Using the IHI White Paper on Sustaining Process Improvement as a reference: Discuss how accountability and standardization produced lasting results for each of the case studies. What

Sustaining Improvement

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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

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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

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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.

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 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

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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

goals during operations. The resulting information is received and used by the operating

forces. Quality assurance’s main purpose is to verify that control is being maintained.

Performance is evaluated after operations, and the resulting information is provided to

both the operating forces and others who have a need to know.” (p. 4.3)

Accreditation is one particular form of quality assurance in health care and is performed by

external regulators or standards bodies. While important, quality assurance and accreditation are

not the focus of this white paper. Similarly, Quality Control should not be confused with the form

of “control” exercised by some managers who periodically respond to summary reports with

directives for staff to respond to problems that may not be current, or for which the manager lacks

complete information. A variant is “tampering” — making changes to a process, based on a limited

understanding of the principles of common cause and special cause variation.6

WHITE PAPER: Sustaining Improvement

Institute for Healthcare Improvement • ihi.org 9

Other Important Sources from the Literature

Our review of selected literature surfaced a number of descriptions of high-performance

management systems that are substantially consistent with the Juran Trilogy, although with

differing terminology and methods. We reviewed key sources from the Lean tradition including

Mann,2 Spear,3 and Toussaint.8 Ando and colleagues document formal standard practices for

“Daily Management” on behalf of the Japanese Society for Quality Control.9 Nolan reports on IHI’s

work to develop “a framework for execution of strategic initiatives aimed at producing system-level

results.”10 Case studies from the automotive industry provide insights regarding myriad issues

involved in implementation of a HPMS.11,12 Previous IHI work provides specific guidance for

organizing frontline standard work to surface process problems requiring QC adjustments or QI

interventions.13

A High-Performance Management System

Figure 2 presents an architectural overview of a high-performance management system, organized

into QC and QI functions and tasks across representative levels of a typical health care

organization. (Note that the authors discussed at length the merits of flipping the vertical

dimension of this figure to show patients at the top, to indicate their position at the focus of the

organization’s purpose, with management tiers arrayed below to signify their role as supporters

and facilitators of QC and QI. Ultimately, we decided on the figure as it now appears because we

recognize the traditional “ups” and “downs” of organizational hierarchies, and we felt that a change

would be confusing to readers.)

In the HPMS, Tier 1 Quality Control (operations management) focuses on guiding the direct

provision of care. For example, huddles conducted by a unit manager at shift changes focus on

immediate process management: ensuring that all job roles are assigned, identifying patients at

risk or in need of special attention, and anticipating needs that will arise in the upcoming hours.

During the shift, the unit manager ensures staff adherence to standard work, monitors care

processes, takes corrective action to avoid errors, pitches in to help where needed, and coaches

frontline staff on work skills, problem identification, and improvement methods. Operational

issues beyond the control of the unit escalate upward, for response by the appropriate

management tier, for whom triaging and acting on escalated issues is part of their regular Quality

Control work. Daily updating and review of operational data, including sentinel events, by every

tier ensures that responses to problems are prompt; delays at any level pose risks to the

organization’s purpose and reputation. (See Appendix A for additional examples that elaborate on

such huddles.)

For Quality Improvement projects initiated to address problems that are surfaced during QP, Tier 1

managers, initially relying on support from organizational QI specialists, surface and scope local

opportunities for improvement (often special cause variation identified in routine QC activities, but

also including minor common cause issues),13 prioritize them, coach staff on QI methods, monitor

progress, and engage frontline staff in testing and implementing process changes. The unit

manager and unit team are responsible (with QI specialist help) for translating key organizational

metrics related to strategy and mission into unit-level measures. Over time, as frontline and Tier 1

personnel become adept at QI, the need for specialist assistance lessens.

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Institute for Healthcare Improvement • ihi.org 10

Figure 2. Architecture of a High-Performance Management System

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