Photo by Caleb Woods | Unsplash
As health care organizations strive to become more reliable in an increasingly complex system, they set ambitious aims to meet the needs of their patients, families, and staff. Yet, they often fail to align improvement activities across the system to meet these aims.
Through decades of partnership and recent practical experience, the Institute for Healthcare Improvement (IHI) has developed a holistic approach to quality management that we call Whole System Quality. Whole System Quality guides organizations to identify, align, and act on improvement priorities that matter to their diverse stakeholder groups. Whole System Quality is achieved by integrating and embedding quality planning, quality control, and quality improvement activities across multiple levels of the health system.
The Whole System Quality journey begins with codifying and communicating a meaningful organizational vision that serves multiple constituencies. Often this vision is referred to as the North Star that serves as a guiding beacon for your organization. Begin by mapping the internal and external stakeholders of your health system and their needs and expectations. Evaluate the current organizational mission and vision. Is it representative of the many people with whom you engage? If not, enlist these stakeholders to deeply understand what matters to them.
Ideally, the organizational vision includes some or all of the components of the IHI Quintuple Aim. At several health systems, we have seen a gap in understanding of the North Star at different levels of the system. While executive leaders may have a clear vision of their North Star and how it connects to the daily work of the organization, there was a high degree of variation of how this cascades down to other levels in the system. The vision and how it directly connects to everyday work needs to be clearly communicated to all stakeholders and reinforced through many modalities of communication.
Once what matters to the stakeholders has been established, you will need a measurement system that offers transparent awareness of system performance and progress. Large organizational goals can be cascaded to local level improvement opportunities and measures. For example, if your organizational goal is to reduce preventable mortality, you may choose to work on more rapid recognition and treatment of sepsis in the emergency room, reducing high-mortality hospital-acquired conditions on general patient care floors, or increasing palliative care services across the organization. Each of these departments or service lines should have improvement goals relevant to their own data and performance which roll up to larger metrics important to the health system and the people they serve. Establishing a robust measurement system will support prioritizing and organizing work aimed at the areas of greatest need and aligned with the North Star.
Having a measurement system to understand how you are performing in relation to what matters is critical but cannot lead to improved performance and progress towards the vision on its own. Realizing the vision requires an integrated delivery system for quality that includes:
- Quality Planning is an (at least) annual exercise to surface and evaluate new and existing improvement priorities across the organization. An effective Quality Planning session asks key questions: Are our priorities aligned with our North Star? Are we using a balanced and equitable approach to address the needs of our stakeholders? Have we assigned the right resources to support improvement in these critical areas?
- Quality Control is the ongoing monitoring and support of routine operations and systems and processes which perform at acceptable levels for health system leaders, staff, and patients who interact with those processes. Quality control establishes standard responses and actions for such processes which exhibit special cause variation. This also includes mechanisms for real-time learning such as escalating huddle structures to surface and solve problems at the appropriate levels of the organization.
- Quality Improvement represents an organization’s structures and processes to apply the science of improvement to close performance gaps. Does your organization have an agreed upon methodology for improvement? Do staff have the capability and capacity to lead or participate in improvement?
Each of these functions are inextricably linked and mutually reinforcing. Strong quality planning will establish a manageable set of improvement priorities. An effective quality control system will enable improvement teams to focus their work on systems and processes which truly need improvement. An effective quality improvement system will build improvement skills and support local ownership of improvement work that contributes to the organizational vision.
Over the coming months we plan to delve deeper into each of these functions to support Whole System Quality. We will be sharing lessons from the field, tools, and tips to help leaders, managers, and staff to find their organization’s North Star.
Jesse McCall, MBA, is an IHI Senior Director and Improvement Advisor. Jessica Behrhorst, MPH, CPPS, CPQH, CPHRM, is an IHI Senior Director. Learn more about Whole System Quality at the IHI Forum.
You may also be interested in:
IHI Whole System Quality white paper
What Kind of Quality Department Best Supports Whole System Quality?
What Does It Mean to Rethink Quality?