Can QI be too much of a good thing?
Interviews find many are burned out
Sociologists are professionally nosy, and Ksenia Gorgenko, PhD, a postdoctoral fellow at University of Pennsylvania in Philadelphia, and Joanna Brooks, PhD, MBioethics, a Robert Wood Johnson Scholar in Health Policy at Harvard, were happy to wander around hospitals asking doctors and other providers, as well as administrators and executives, about quality improvement (QI) efforts.
What they found was surprising: a lot of burnout. A feeling of QI overload. Worry that people expected too much too soon from folks who were already wearing too many hats to count. They wrote about their conversations in a Health Affairs blog (http://healthaffairs.org/blog/2014/03/07/the-dangers-of-quality-improvement-overload-insights-from-the-field/).
One of the stark examples of the kind of burned-out environment they saw relates to the surgical time-out, which just about everyone seems to think is a great idea. In reality, it has led many organizations to a quick, almost mechanical recitation of a speech before surgery that isn’t as meaningful as its intent, according to the blog post. If the participants aren’t "present" during the time-out, did the time-out really happen?
"We were working on a project and had all this data. And we wondered why some places were in overload and some weren’t," says Gorgenko. Thus the interviews. And in light of the 150 interviews they’ve done at six hospitals, they have developed some insight into what works, and what potentially leads to burnout.
Brooks says there is great variation. One great determinant is whether the person has protected time available for QI projects. If they don’t, they are much more likely to let a project lag, be unwilling to participate, or to participate in a less than full-hearted manner.
Frontline staff should always be part of projects, too, Gorbenko says, as long as they do have protected time. They are the people who have a vested interest in making things easier, better, and safer, so including them is a good way to ensure buy-in for new procedures.
Keeping staff informed of what you are working on and why is another way to help keep interest high and burnout low, Brooks says. "If they don’t know what is happening on a particular project, they can hardly be expected to care. And if they aren’t interested, then that might be a sign of overload."
Small projects with quick hits of success seem to be best at ensuring staff stay keen on QI, says Gorbenko. Huge projects with many moving parts that have a long wait time for a payoff? Those are harder to sustain interest, and it might be better to break them into smaller parts that have the potential for small successes, which she says is a better way of avoiding QI burnout among staff. "Small baby steps is better. When you try to say, Let’s change it all right now!’ people are overwhelmed. We can’t make something perfect all at once."
Taking small bites out of the elephant rather than asking them to chow down all at once has the added bonus of making staff feel more cared for, which makes them do their job better, and thus makes patients safer, Gorbenko adds.
"One thing that motivated us to write the blog post was we found that hospitals are trying to do so much that they can’t do anything effectively," Brooks says. "Trying to do hundreds of projects in one facility, no matter how big, is undoubtedly overload." There is a lot pressure to participate in various QI initiatives and consortia, she says. "But we need to pause. We are getting to the point of too much."
She continues: "Hospitals are constantly changing. Technology is constantly changing. There is so much movement all at once, and staff is bombarded on all sides with requests for data and improvement and demands to meet benchmarks."
The best answer, Gorbenko thinks, is the one-bite-at-a-time method. But there are other ways to reduce burnout, too. Consider these suggestions.
1. Have a meeting, Brooks says. Go down to the floor or bring frontline staff to you and ask how things are going. Ask what their biggest frustrations are, where they think patients can be harmed. Without their voice, she says, "QI is challenging."
2. There is a lot of turnover in hospitals, Gorbenko says. What happens to Dr. Smith’s pet QI project when she moves to Iowa? Figure out what isn’t being done anymore, what’s still running in a meaningful way, and what is sputtering along half-heartedly. Kill the dying ones, bury the dead ones, and put your effort into the projects that have interest and effort behind them, Gorbenko says.
3. Now that you have an inventory of your actual live projects, look at that list and compare it to the resources you have. Can you manage the list? Do you have people to run the projects with protected time? "It’s better to do fewer projects that get done than try to do more that don’t," Gorbenko notes.
4. Consider taking on projects that will improve staff morale. "We were surprised, but sometimes, little steps that improved the life of the worker were effective at improving patient care," says Brooks. "It helps to make them more engaged. It might not seem directly connected to patient safety, but it ensures buy-in from staff."
For more information on this topic, contact:
• Ksenia O. Gorbenko, PhD, Postdoctoral Researcher, Sociology Department, University of Pennsylvania, Philadelphia, PA. Email: firstname.lastname@example.org.
• Joanna Veazey Brooks, PhD, M.Bioethics, Robert Wood Johnson Scholar in Health Policy Research, Harvard University, Cambridge, MA. Email: email@example.com.