropriate assets and resources needed for each.

For example, we were working on improving care for acute kidney injury in children. Over the last year, we realized we were not making enough progress. By taking a closer look, we discovered we had misjudged the amount and nature of the resources required to make change by misclassifying it as a local improvement project. So, now the project is a system-level priority, and we increased the allocation of resources and assets.

The Impact of Whole System Quality

In addition to supporting better planning and prioritization, using the whole system quality approach can help an organization in multiple ways:

  • Transition from a series of projects to an organization-wide approach to quality. Twelve individuals are part of our quality core group. There is representation from the major services, including surgery, medicine, nursing, and infection prevention. The core group incorporates key members of the executive team because it is important for them to hear our conversations and feel the tension of our decision-making. We spend about four and a half hours once a year going through between 30 to 40 possible priorities to understand the definition of each problem, our theoretical framework, our key driver diagram, and what we have accomplished so far.
  • Develop a deeper understanding of your data. We are on a journey away from using aggregate measurement and red/green indicators to looking at quantitative and qualitative data over time. We can now say, “Yes, we’re performing well here, but let’s break this down and look at our in-institution variability.” We try to understand common and special cause variations. We have developed a deeper appreciation for using and understanding data at all levels of the organization.
  • Focus on the outcome. With the whole system quality approach, instead of focusing on the change idea or proposed solution, you are always focused on the outcome. This leaves your mind open to considering the possibility that you do not have the right solution. This allows you to adapt and learn.
  • Build confidence in your improvement work. Before using whole system quality, our tendency would have been to recognize an opportunity for improvement, develop a program, and implement the program. We may not have measured its effectiveness. And, if we had seen an improvement, we would not have had confidence that the intervention yielded the improvement. It would have been very difficult to separate secular trend from our effort for improvement. Taking a whole system quality approach forces us to be clear on our theory for improvement instead of thinking that developing a program is the solution.

For those considering using the whole system quality approach, I can say we have found it helpful that the physicians, nurses, and administrators in the core group have quality improvement expertise. They apply quality improvement in their daily work. Having those skills helps us evaluate our work critically.

Children’s Healthcare of Atlanta is on a journey. We have a shared sense of purpose, curiosity, and wonder. We find joy in doing this work and have a willingness to learn. We have made progress, but we see ourselves as less of a success story and more of a work in progress.

Srikant Iyer, MD, is Chief Quality Officer and Division Chief, Emergency Services, at Children’s Healthcare of Atlanta.

You may also be interested in:

What Kind of Quality Department Best Supports Whole System Quality?

Finding Your North Star: Where the Whole System Quality Journey Begins

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