Health system quality departments are beginning a transformation from the oversee-everything focus of past years to a more efficient process in which quality managers provide support, while allowing front line leaders to analyze and act on data.
Traditionally, it has been the quality department’s job to identify, prioritize, and provide resources to process improvement processes, says Gayle Sandhu, MS, FACHE, corporate senior director, quality assurance, Scripps Health in La Jolla, CA. Sandhu spoke about data and the business case for improvement at the 2015 Hospital Quality Institute Conference, held Nov. 11-13, 2015, in Sacramento, CA.
“Everything was managed through the quality department, and that led to year after year of incremental improvements,” Sandhu says.
But that model is falling behind with the need for clearer, faster, more actionable data. Instead, quality departments are moving toward a model in which data that is most useful is directed to the front line manager for analysis and action, she explains.
“By providing feedback directly to the front line manager, we are able to accelerate the pace of change,” Sandhu says.
Meantime, the quality department can provide support around process insights and managing for daily improvement and workflow redesign, she adds.
“This is a more efficient and respectful environment for managers,” Sandhu says.
Scripps Health developed a model for structuring this new philosophy toward quality management, calling it, “Inch Wide Mile Deep.” It includes medical management, performance improvement, quality assurance, and risk management/regulatory/infection control.
“In the past, quality leaders operated in one mile wide and one inch deep — a little of everything, but not a lot of any one thing,” Sandhu says. “Now, we’re shifting into being a coach with knowledge and expertise.”
From the quality assurance perspective, this model means that quality managers give data directly to the front line managers, placing them at the front and center of understanding what is happening in their units, she explains.
The quality department has identified six insightful value-adds to the process change. They include the following:
• Inch-wide, mile-deep thinking. “That’s a philosophical model for the quality department itself,” Sandhu says.
Quality department leaders often are called to manage more than data and quality improvement. They might also have these roles: regulatory management, patient improvement, staff and/or patient safety, readmissions, clinical care outcomes, and other roles. But having one person or one department handle all of these responsibilities is inefficient, Sandhu notes.
“You can’t be an expert in 10 things, so when we look at the model of designing the corporate office to support sites, each of us will take a small slice of that,” she says.
It’s difficult for healthcare organizations to make this philosophical and structural change, but it’s necessary to change structurally if they desire to improve outcomes and efficiency, she adds.
• Empower front line leaders to solve problems and manage quality. Putting front line managers into the feedback loop is a first step in empowering them, Sandhu says.
“You have them write their own analysis and action plan, and then it extends resources of the quality department across more things so they become a really important support system,” Sandhu says. “It’s a work in progress.”
By empowering front line leaders, an organization can solve site problems more efficiently through what Scripps calls A3, solving site problems using value by design principles and tactics, including standard work, quick process observation, tiered huddles, and visual management boards.
“It’s a single approach to problem solving,” Sandhu says.
• Prioritize initiatives through a simple model that people can relate to. The simple model is a quality assurance pyramid hierarchy in which the base includes the tasks a quality department must do, such as patient safety measures, National Quality Strategy Measures, Centers for Medicare and Medicaid Services (CMS) Pay for Performance Measures and publicly reported measures, brand and reputation measures, and Leapfrog, Hospital Engagement Network, Patient Safety First.
The middle layer of the pyramid has the tasks that data suggests are important, including opportunities for improvement, regulatory deficiencies, and other items.
And the top of the pyramid has the things that quality managers want to do, including innovation and quality measures for new standard work.
“We categorize all the measures that we want to do,” Sandhu says. “If we’re not performing on the things at the bottom of the pyramid, then it’s important to have a conversation about how you can’t move onto the other things.”
Quality leaders are passionate about their work and they might be excited about starting a new project, but their data collection and focus must be prioritized, she adds.
Flitting from one task to another without prioritization results in incremental improvements at best and is not sustainable, Sandhu adds.
Scripps Health makes the priorities with input from physician quality leaders and senior leadership, she says.
• Instill discipline in your data collection systems. Typically, data is collected by nurses or other staff. They might use national definitions and worksheets, Sandhu says.
This method does not ensure consistency without a quality assurance process. For example, in collecting data about infection control, there can be disagreement over whether particular cases involve infection, she explains.
“You have to make sure your data is right,” Sandhu says. “The worst thing we could do is provide inaccurate data to our front line.”
The key is to ensure the accuracy of all data collected, which helps advance the goal of building trust among front line staff, she adds.
One way to improve data collection is to have people trained in data collection, including following the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN) infection tracking system. The NHSN has definitions and guidelines for data collection. There are similar national resources that could help with other types of data collection, as well, Sandhu says.
“For safety indicators, there are coders who can pick up complications,” she notes. “You can engage with them and develop a relationship so they can understand the importance of their work.”
• Consider a single approach to problem solving: “We used the A3 method for problem solving,” Sandhu says.
A3 problem-solving is a performance improvement method that can be compared with lean thinking. It’s named A3 after the European metric equivalent to a standard paper size — an 11-inch by 17-inch paper, which is called A3.
A team has to solve a problem using a single page, Sandhu says.
“They use pencils and have to scribble on the paper, writing their thoughts and then presenting it to senior leadership,” she explains. “You quickly and clearly see the barriers to solving that problem.”
The idea is that when people have to write out answers instead of typing them into a computer, they will spend no time on making their answers look good and more quickly get to the bottom line, she adds.
“Our A3 paper has nine boxes and each has to be responded to,” Sandhu says. “When you run these by other leaders, the ideas start to mature, and you gain insights to processes and barriers.”
• Efforts in transparency should mirror efforts to support your leaders. This final strategy involves prioritization and assessing health system-wide performance.
Quality departments often struggle with decisions about whether and when to retire certain data collection initiatives and when they have enough quality improvement projects, Sandhu says.
When a quality department begins to send data directly to front line managers, it’s important to send data that is useful and drilled down to its most actionable elements, she adds.
“We’ve built in a number of business rules around our data,” she explains. “It only hits the managers’ radar if an alert goes off.”
The information technology automatically screens data for trends that need to be looked at, saving considerable time over the old process of having an analyst run reports, analyze them, and then decide if there’s a performance issue, Sandhu says.
“So you can monitor hundreds of indicators and because of the analytic rules, you don’t have to worry about them,” she adds. “You are notified only if you need to pay attention.”
Dashboards or reports showing the data identified as an issue are visually simple and easy to understand, she says.
“We used principal of design to support the front line,” Sandhu says.
- Gayle Sandhu, MS, FACHE, Corporate Senior Director, Quality Assurance, Scripps Health, La Jolla, CA. Telephone: (800) 727-4777. Email: firstname.lastname@example.org.