February 8, 2023

Distinguish performance improvement gaps. Summarize process improvement concepts, principles, and strategies in a healthcare organization. (III.A.4.ii) Critique performance management co

Purpose

This assignment is intended to help you learn to do the following:

Distinguish performance improvement gaps.
Summarize process improvement concepts, principles, and strategies in a healthcare organization. (III.A.4.ii)
Critique performance management concepts, principles, and strategies in a healthcare organization. (III.A.4.i)
Recommend a performance improvement implementation plan and strategies.

Overview

This assignment represents Part 2 of a two-part project that you will complete for your ePortfolio. As you work on this assignment, you will be developing the following Commission on Accreditation of Healthcare Management Education (CAHME) competencies:

III.A.4 Critical Thinking, Analysis, & Problem Solving

Performance Management
Process Management

Action Items

Complete Exercise 7: Improving a Performance Gap in my Organization (p. 301) in your textbook. (attached below)
Prepare your assignment for submission:
- Follow all applicable APA Guidelines Links to an external site. regarding in-text citations, list of cited references, and document formatting for this paper. Failure to properly cite and reference sources constitutes plagiarism.
- Write 3-4 pages paper. The title page and reference list are not included in the page count for this paper.
- Proofread your assignment carefully. Improper English grammar, sentence structure, punctuation, or spelling will result in significant point deductions.
Submit your assignment. Your work will automatically be checked by Turnitin.

CHAPTER

229

USING IMPROVEMENT TEAMS AND TOOLS

Learning Objectives

After completing this chapter, you should be able to

• identify strategies for creating improvement project teams; • describe the role of managers in team decision making; • differentiate how, when, and why to use common improvement tools;

and • recognize what tools are best to use at each step of an improvement

project.

T he nursing shared leadership committee in a midsize hospital came up with a great idea for improving the work environment for bedside nurses, who spend time in face-to-face group meetings that take them

away from patient care duties. The committee proposed using electronic message boards to reduce the need for these meetings. The nurses could use this medium to complete some group work during their downtime rather than depart from units to attend formal meetings. This change would potentially help nurses be more productive at the bedside and improve the way they get their work done. The electronic message boards could also be used to update everyone on the work of various committees and share evidence-based practice recommendations.

The information technology department set up electronic message boards for each unit, and nurses were instructed on how to use the medium and its purpose. However, what seemed like a great idea did not catch on with the bedside nurses. Simply making this new communication tool available was not enough to get people to start accessing the board to interact with one another. The value of using the message boards for communication was unclear to people at the grassroots level, and face-to-face meetings had been their usual way of interacting for years. The committee chairs, charge nurses, and clinical leaders were not made responsible for regularly posting content on the message boards. The staff nurses quickly stopped logging into the message boards when they found very little to read.

Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324. Created from franklin-ebooks on 2023-02-08 00:23:25.

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Applying Qual i ty Management in Healthcare: A Systems Approach230

This change effort failed for several reasons. First, and most important, it was initiated with a top-down approach. The electronic message boards may have been a great idea; however, the frontline nurses were not engaged in the improvement project. The idea was pushed down from the upper levels of the nursing department, and the message boards were designed without any input from staff. Whether the frontline staff considered improved productivity and enhanced communication to be important goals was never fully explored before implementation.

Often, improvement projects result in people being asked to change the way they have always done things—thus, a bottom-up, team approach is more likely to be successful. This chapter describes how managers can reduce the likelihood of unsuccessful improvement projects. The first step is to charter the project, which involves clearly defining the project goals and scope. Next, the members of the improvement project team need to be carefully chosen. This chapter also discusses the various improvement tools that will be used by the team to understand the current process and select the best interventions for achieving the performance improvement goals.

Charter Improvement Projects

Before embarking on an improvement project, the manager or managers in the departments or units affected by an improvement project should establish clarity about the project scope (areas affected) and purpose (desired outcome). The more issues clarified up front, the less likely the team will be to experience false starts. A written project charter is essentially a contract between the organization’s management and the improvement team.

The project leader and the sponsoring manager(s) may jointly create the chapter, or it may be created at the first team meeting. Issues that should be addressed in creating the project charter include these (Rohe and Spath 2005):

• Purpose: In one or two sentences, describe the purpose of the project. The brief explanations should define, in specific terms, what the project is expected to achieve.

• Objectives: List some of the measurable outcomes of the project. The objectives should answer the questions, “How will we achieve our purpose?” and “What are the signs of success?”

• Deliverables: What are the tangible milestones anticipated along the way? What are the progress points that can be expected? When defining deliverables, include dates—they add commitment and urgency to the project completion.

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Chapter 12: Using Improvement Teams and Tools 231

• Team and team resources: Identify the people and resources needed to analyze, create, and carry out the purpose.

• Success factors: These are the essential elements outside the team needed to make the project successful, such as buy-in from the staff or financial resources.

A typical charter consists of a one-page summary of critical details of the project, allowing all stakeholders to agree on the goals to be achieved, the scope, the time line, and the resources needed for the project to be successful. Exhibit 12.1 illustrates a project charter template.

Project Title

Purpose

What are we trying to achieve?

Objectives

What are we trying to achieve? How will we know we got there?

The new/redesigned process will (be specific):

• • •

Deliverables

What must be done to achieve the objectives?

The team is expected to complete the following:

By __/__:

By __/__: By __/__:

By __/__:

Team and Resources Core project team members: Leader: Other members:

People who have knowledge or skills that will be helpful for completing the project:

Success Factors

What leadership and resources are needed to make this improvement a success?

• • • •

Source: Adapted from Rohe and Spath (2005). Used with permission.

EXHIBIT 12.1 Improvement Project Charter Template

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Applying Qual i ty Management in Healthcare: A Systems Approach232

Once the initial project charter is drafted, its completeness can be evaluated using the following criteria:

• It specifies, in detail, the performance problem to be addressed. • It contains measurable objectives that include target goals to be

achieved. • It sets realistic deadlines and expectations. • It contains defined time lines for completion of the project. • It is relevant to the organization’s strategic quality goals.

If revisions are needed in the charter, the team should make them before the start of the project. Otherwise, the lack of clarity can eventually derail the improvement effort.

Performance Improvement Teams

Improvement methodologies such as Plan, Do, Check, Act and Six Sigma serve as critical thinking frameworks for managers studying any problems that may arise. Project teams also use these methodologies as they work to improve performance in a particular functional area. Regardless of the model used for an improvement project, assembling a team of people personally knowledgeable about the process to be improved is essential. Composition of the team (the number and identity of the members) and meeting frequency and duration are guided by the process purpose and scope. The questions that influence makeup of the team should include the following:

• What knowledge is required to understand the process and design the actual improvement intervention(s)?

• How should the team be designed to support the processes needed to accomplish implementation within the project constraints?

The number of team members needed to successfully achieve the project objective will vary. Managers need to take into account the number of staff members that can be taken away from their usual work without adversely affecting services. The optimal size of a team is between five and eight individuals. However, the size of the team is not as important as the diversity of its members. The team should include people who have different roles and perspectives on the process to be improved (Agency for Healthcare Research and Quality 2013). Individual contributions during a meeting tend to diminish as the size of the group grows beyond six members.

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Chapter 12: Using Improvement Teams and Tools 233

Just as managers use human resources practices that promote matching an employee’s traits with the requirements of the job, managers may also match employees with the various roles and stages required in a change or improvement process. Problems in group processes tend to arise from a mismatch between a project stage and an individual rather than from problems inherent in the individuals themselves. Intentionally engaging individuals at the appropriate time, as well as offering support or requesting patience during other times, can enhance the effectiveness of both the team and the manager.

For instance, a team member favoring concrete thinking may get frustrated with creating a vision, though he will be essential in determining the logistics of implementing process changes. Someone with well-developed interpersonal or relational skills can be on the alert for any staff morale issues related to the changes. An employee who is good at seeing the big picture will be invaluable in identifying unintended consequences. A team member who is detail oriented can be an ideal choice for monitoring progress and ensuring follow-through; another member who is action oriented can make sure the project moves along on schedule.

Meeting Schedules and Frequency Typically, team meetings are held weekly, biweekly, or monthly, and they generally last one to two hours. Some of the challenges associated with this approach in health services organizations include the time-consuming patient care duties required of clinical providers, the late arrival of team members because of other competing responsibilities, the need to devote portions of the meeting to updating team members, and dwindling interest as the project drags on.

Consider an alternative approach. If managers use a systematic method for approaching improvements, they will begin to get a sense for the total team time required for an improvement effort. For example, a team may take about 40 hours to complete the various phases of an improvement project. If the improvement effort is constrained by time or dollars, the team is faced with increasing its own productivity or reducing its own cycle time. With this limitation in mind, the 40 hours of time may be distributed in a variety of ways other than in one-to-two-hour segments. For example, ten four-hour meetings or five eight-hour meetings may better meet the needs of a particular project team. The meetings may occur once a week for ten weeks, twice a week for five weeks, or every day for one week. Based on the work environment, a strategy may be selected that balances project team productivity, daily operational capacity and requirements, the scope of the desired improvement, and project deadlines.

A concentrated team meeting schedule has several advantages:

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Applying Qual i ty Management in Healthcare: A Systems Approach234

• It demonstrates the organization’s or management’s commitment to change.

• It saves duplication and repeated work associated with bringing everyone up to speed at each meeting.

• It establishes traction by contributing to the elements of creative tension.

• It reduces the cycle time from concept to implementation. • It forces managers and teams out of the “firefighting” mentality into

one of purposely fixing not just the symptoms of problems but also the underlying problems themselves.

Decision Making Consensus is a commonly employed approach to decision making in which the team seeks to find a proposal acceptable enough that all members can support it (Scholtes, Joiner, and Streibel 2003). Seeking consensus may, however, reduce decisions to the lowest common denominator (Lencioni 2002). In a team comprising primarily concrete, practical, linearly thinking members, how likely is it that an idea posed by the one creative, conceptual team member will gain enough acceptance to be considered a possible solution to a problem? Conversely, on a team of creative, conceptual innovators who are quickly moving forward on an idea without regard for the practical considerations of implementation, how likely will it be that they embrace the input from the one concrete, practical, linearly thinking team member? In either case, the result will be less than optimal. The best result (i.e., improvement intervention) in these two circumstances may come from listening to the “outlier”; perhaps that team member’s perspective best matches the requirements of the decision at hand.

Using decision criteria is an alternative to consensus. For example, in one improvement effort, the criteria for pursuing an improvement idea include the following (Kelly 1998):

• Does it fit within the goal of the effort? • Does it meet customer requirements? • Does it meet regulatory or accreditation requirements? • Does it remain consistent with the department’s or organization’s

purpose? • Does it support the vision? • Does it demonstrate consistency with quality principles?

In this case, team members are expected to question and challenge each improvement idea. Those that meet the criteria are further evaluated by the team. All team members may not completely understand an idea the first time

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Chapter 12: Using Improvement Teams and Tools 235

it is discussed, but the team can save time by quickly discarding ideas that do not meet criteria. Instead, they can then spend time on understanding and evaluating ideas that do meet criteria.

Managers can help support team decision making by staying informed about the progress of improvement projects. They can best keep up with events through periodic meetings with the team leaders. Unexpected “drop ins” by team managers in search of project updates can be disruptive to the team process. Some types of questions a project team leader would find helpful to discuss face-to-face with the manager or managers affected by the improvement project are listed in exhibit 12.2. These questions are especially useful during the action-planning stage of a project, when they can provide the team leader with a better understanding of leadership support, communication needs, and direction.

Improvement Tools and Techniques

In most improvement projects, regardless of the methodology followed, similar process improvement tools and techniques are used for understanding the performance problem and how to correct it. Appendix 12.1 provides descriptions of many frequently used tools and techniques. Some items in the list are described in greater detail in this chapter or covered in chapter 10.

• Does the manager have any preset expectations about what needs to be done to improve performance? Is the manager open to accepting the team’s recommendations, or does she have alternatives?

• Are the desired time frames for completing the improvement interventions realistic? Can the manager support these time frames?

• What resources (dollars, time, etc.) can be spent on the improvement interventions? What are the resource limitations?

• Is the manager willing to tolerate possible dips in productivity or service while the process changes are being implemented?

• Will the manager help prepare people to minimize disruptions during the implementation of improvement plans?

• What will make the manager anxious during the intervention design and implementation phase? How soon does he expect to see positive changes?

• If an individual or group resists making the needed changes, will the manager be willing to initiate appropriate pressure to correct the problem?

• Will the manager help dismantle the “old way” of doing things by holding fast to and reinforcing the redesigned way until it has had time to prove its effectiveness?

EXHIBIT 12.2 Project Team Leader and Manager Discussion Questions

Source: Adapted from Rohe and Spath (2005). Used with permission.

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Applying Qual i ty Management in Healthcare: A Systems Approach236

Readers are encouraged to learn more about tools not explained in depth here by using the resources found at the end of this chapter.

Document the Process Some of the most valuable improvement tools are those that help managers and teams better understand work processes. Often, a process is followed because “that’s how we’ve always done it” or because a certain way of doing things has simply evolved over time. Before a process can be improved, it must be understood. The tools described in this section help managers and teams understand processes by documenting the steps involved.

According to the American Society for Quality (ASQ), a process is “an organized group of related activities that work together to transform one or more kinds of input into outputs that are of value to the customer” (ASQ 2016a). This definition suggests the following key features of a process (ASQ 2016a; italics added):

• A process is a group of activities, not just one. • The activities that make up a process are not random or ad hoc; they are

related and organized. • All the activities in a process must work together toward a common goal. • Processes exist to create results your customers care about.

A process flowchart is a graphical representation of the steps in a process or project. Types of activities in the process are represented by variously shaped symbols. An oval indicates the start and end of the process, a rectangle indicates a process action step, and a diamond indicates a decision that must be made in the process. Depending on the decision, the process follows different paths. A simple process flowchart is illustrated in exhibit 12.3. Clinical providers may already be familiar with this tool, as many clinical algorithms and guidelines are communicated using process flowcharts. Professionals from other specialties, such as laboratory, radiology, and information systems, may also be familiar with this tool, as more complex versions of a process flowchart are used to document technical standard operating procedures or data and information flow.

At times, many individuals, departments, or organizations are involved in carrying out different steps of a single process. In such cases, a deployment flowchart (vertical flowchart) or “swim lanes” chart (horizontal flowchart) is used to indicate who is responsible for which steps of the process. Efforts to improve coordination of process steps may be enhanced by identifying, documenting, and understanding the essential handoffs that occur in a process.

process “an organized group of related activities that work together to transform one or more kinds of input into outputs that are of value to the customer” (ASQ 2016a)

process flowchart graphical representation of the steps in a process or project

deployment flowchart process flowchart diagram that indicates who is responsible for which steps of the process

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Chapter 12: Using Improvement Teams and Tools 237

Exhibit 12.4 shows simple deployment flowcharts illustrating coordination between an orthodontist and an oral surgeon in providing care for a teenage patient.

Using a flowchart to document a process allows managers and teams to see a picture of the process. Often, just seeing a picture leads to obvious ideas for improvement. Additional benefits include the opportunity to distinguish the distinct steps involved; identify unnecessary steps; understand vulnerabilities where breakdowns, mistakes, or delays are likely to occur; detect rework loops that contribute to inefficiency and quality waste; and define who carries out which step and when. The process of discussing, reviewing, and documenting a process using a flowchart provides the opportunity for clarifying operating assumptions, identifying variation in practice, and establishing agreement on how work should be done.

Uncover Improvement Opportunities A cause-and-effect diagram is a tool for organizing and documenting, in a structured format, the causes of a problem (Scholtes, Joiner, and Streibel 2003). The diagram may capture actual (observed) causes and possible (from brainstorming) causes. Kaoru Ishikawa, a Japanese quality management specialist, originally created this tool for use in product design and defect prevention.

cause-and- effect diagram (or fishbone or Ishikawa diagram) tool for organizing and documenting, in a structured format, the causes of a problem

Time to get up

Alarm goes off

Too tired?

Wake up

Get out of bed

Start and end of process

Action step

Decision step

Hit snooze button

Yes

Connects process steps

EXHIBIT 12.3 Simple Process Flowchart

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Applying Qual i ty Management in Healthcare: A Systems Approach238

Because this diagram resembles a fish (the head represents the problem and the bones represent the causes), it is also referred to as a fishbone diagram (see exhibit 12.5). The problem is written on the far right of the diagram. Categories of causes are represented by the diagonal lines (bones) connected to the horizontal line (spine), which leads to the problem (head). The bones of the fish may be labeled in a variety of ways to represent categories of causes, including people, plant and equipment, policies, procedures, manpower, methods, and materials. Exhibit 12.6 is an example of a fishbone diagram.

Identify need for

oral surgery

Orthodontist

Make referral

Assess patient and plan surgery

Perform surgical

procedure

Continue orthodontia

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Distinguish performance improvement gaps. Summarize process improvement concepts, principles, and strategies in a healthcare organization. (III.A.4.ii) Critique performance management co

Purpose

Overview

Action Items

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