Trust the process: Quality improvement as a source of stability and adaptive strength
On the Zoom call, Irene asks, “How do we do quality improvement in a crisis situation, or in this next phase of making big changes fast? What does that look like?” There were nods and thumbs-ups from the five awkwardly-lit faces in their separate little video cubes.
This one is for me. I click the microphone icon to unmute myself. I want to answer with real talk and not generic boosterism.
If you aren’t familiar, quality improvement (or “QI”) is a structured approach to getting better results from complex systems. QI uses small teams, data, and experimentation. Of its many pieces, the biggest difference from traditional top-down management is that the people who do the daily work figure out the solutions. They use brief, small experiments to test good ideas in their actual regular work. When a QI approach carries through the whole organization, the change from the bosses having all the answers, to making it the work of frontline staff teams to figure out the answers, is a transformative culture shift.
Irene works as a coach in QI projects with health care organizations. Here are some of the questions she was testing with health care providers in different QI teams before the COVID-19 pandemic:
• Will a weekly phone call to five (small test!) of our patients with diabetes help them to better manage their health? Or is it a waste of time or a nuisance?
• Will a smartphone app for mental health help teenagers with anxiety?
• Will a referral tracking dashboard help us support patients to follow through with mammogram referrals?
Doing QI in a classic project approach requires what most change efforts require: regular meetings, a way to measure the impact of changes, and a management mechanism to standardize the new proven tasks across the organization. Teamwork and change work require a lot of talking, and that talking takes time.
But we are in a crisis. In March, the game changed, literally overnight. In health care, everything turned upside down. The mandate in primary care became “care for as many people as possible while keeping them away from the office.” For people who need in-person care, the job now includes screening them for coronavirus exposure. People are too busy reacting and adapting to continue many pre-crisis projects and meetings.
Back to coach Irene’s question, here with a rephrase: “Can we use our process redesign skills and tools in a crisis? Or do we need to put QI aside and use only a top-down management approach, for speed and clarity of marching orders?”
The answer I gave: Quality improvement (and other structured team-based change work) is more important than ever. The habits and tools of quality improvement are the habits and tools of adaptation through teamwork. QI provides a familiar and reassuring way to move through uncertainty. We know the steps. We know how QI works. It gives us a way to work together, since it requires teamwork and provides a shorthand we need to keep moving and striving in a crisis. “We have each other,” you could say to your colleagues, “and we have our learning and change methods.”
Here are some questions that QI work in primary care could answer during the COVID-19 crisis:
• How can medical assistants best support patients and providers when providers are working from home?
• What step-by-step process works best to quickly and safely welcome patients in the parking lot and screen them for COVID-19 symptoms before bringing them inside the building?
• Can we design a safe and effective process to give children recommended vaccines without them having to enter the building? Whether they arrive in a car or on foot?
Let’s answer, finally!, Irene’s question “What does QI look like in a crisis?” Here, and in the diagram that accompanies the article, is a simplified comparison of how QI works normally, and how it can work in a crisis.
Quality improvement in regular operations
1. Choose an area of performance to improve. Diabetes care, breast cancer screenings, revenue maximization, specialty care management. The topics are almost endless as long as the effort matters to leadership.
2. Build a team. Pick interested people who have a role in the work being redesigned, more frontline staff than managers. The ideal team size is four to eight people.
3. Apply steps and tools of QI. Set a measurable goal, on a topic important to management and to patients/clients/customers. Test new ideas. A team of frontline staff tests a range of ideas to get to the goal, and measures the impact of each small experiment.
4. Redesign old ways of working, or create new services. The team learns the exact few changes that work to get better results, and documents them to propose to managers.
5. Implement the new and detailed processes widely. Managers direct staff to implement the tactical changes that work, and support this with training and change management.
Quality improvement in a crisis
1. React to the crisis. Make big changes fast. Managers learn what changes are required and direct everyone to make the changes immediately. An all-hands-on-deck approach makes the details, like whose job it is to do which thing, less important in early days. But there are lots of questions about those details. In the current crisis, for example: Who takes over the duties of the people who now work in the parking lot doing COVID-19 screenings?
2. Build a team. This can be the same step as the QI team projects described above, or, if people are too busy with the crisis to have a new meeting, the team could be larger existing staff groups, with QI work integrated into existing crisis response meetings.
3. Apply steps and tools of quality improvement. Set measurable goal or goals. Test. Measure. Learn. Report. If the team larger and less defined than a classic QI team, you need a simple and clear process for when and how to run tests, discuss results, and make decisions. (“Everybody try things!” without structure and discipline adds chaos and makes it impossible to measure results.)
4. Discover the ideal, detailed process steps for the big changes already in place. These new details clear up most of the questions and confusion that arises when big changes happen suddenly. This is the learning and decision-making that allows you to move from “all hands on deck” to defined roles and responsibilities.
5. Add the new details to the big changes. Implement widely, with training as needed. Managers decide which tests will become standard work in crisis-era operations, and lead the roll-out of these new expectations. An added bonus: Everybody is reminded of the wisdom of teams and the value of QI in a reassuring and stabilizing “we got this” way.
If it helps you, please copy and save the diagram that accompanies this article as a reminder of how improvement work provides structure and focus for changing how we work. We need all the structure and focus we can get!
Two other articles you might enjoy, about the interpersonal aspects of teams and change: