Discuss how accountability and standardization produced lasting results for each of the case studies. What alternative strategies may these organizations have employed to achieve the same results?
Sustaining Improvement
AN IHI RESOURCE
20 University Road, Cambridge, MA 02138 • ihi.org
How to Cite This Paper: Scoville R, Little K, Rakover J, Luther K, Mate K. Sustaining Improvement. IHI White Paper. Cambridge,
Massachusetts: Institute for Healthcare Improvement; 2016. (Available at ihi.org)
WHITE PAPER
AUTHORS:
Richard Scoville, PhD: Improvement Advisor and IHI Faculty
Kevin Little, PhD: Principal, Informing Ecological Design, LLC,
and IHI Faculty
Jeff Rakover, MPP: Research Associate, IHI
Katharine Luther, RN, MPM: Vice President, IHI
Kedar Mate, MD: Chief Innovation and Education Officer, IHI
Acknowledgements:
The authors wish to thank the many reviewers who generously contributed their time and good judgment. Don Goldmann,
IHI Chief Medical and Scientific Officer, provided formative guidance on our earliest drafts. Maureen Bisognano, IHI
President Emerita and Senior Fellow, reminded us that it’s the stories that bring the theory to life. Pierre Barker, IHI Senior
Vice President, helped clarify our understanding of the Juran Trilogy. Comments by IHI staff Andrea Kabcenell, Dave
Williams, and Christina Gunther-Murphy, Rohit Ramaswamy of the University of North Carolina at Chapel Hill, and Steve
Meuthing of Cincinnati Children’s Hospital Medical Center pointed out needed clarifications. Clareen Weincek, President of
the American Association of Critical Care Nurses, provided frontline nursing perspective. IHI editors Jane Roessner and Val
Weber provided valuable ideas to improve the structure and expression. Of course, the authors assume full responsibility
for any errors or misrepresentations. In the spirit of “all teach, all learn,” we welcome readers’ reactions, corrections, and
suggestions.
The Institute for Healthcare Improvement (IHI) is a leading innovator in health and health care improvement worldwide. For more than 25 years, we have
partnered with a growing community of visionaries, leaders, and frontline practitioners around the globe to spark bold, inventive ways to improve the
health of individuals and populations. Together, we build the will for change, seek out innovative models of care, and spread proven best practices. To
advance our mission, IHI is dedicated to optimizing health care delivery systems, driving the Triple Aim for populations, realizing person- and family-
centered care, and building improvement capability. We have developed IHI’s white papers as one means for advancing our mission. The ideas and
findings in these white papers represent innovative work by IHI and organizations with whom we collaborate. Our white papers are designed to share the
problems IHI is working to address, the ideas we are developing and testing to help organizations make breakthrough improvements, and early results
where they exist.
Copyright © 2016 Institute for Healthcare Improvement. All rights reserved. Individuals may photocopy these materials for educational, not-for-profit uses, provided that the
contents are not altered in any way and that proper attribution is given to IHI as the source of the content. These materials may not be reproduced for commercial, for-profit use in
any form or by any means, or republished under any circumstances, without the written permission of the Institute for Healthcare Improvement.
Institute for Healthcare Improvement • ihi.org 3
Contents
Executive Summary 4
Background 4
Theoretical Context: “Doing the Work, Improving the Work” 6
A High-Performance Management System 9
Key Drivers of High-Performance Management at the Front Line 11
Implementing a High-Performance Management System: Lessons from the Field 16
Conclusion 19
Appendix A: Case Examples of Standard Work Implementation in Health Care 20
Appendix B: Examples of How Informant Organizations Execute Drivers of Quality Control 29
References 32
WHITE PAPER: Sustaining Improvement
Institute for Healthcare Improvement • ihi.org 4
Executive Summary
This white paper presents a framework that health care organizations can use to sustain
improvements in the safety, effectiveness, and efficiency of patient care. The key to sustaining
improvement is to focus on the daily work of frontline managers, supported by a high-performance
management system that prescribes standard tasks and responsibilities for managers at all levels
of the organization. To inform this work, we reviewed selected literature and interviewed leading
organizations. The result presented here is a description of high-performance management in
theory and practice, along with recommendations for organizations interested in pursuing these
methods:
A theoretical context for high-performance management, grounded in the Juran
Trilogy (Quality Planning, Quality Control, and Quality Improvement) and selected current
literature;
An organizational framework for a high-performance management system
(HPMS), illustrating standard work for each tier of management and the integrated
organizational hierarchy that reinforces, supports, and improves work at all levels;
A driver diagram that summarizes our theory of the key factors for
implementing a HPMS through standardized management tasks, pervasive Quality
Control (as defined by Juran to mean monitoring the system and making necessary
adjustments to ensure stability over time), coordinated Quality Improvement, and
development of a culture of candid transparency that encourages and sustains these activities;
Case examples that describe three health care organizations’ approaches to testing and
implementing management standard work; and
Appendices containing additional guidance for organizations seeking to implement these
practices.
Background
Leading health care organizations are coming to recognize that sustaining improvement is
essential. Typically, they have spent years building improvement capability and applying it
throughout the organization. But too often, hard-won improvements are lost as attention shifts to
other priorities and staff revert to the “old way” of doing things.
Having achieved high levels of clinical quality and safety, organizations with reputations for
clinical excellence are increasingly focused on sustaining improvement — ensuring that, following
improvement, care and support processes continue to perform at the new levels of quality and
safety. In the research that informs this white paper, we set out to understand the systems for
sustaining improvement developed by ten outstanding health care systems — and to synthesize
them into a framework that other health care organizations can use to ensure that improvements
are sustained over time.
Two main schools of thought were especially influential in framing our investigation: Joseph
Juran’s “Trilogy”1 for quality management (i.e., Quality Planning, Quality Control, and Quality
Improvement); and Lean management, articulated by David Mann,2 Steven Spear,3 and others.
WHITE PAPER: Sustaining Improvement
Institute for Healthcare Improvement • ihi.org 5
Our study of ten high-performance health care systems revealed a common focus on explicitly
organized frontline management — daily work for unit leaders — that guides day-to-day
provision of excellent patient care by all frontline staff. In this white paper, we refer to such regular
daily work using the Lean term “standard work”: the routine daily care and support tasks enacted
in nursing units, ICUs, ORs, ERs, or clinics where patient and provider meet and care is sought
and delivered. We also learned about specific coordinated practices at higher levels of
management — an integrated “management system architecture” — that enable effective Quality
Planning and reinforce, support, and improve work at the front line.
Using Juran’s terminology and definitions,1 our primary focus in this paper is not on Quality
Improvement, but on Quality Control — and by Quality Control, we expressly are not referring to
the regulatory systems of inspection and accreditation that play a vital role in standardizing quality
across the health care industry; nor do we mean the kind of micromanagement practiced by some
leaders. Of course, the astute reader will recognize that Quality Control and Quality Improvement
are not separable activities, but integrated elements of a high-performance management system
(HPMS).
Our investigation revealed a view of management work as disciplined standard work, analogous to
the protocol-driven work of frontline caregivers, integrated vertically and horizontally by means of
frequent team-based communication and ubiquitous, graphically displayed process measurement
(often in the form of Shewhart control charts). Process abnormalities (special causes) trigger
frontline adjustments or surface issues that are escalated to formal improvement initiatives.
Continuous frontline attention to quality and a culture that focuses on problem analysis (versus
personal blame) provide the foundation for Quality Planning, Quality Control, and Quality
Improvement. Formal, negotiated Quality Planning relies on candid, energetic staff participation,
and aligns frontline improvements with the organization’s strategic intent. In a HPMS that
incorporates standard work, managers serve primarily as coordinators and coaches in order to
build staff capacity and expertise for improving quality.
While leadership commitment at the most senior levels (e.g., C-suite, boards of directors, vice
presidents, chairs and chiefs of departments and divisions) is necessary to cultivate and lead
improvement throughout an organization, frontline clinical leaders — those who most directly
impact the patient experience of care — need complementary guidance in the form of a system of
practical direction and support. Senior leadership commitment is needed to achieve fully
integrated, consistently excellent performance; yet smaller, incremental steps within service
delivery units can also build will and set the stage for whole system change.
Many of IHI’s strategic partners have developed world-class improvement infrastructures and are
now exploring the methods and benefits of managing standard work. This white paper seeks to
understand their efforts, learn from their experiences, and suggest a way forward for organizations
that are now starting down this path.
Representatives of the following organizations informed our work: Intermountain Healthcare
(Utah); ThedaCare (Wisconsin); Virginia Mason Health System (Washington); Essentia Health
(Minnesota); Greater Baltimore Medical Center (Maryland); Children’s Mercy Hospital (Missouri);
Saskatoon Health Region (Canada); Saskatchewan Health Quality Council (Canada); Denver
Health (Colorado); and Cincinnati Children’s Hospital Medical Center (Ohio).
These organizations were selected based on their reputation for clinical excellence and
implementation of standardized management approaches (e.g., Lean, Juran, IHI’s approach to
WHITE PAPER: Sustaining Improvement
Institute for Healthcare Improvement • ihi.org 6
Quality Improvement) that characterize recognized world-class enterprises both within and
outside of health care.4
Three case examples, drawn from interviews with informant organizations, illustrate in depth the
implementation of a HPMS by three leading North American health systems (see Appendix A). Our
investigations for this white paper focused on management systems in acute care settings; but the
principles of high-performance management can be applied in any care setting, just as they have
been deployed in diverse enterprises outside of health care. We expect to explore such variations in
future research.
Theoretical Context: “Doing the Work,
Improving the Work”
Excellence in care delivery demands systems capable of reliably supporting the clinical skills of
physicians, nurses, and staff — and in such systems, everyone has two interdependent roles: doing
the work and improving the work. Several key theoretical concepts underpin the high-performance
management system described in this white paper.
Health Care as a System
W. Edwards Deming described a “system” as a set of interdependent components — structures,
people, and processes — working together toward a common purpose.5 A health care organization
is a complex, adaptive system animated by hundreds or thousands of providers, administrators,
patients, and support staff. For the organization to deliver on the promise expressed in its mission
statement — for every patient, every time — requires that everyone in the system knows what to do
and why, how and when to do it, and how to adjust when necessary to maintain fidelity with the
organization’s mission and values.
As demonstrated by our informant organizations, standardizing routine tasks at the front line of
care creates an orderly, predictable work environment — thereby reducing the fumbles and
ambiguities that take staff away from the patient’s side, and that lead to “unintended variation”
that endangers patient safety and impedes the effectiveness and efficiency of care.6 Standard
frontline work provides a stable “platform” on which clinicians can most effectively exercise their
clinical skills, and on which systematic, integrated improvement initiatives can be conducted and
their results sustained.7
As Deming proposed, management is responsible for establishing and maintaining such a system.5
The coordination and alignment of diverse parts to the purposeful whole is the essential function of
a high-performance management system.
The Juran Trilogy
The Juran Trilogy1 consists of three key quality-related functions for managers: Quality Planning,
Quality Control, and Quality Improvement. Together these functions constitute an active,
integrated system for pervasive organizational attention to customers’ (i.e., patients’) needs, the
design and delivery of products and services consistent with the best technical specifications to
consistently meet those needs, and the ongoing management and continuous improvement of the
systems of production.
WHITE PAPER: Sustaining Improvement
Institute for Healthcare Improvement • ihi.org 7
Quality Planning (QP): Quality Planning begins with a comprehensive understanding of
customer needs. In health care, the Triple Aim provides a framework for conceptualizing the
needs of patients: experience of care, health, and cost of care. Other stakeholders, including
physicians, staff, payers, regulators, and the community at large, place additional demands on
care systems. QP thus comprises processes for understanding patient experience; the
establishment of evidence-based protocols; the design of physical space, technology, and
specific care routines to ensure that the best available technical knowledge gets translated
into standard practice; the establishment of a sustaining and rewarding work environment;
and much more. QP also includes the design and operation of systems of management, such
as the HPMS described in this paper, as well as an infrastructure to identify gaps in
performance and commission improvement projects to close the gaps. This white paper can
be used as guidance for Quality Planning to establish frontline Quality Control, based on the
HPMS.
Quality Control (QC): Quality Control focuses on operations: monitoring the system of
production for stability, detecting emerging process problems (special causes), and taking
steps to address them. QC is based on measurement of performance; processes are
continually examined (via statistical methods, technology, or direct observation) for
conformance with current quality expectations (goals). When gaps are detected between
expected and observed performance, frontline staff undertake problem-solving methods such
as root cause analysis to identify the source of the problem and devise a remedy. If the current
process is not capable of meeting customer needs and the needed changes are beyond the
scope of the frontline unit, a QI initiative is planned to redesign the process. Quality Control
fundamentally is about ensuring that a process remains stable (“in control”) over time — that
is, its performance remains within the upper and lower control limits. QC is usually
performed by those closest to the process.
Quality Improvement (QI): In a QI initiative, a designated team of managers and staff
with relevant expertise, with technical assistance from dedicated QI specialists, analyzes the
current process, identifies the symptoms and causes of poor quality, and frames a theory of
what is required to improve the process. The team uses a variety of methods and tools to
develop, test, and implement changes, and if needed redesigns the relevant processes.4
Following successful improvement, QC is then used to monitor the redesigned process to
ensure it performs at a new level (with new upper and lower control limits), with new work
specifications, improved results, and reduced variation.
Figure 1 shows QC and QI as interlocking loops of activity. Quality Control involves the routine
enactment of standard tasks, monitoring quality, and making routine adjustments and local
improvements. (Note that the “Adjust” step in the QC loop may involve frontline application of the
Model for Improvement, with its own nested Plan-Do-Study-Act, or PDSA, cycles to test and refine
changes that will lead to improvement.) When problems arise that are beyond the scope of the
local team, or that point to the need for improvements in process capability (for example, when a
new clinical protocol is introduced that fundamentally changes processes of care or patient
expectations, or when the problem requires interdepartmental coordination), the problem is
escalated to a higher-level QI initiative to redesign the process, or to Quality Planning functions to
fundamentally revise the production system.
WHITE PAPER: Sustaining Improvement
Institute for Healthcare Improvement • ihi.org 8
Figure 1. The Relationship of Quality Improvement and Quality Control
It is important to distinguish Juran’s conception of Quality Control as an integral component of
everyday work and management from the common misperception that QC is the same as quality
assurance or inspection. It’s well worth consulting Juran’s Quality Handbook1 on this point:
“Quality control and quality assurance have much in common. Each evaluates
performance. Each compares performance to goals. Each acts on the difference. However
they also differ from each other. Quality control has as its primary purpose to maintain
control. Performance is evaluated during operations, and performance is compared to
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