Want your QI program to succeed? Keep your eye on the fundamentals
Want your QI program to succeed? Keep your eye on the fundamentals
Sophisticated tools don’t lessen the significance of stakeholders
The top professional basketball players still practice foul shots. The best golfers in the world spend hours at the practice range. Whatever their profession, successful individuals continually practice the fundamentals.
That’s why some observers are expressing concerns that quality managers are either beginning to lose sight of — or have undervalued — the importance of bringing stakeholders and process owners on board in any QI undertaking. In fact, they say, it’s essential if you want your project to succeed.
"Many times in organizations, middle managers or others will make decisions without involving the people most affected by them," asserts Judy Homa-Lowry, RN, MS, president of Homa-Lowry Healthcare Consulting in Metamora, MI.
"If they are not included in the process, people will either create workarounds, or they just do it because they are coerced," she adds.
"If you try to impose things on stakeholders who are not bought in [to the process], the whole thing will fall apart," adds Patrice L. Spath of Brown-Spath & Associates in Forest Grove, OR.
"My feeling, in teaching this on a regular basis, is that I still don’t think organizations have gone about identifying their major systems and processes or subprocesses," Homa-Lowry says.
"What I still see in the quality arena is people recognizing that they have to take certain actions to pass accreditation, but [not seeing improvement initiatives] in terms of being able to look at things globally and seeing how all things fit together, and getting it to a continuous process," she adds.
This continuous process, Homa-Lowry emphasizes, will become even more important on Jan. 1, 2006, when all JCAHO surveys be unannounced.
What about stakeholders?
So, what does this all have to do with stakeholders and process owners?
"A stakeholder is anyone who has a responsibility for ownership of things in the organization — doctors, nurses, of course, but basically all employees," she explains.
"Process owners are individuals responsible for a process. For example, you may be responsible for the advanced directive process. That’s fine, but you have to make sure it is in line with all the subprocesses that feed into the bigger system," Homa-Lowry adds.
She recalls an incident at one hospital where the admitting staff became angry with management. "What they did was, they all put 999-99-9999’ where the patient’s social security number was supposed to be," Homa-Lowry relates.
"This did not get picked up until the people were on the unit and case management became involved. And then the forms were not sent back to admitting; someone else fixed them," she points out.
In other words, in the admitting process, the process owners performed a subprocess poorly, and this affected other processes down the line. "This does not bode well for continuum of care," Homa-Lowry notes.
Empower your people
One of the key methods for avoiding such problems, Homa-Lowry explains, is to empower your process owners.
"They don’t always know where they fit in," she continues. "Good clinicians get promoted, and then if they feel uncomfortable, they may go back to what they were doing rather than leading. For things to work well, people need to understand all the processes and how they fit together."
Of course, when it comes to a specific performance improvement initiative, the first key step is to identify your stakeholders and process owners.
"If it’s a nursing initiative, then it’s all the nurses," notes Sandy Abnett, director of quality management at WellSpan Health in York, PA.
"But if it’s a multidiscipline project, the medical staff are key. We identify them through brainstorming sessions with the team I work with, by asking who will be affected by the change we are contemplating," she adds.
As for process owners, they often are pre-identified at York through the facility’s group structure, notes Gregory M. Gurican, RN, nursing PI and NDNQ site coordinator at Wellspan’s York Hospital.
"For example, our pain management process is under the auspices of a pain management task force, which is also a subcommittee of the pharmacy and therapeutic committee," he explains.
"That group is responsible for that team’s management procedures and its implementations. Within that, pain management is nursing a procedure that a CNS [clinical nurse specialist] in effect owns, is responsible for the annual reviews and updates. Some of her input comes from key stakeholders," Gurican explains.
York employs a shared decision-making process in nursing, he continues.
"So, the nurse process owner has to gather some information from various bodies like the P.I. council, the education council, the leadership council, and so forth," Gurican points out.
"Then, she will deliver the proposed changes to the councils, the council reps take those changes back to their nursing units, discuss them with staff, and those reps will come back to the council either with approval or suggested changes," he says. "This way, there is more widespread buy-in of the change."
Thus at York, the process owners "are really dedicated flag bearers for their area; it is their process, and they are, in fact, the owners," says Gurican. "They have the responsibility to review and upgrade procedures."
Stakeholders represent challenge
Because they are a more diverse group and appear to have less direct ownership for change, stakeholders represent a greater challenge, says Gurican. "This is probably the most difficult part of the process," he concedes.
At York, buy-in is pursued through multiple means of communication.
"We have a service line representative go back to the staff on their units [to communicate the proposed change], and we do a lot of e-mailing to all individuals on the staff," he says.
"The nurse managers themselves get apprised of these changes, and they have regular staff meetings in which they can bring them up and discuss them," Gurican adds.
In addition, every nursing unit has its own independent councils that reflect the corporate councils, so there are multiple means of communication.
"We also have a newsletter, which is published monthly and distributed by e-mail and via hard copies," he says.
"I once heard you have to communicate 788 times eight different ways to change behavior," notes Abnett, underscoring the need for multiple communication vehicles.
"But a nurse once told me, If you have a topic and provide me with enough meaningful information that I know it’s a priority, I will work with it.’ The same goes with physicians — the information, and the way you portray it, can really influence people," he explains.
Gurican agrees. "Staff are more likely to accept something that is directly related to patient care," he says.
"As for some of the regulatory changes we must face, they do it because it is required, and they do not have that same level of interest," Gurican notes.
How do you keep it going?
As tough as gaining buy-in is, keeping it can be even tougher.
"Well, it is something you can put in a performance evaluation," suggests Abett, adding that she also works with "carrots."
"There are always peaks and valleys, but if you see yourself hitting a valley, you need to spice things up," she offers.
"If you have your topic, hold a meeting and bring in a senior leader; this often helps to bring back the momentum," Abnett says.
"We also look at rewards and recognition for overall improvement, but sometimes you just really have to be creative — like going out and bringing in a guest speaker," she adds.
Need More Information?
For more information, contact:
- Sandy Abnett, Director, Quality Management, WellSpan Health, York, PA. Phone: (717) 851-5869. E-mail: [email protected].
- Gregory M. Gurican, RN, Nursing PI and NDNQ Site Coordinator, Wellspan Health — York Hospital, 1001 S. George St., York, PA 17405. Phone: (717) 851-2133. Fax: (717) 851-2089.
- Judy Homa-Lowry, RN, MS, Homa-Lowry Consulting, 560 W. Sutton Road, Metamora, MI 48455. Phone: (810) 245-1535. E-mail: [email protected].
- Patrice L. Spath, Brown-Spath & Associates, P.O. Box 721, Forest Grove, OR 97116. Phone: (503) 357-9185. E-mail: [email protected].
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