8 Key Steps of 8 Key Steps of Implementing Quality Implementing Quality Improvement ProjectsImprovement Projects

Amelia Broussard, PhD, RN, Amelia Broussard, PhD, RN, MPHMPH

Step 1Make Commitment; Start Step 1Make Commitment; Start WorkWork

: : • Promise time/resources to do this right.• Budget time for improvement activities.• Use quality tools and resources creatively, • Alter strategies as needed for staff and

culture to support “ownership” of improvement work.

• Don't do this alone. Process requires a “core team”

• Include at a minimum of division leadership and key owners of the processes under improvement.

Step 2: Form a TeamStep 2: Form a Team

• What is a team?• A group of individuals working together for

a common purpose. • Team shares mutual accountability for

successful outcome.• Teams create environments in which

participants can keep up with needed changes, learn more about core processes, and gain skills in collaboration

Teams are more Effective IfTeams are more Effective If

• Task is complex• Creativity is needed• Path forward is unclear• More efficient use of resources is required• Fast learning is necessary• High commitment is desired• Implementation of plan requires

cooperation of others• Task or process is cross-functional

Teams RequireTeams Require

• Clearly defined purposes and goals that serve organization

• Defined parameters within which to work• Communication within the organization• People with necessary knowledge and

skills to accomplish task• Knowledge about how they are going to

accomplish tasks

Teams and ChangeTeams and Change

• Most teamwork involves change • Change is seldom easy. • “Laws” of organizational change:

– People don’t resist change, they resist being changed;

– Things are the way they are simply because they got that way;

– Unless things change, they are likely to remain the same; and

– Change would be easy if it weren’t for all the people!

Forming a Successful TeamForming a Successful Team

• Three to six members are typical size• Include people from work areas that

will be impacted by changes• Representation of all affected areas

ensures understanding of projected improvement

• It also promotes buy-in for changes.

Team SelectionTeam Selection

• Composition is the most critical success factor in any improvement project

• Division Leadership is responsible and accountable for team composition.

• Smaller the team, the faster and better the results.

• Five or six team members are ideal. In a small setting, four member teams are norm.

• .• Team members should be prepared to meet at

least twice a month; weekly is ideal

Selection ProcessSelection Process

• Selection process consists of three steps: – Identifying good candidates for the

project– Determining the optimal team mix, – Recruiting the team

Who Makes A Good Team Member?Who Makes A Good Team Member?

• Potential team member, want to ask following questions:– Is this person respected for their

judgment by a range of staff?– Does s/he enjoy a reputation as a team

player?– Technically, what is person’s area of

mastery

Good Team Member Cont’dGood Team Member Cont’d

• Is s/he an excellent listener?• Is this person a good verbal

communicator?• Is person a proven problem solver?• Is s/he frustrated by current systems

and processes?• Is person demonstrably open to

change?

Identifying Team LeadersIdentifying Team Leaders

• Members in three leadership roles will guide team activities

• Senior Leader• Process Champion• Quality Lead. • All three leadership roles function as

team liaisons and representatives across programs and divisions.

Senior LeaderSenior Leader

• Has authority to allocate time and resources needed to achieve team’s aim (goal)

• Has authority over areas affected by change

• Will support spread of successful changes throughout organization

Process ChampionProcess Champion

• Is an opinion leader and is well respected by peers

• Understands processes of work involved in change effort

• Has a good working relationship with colleagues and day-to-day leader

• Wants to drive improvements in system

Quality LeadQuality Lead

• Drives project, ensuring that cycles of change are tested and implemented

• Coordinates communication between team and leadership

• Oversees data collection• Works effectively with champion and

other team members

Teamwork PrinciplesTeamwork Principles

• Members need to work at active listening and respecting one another’s point of view.

• Ground rules for group should be established, documented and reviewed periodically

• Ground rule examples include: start on time, make no judgments, and keep confidentiality among group members, ensure that all voices are equal, use humor

Meetings Work Best When Meetings Work Best When Members of Team:Members of Team:

• Commit to meeting time and process• • Clarify roles and responsibilities each

time• • Begin and end meetings on time• • Listen to and respect perspectives• • Do assigned “homework”• • Give honest feedback• • Evaluate and mark success• • Make time enjoyable

Stages of Team GrowthStages of Team Growth• Stage 1: Forming – members cautiously

explore boundaries of acceptable group behavior

• Stage 2: Storming – teams begin to realize task is different and more difficult than they imagined, and become testy, anxious, or overzealous

• Stage 3: Norming – team members reconcile team loyalties and responsibilities

• Stage 4: Performing – team settles it’s relationships and expectations and starts performing

Step 3: Select and Define an Step 3: Select and Define an Improvement ProjectImprovement Project

• Guidelines for selecting project • Is important to organization and its clients

or grantees?• Is it an area where senior leaders, division

directors, and staff will cooperate in improvement effort

• Is not already undergoing major changes or being studied by another group

• Is relatively simple, with clearly defined starting and ending points.

• May break complex issue into simpler task

Define the ProcessDefine the Process

• Goal is to develop useful description of your process as it currently works.

• May lead to discoveries of obvious improvements.

• Allows everyone on team to come to agreement on key tasks involved

Key Methods Of Describing A Key Methods Of Describing A ProcessProcess

• Set boundaries on the process• Flowchart process• Diagram physical workflow• May use Fishbone diagram to

determine areas for possible improvement

Step 4: Define an Step 4: Define an Improvement Aim (Goal)Improvement Aim (Goal)

• Where Are You Now?• Where Do You Want to Be?• Make Baseline Performance

Assessments • Validate level of performance on

selected improvement project

Write an AIM Statement:Write an AIM Statement:• An AIM (goal) statement articulates in 1 or 2

sentences what the team is trying to improve • Based on assessment of current performance

already completed • Agreement with group on suitable stretch goal for

improvement. • Important to do process well first time to keep

team on track• It will keep team focused, re-orient members when

they get off track • Facilitate development of simple measurements to

determine if a change is indeed an improvement.

Develop measurements to Develop measurements to evaluate your evaluate your improvementsimprovements

• What is it you are trying to improve and for whom?

• It is important to identify simple way to evaluate improvement progress over length of your project

• Learn from consumers of your process and use these lessons to inform team’s improvements

How To Know Change Is An How To Know Change Is An Improvement?Improvement?

• Remember to look at small microsystems (small replicable units) of process

• Is there already data collection process in place that measure impact?

• Can real time data collection be easily inserted into current flow of work?

Step 5: Cause AnalysisStep 5: Cause Analysis• It’s critical to identify causes of problem

under study before jumping to conclusions on best solutions.

• Best to localize occurrence of problem before attempting to identify specific or root causes.

• Important to be sure everyone agrees on definition of problem.

• Explore “causes of causes” to make sure your addressing “upstream” issues affecting actual problem under study.

their effects.

Root Cause AnalysisRoot Cause Analysis

• Systematic analysis of an issue to identify the root causes rather than the symptoms.

• Cause and effect charting is another way to clearly sort causes from their effects.

““Brainstorm” As A GroupBrainstorm” As A Group • Brainstorming is process of offering creative ideas

that comes to mind (without any judgment attached to it).

• Use flip chart to write down ideas that members of team feel might be addressed

• All team members should be encouraged to participate in this process – perhaps go around the table and take turns providing one suggestion at a time.

• Write down all ideas, some ideas may address the same

• Combine similar themes. • Avoid jumping to solutions at this point.

Prioritize IdeasPrioritize Ideas

• Prioritize objectives. • Team should vote on which objective

needs to be worked on first, second, and third

• Plan to focus on 2 or 3 objectives at first then revise if necessary

• Important that all team members participate in anticipated improvement within specified timeframe.

• Each team member should be working toward this goal.

Step 6: Plan and Test Step 6: Plan and Test ChangesChanges

• Develop appropriate solutions• Test changes that lead to improvement• PLAN, DO, STUDY, & ACT Cycle (PDSA):• Simply defined:

– Plan simple improvement project according to goals and objectives

– Do project activities– Study whether project is making an

improvement (or not)– Act accordingly, incorporating any changes or

course corrections

Step 7: Implement and Sustain Step 7: Implement and Sustain Successful ChangesSuccessful Changes

• Key to sustaining improvement is institutionalizing successful changes

• Steps to be taken to secure permanent changes to make it part of the larger system:– Document e new process or changes to system– Educate and communicate changes to ALL staff

involved– Add new process to any orientation or staff

training procedures– Develop mechanisms to continually assess

changes

Step 8: Ending Step 8: Ending Improvement Improvement

Teams/ProjectsTeams/Projects• Results checked against original goals and needs of division, staff and improvement target

• Identified any remaining tasks to be done,• Established responsibility for monitoring change over

time• Documented and trained people, when necessary, in

new process.• Communicated changes to everyone affected by

them.• Reviewed team’s accomplishments for areas of

improvement.• Celebrated efforts of team with a lunch, formal

announcement of team results, special presentation to the division, Quality Council, or other expression of celebration.