Quality improvement leaders at Madison Memorial Hospital in Rexburg, ID, faced a problem familiar to their counterparts at hospitals across the country: They would identify opportunities for improvement and find evidence-based solutions, but the effort would fall flat because there was no buy-in from others.
Director of Quality Improvement Mikel Barr, RN, says it had become a pattern.
“We were getting frustrated because we would get calls from different areas of the hospital saying, ‘we’re having an issue here and need help with this process,’ asking us to come in and fix it,” Barr says. “We would research it and come up with this big solution, but when we tried to implement the solution we would get resistance and pushback. There was no buy-in to what we were trying to do.”
A major shift in attitude was needed, so the hospital launched the Cultural Revolution: A Three Phase Volume to Value Transformation. The project significantly changed how the hospital looked at quality and patient safety, says Nolan Bybee, RRT, director of risk management and compliance.
A key part of the effort, Barr says, was for her and Bybee to acknowledge that it wasn’t working for them to devise solutions and deliver them to the people affected by the issue. Those people, the experts in whatever matter was being addressed, had to be an integral part of finding a solution so it would be most effective and so they would support it.
Value Equation Created
Barr and Bybee built the effort on three methodologies: Lean to eliminate waste, Six Sigma to reduce variation, and the PDSA model to facilitate rapid testing of models before implementing them.
“We knew we could go out and teach these methodologies to people, but we wanted to keep them at the forefront of everything we were trying to do,” Barr says. “We tried to focus our organization on using these methodologies for every improvement effort, whether it’s a preventive action, a corrective action, or just working on an improvement project. At the beginning of 2016, we went to our board of directors and basically taught them how to hold us accountable for using these methodologies.”
They also educated top management at the hospital, emphasizing what Barr and Bybee called their value equation: Value = Quality + Service divided by Cost.
“Everything we do has to increase value, so we’ve taken that concept and applied to our process improvement and any project we do,” Bybee says. “If it’s going to be of value, it has to increase quality and/or service a lot more than it increases cost. We know there are some things that will cost money, but the value and service improvement have to outweigh that or else there is no value.”
Let Staff Make Changes
Another goal was to make managers the quality leader in their departments, which Bybee says was a major culture change. Changing the way people thought about quality improvement and their role in it was the underpinning of the whole project, he says. Doing things the way they had always done it was only going to produce the same disappointing results, Bybee says.
“That was a major culture change and took a lot of work,” Bybee says. “We learned that the culture of an organization will always trump the strategy. We had to make our quality revolution big and bold, because with any revolution it must be out in front, public, and big. It can’t be something you do in the background.”
One part of that culture change was empowering people to act on improving quality rather than waiting for approval and orders from the top. To that end, Barr and Bybee encouraged staff to “proceed until apprehended.” Do what you think is best until someone tells you to stop.
“That was a big deal for us, and I recommend it for any hospital,” Barr says. “Once your frontline people and everyone else in the organization has been trained to the value equation, you have to make sure you don’t have too many layers getting in the way of them acting on what you’ve taught them. You want your front line staff to have the ability to make change happen.”
Prior to the quality revolution, nothing could be changed without running the idea through top administrators, which was discouraging and demoralizing to staff members with good intentions, and it often resulted in the idea being lost in the bureaucracy or refused for a vague reason.
“If they’re using our value equation, we want to trust our staff members and have them make that change without having to get a bunch of approvals and a stack of papers signed,” Barr says. “It takes a lot of letting go and trusting people all the way down to the direct care staff.”
Value Over Volume
The constant message to employees is that the hospital wants and will reward value over volume. As the culture shifted, Nolan and Bybee introduced strategies to improve quality and safety. The following are some of the initiatives:
- Training modules were developed for employees and specific task groups throughout the organization.
- The hospital created an Employee Engagement Committee to break down silos and bring people from different departments together for social events.
- A team huddle now takes place every day at 8:32 a.m. and 8:32 p.m. — odd times chosen to make them stand out from other scheduled events.
- After the team huddles, there is a patient safety huddle that must be attended by a representative from every department to discuss any potential or real safety issues. For example, the morning after a heavy snow the safety director might explain that work is ongoing to clear outside walkways and, in the meantime, they should remind staff and visitors to use extra caution to avoid falls.
- The Lean A3 form was modified for use as a “value summary” to help track and record data related to performance improvement, corrective actions, and root cause analyses.
- A risk matrix was introduced to help employees decide the likelihood and consequence of an undesirable event and identify a risk score.
To keep everyone focused and sustain the effort, Madison Memorial also began tying staff pay increases to quality and safety outcomes. In addition to personal performance and other factors, every employee’s income is dependent on the hospital’s performance on quality and safety metrics.
“There’s not much more that pulls people into line than compensation,” Barr says. “It helps people understand the bigger picture of how quality and safety matter to an organization. Now if a patient falls, you can’t say it’s that department’s problem. It now impacts every single person in the organization.”
That idea met resistance at first, with people complaining that if they worked in accounting or IT they had no influence on quality and safety, Bybee notes. It took a change in mindset for people to accept that everyone in the organization is responsible for its overall quality, he says.
“Don’t get discouraged. It’s easy for staff to dismiss your message as just the flavor of the day, and they wait for you to drop it so they can get back to the way they always did things,” Bybee says. “You have to keep the culture change going, keeping it out front and continuing to add pieces to it to make it more stable and effective. The staff will see that it makes a difference, and that’s when they get on board.”
- Mikel Barr, RN, Director of Quality Improvement, Madison Memorial Hospital, Rexburg, ID. Telephone: (208) 403-6393. Email: firstname.lastname@example.org.
- Nolan Bybee, RRT, Director of Risk Management and Compliance, Madison Memorial Hospital, Rexburg, ID. Telephone: (208) 359-6900. Email: email@example.com.