Even the most dedicated quality improvement champions get overwhelmed sometimes. We see seemingly endless opportunities to improve patient care, processes, and our work environment. In addition to our own ideas, requests — or, often, demands — for QI projects also come from hospital leadership, accrediting bodies, the government, and payers.
But not all improvement projects are created equal. How do we avoid wasting time and resources on initiatives that don’t succeed or “stick”? How can we prevent overwork, resentment, and burnout related to QI? We need to take a hard look at how we design and prioritize improvement initiatives. One way to do this is to use the “Highly Adoptable Improvement” model.
Development of the Highly Adoptable Improvement model came from existing literature and theories that a panel of quality improvement leaders then developed. It was tested over the past four years by IHI Improvement Advisors and others. According to this model, change initiatives that don’t add to workload and have high perceived value are most likely to be adopted, cause less workplace burnout, and achieve their intended outcomes. To increase the likelihood of sustainably adoptable improvement, change initiatives must address:
- End-user participation — Active participation of end-users in the design, testing, revision, and implementation of change interventions increases the likelihood of higher perceived value. A change developed with end-user participation is also more likely to be easier to put into practice, thus increasing the chance of sustained adoption.
- Alignment and planning — Change initiatives aligned with an organization’s goals, values, and objectives and planned to inform end-users and avoid conflicts between projects or priorities are more likely to increase perceived value and achieve sustained adoption.
- Resource availability — Providing the necessary support and resources to aid understanding and implementation of the change initiative helps end-users adapt changes into their existing workflow.
- Workload — Interventions that require less effort or improve the current workflow are more likely to be sustainably adopted and reliably performed.
- Complexity — Interventions that are simple and easy to use are more likely to be sustainably implemented and reliably performed.
- Perceived efficacy — When people trust the quality and validity of the evidence supporting an intervention, it is more likely to be adopted and results in less change fatigue and cynicism.
If we are deciding whether or not to support a cause, we generally do so because we see it as worthy of our investment of money or time. Likewise, “perceived value” in the Highly Adoptable Improvement model is not about inherent value, but refers to how the clinician or end-user assesses the worth of the change.
For example, frontline clinicians may not have high perceived value of reducing hospital length of stay to reduce cost or increase throughput, especially if they believe patients get discharged home too quickly or worry that success may result in job cuts. Similarly, if the intervention to reduce ventilator-associated pneumonia (VAP) includes a cumbersome checklist that doesn’t support implementation of best practices, those closest to the point of care may not perceive the intervention as valuable despite their recognition that, in theory, it reduces VAP.
Engaging Those Making Change
For QI initiatives to have perceived value, we need to work closely with those who have to adopt the change. We must be clear about the intended benefits for them, their patients, or their work environment. By co-designing, we are more likely to develop an intervention that implementation teams see as worth their time and effort. One example shared by a team that tested the Highly Adoptable Improvement model helps illustrate this.
To decrease the likelihood of readmission, the team decided to work on improving follow-up for patients discharged from the hospital. The QI team chose to test a process in which a patient receives a follow-up phone call several days after they go home to see how they are doing. The team developed a telephone script they validated with frontline nurses, a set of responses to guide the patient to resources, and a checklist to connect patients with appropriate services.
When the QI team brought the discharge follow-up process to the nurses for whom they wanted to implement, they got an unexpected response:
“Oh . . . you wanted us to do that? We don’t have time.”
The team managed to convince the nurses to test the process and measured how much this new process contributed to the nurses’ workload. They quickly saw that it took several phone attempts to reach each patient. It took as much — if not more — time to then notify referral services when needed. The increase they saw in workload was far higher than the QI team anticipated. They realized this would undermine the possibility of the project’s success. This prompted the QI team to 1) rethink who could implement the discharge follow-up; 2) co-design the next test with whoever they had in mind for implementation; and 3) address whether it could be simplified.
What’s the moral of the story? Point of care providers need to be involved in creating change, and not just responsible for implementing change thrust upon them.
As I’ve worked with teams around the world, the most important thing I’ve learned is that health care providers are overwhelmed with multiple demands on them and they want to improve their systems. Many QI teams using the Highly Adoptable Improvement model have realized that they have been inadvertently adding unnecessary complexity and giving unneeded extra work to point of care providers. Not surprisingly, in many cases this resulted in change that was not valued or adopted sustainably.
Care providers want to make a difference in the lives of their patients and their colleagues. They need the resources (including time) to do meaningful work. When they don’t have this, they create workarounds, feel they have little control, and become overwhelmed. This begets burnout.
If initiatives meant to improve patient care and outcomes complicate and add to the workload of care providers, they will ultimately contribute to the already serious problem of burnout. On the other hand, if improvement leads to high perceived value and a lower workload, it helps clinicians and staff to provide better care without overburdening them. There are many factors that contribute to burnout, but improvement shouldn’t be one of them.
Christopher W. Hayes, MD, MSc, MEd, is Chief Medical Information Officer, St. Joseph’s Healthcare Hamilton and faculty for IHI Virtual Expedition: Highly Adoptable Improvement. He was also an IHI Harkness Fellow in Health Care Policy and Practice (2013-2014).
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WIHI: Making the Work of QI Less Draining and More Sustaining