Developing a quality improvement system is no easy feat. It takes patience, creativity, vision and a fine eye for detail (oh, and did I mention lots and lots of coffee?). Getting started can seem daunting, but it doesn’t have to be so scary. With every major project comes challenges, some of which you didn’t see coming, and that’s all part of what ultimately makes it so rewarding. However, there are some common barriers that keep organizations from staying on track with developing (or significantly revising), their quality improvement system.
1. Differing visions: Compliance vs. quality improvement
A shared, clear vision of what QI means internally is critical. Is your organization solely focused on meeting licensing, funding, and regulatory body requirements, or is it determined to delve deeper to strengthen its practices on a continuous basis? It’s the difference between being compliance-driven and quality-driven. The Health Care Compliance Association defines compliance as “systematic procedures instituted by an organization to ensure that the provisions of the regulations imposed by government agencies are being met.” The operative word here is imposed – the organization is guided by deliverables set by an outside entity. Quality improvement includes aspects of compliance. Joseph DeFeo, author of Juran’s Quality Handbook, views quality improvement as being of “exceptionally high quality, defined only in terms of the organization’s internal standards.” Both compliance and quality improvement are connected to the same end user – the client — but success is defined in different ways.
A quality-driven organization begins with quality-driven leadership. Leadership is responsible for creating a culture of improvement guided by factors beyond the expectations of external entities, and they need to be significantly motivated by internal targets/goals. This requires that leadership embrace transparency, and not disregard information that may cast certain aspects of the organization in an unflattering light. Exposing organizational weaknesses is fundamental to improvement, and leadership needs to be straightforward about it early on as they develop and commit to a definition of QI that will lay the foundation for the work ahead.
2. “We have plenty of time!”
Building a QI system takes time, so it’s better to err on the side of caution and give yourself a lot of it. True, time isn’t always on our side, and often those who oversee QI activities do so on top of other responsibilities. Don’t let time be the enemy; start early, and begin by educating staff on all the moving parts that comprise a quality improvement program. This way they’ll understand why you’re starting twelve months in advance rather than three months prior to the target implementation date.
There are two major phases in this process: planning and implementing. In the planning phase, you need time to develop a work plan, meet with all programs and administrative departments to brainstorm metrics, create procedures, and put all the pieces together. Take into account that brainstorming sessions will likely take place over the span of several meetings. The implementation phase includes collecting, analyzing and reporting data, and meeting with different forums to discuss the information. These exercises shouldn’t be rushed, and may take significant time to complete.
In the implementation phase, it’s important to obtain staff feedback on data reports and analyses to ensure the information is clear, beneficial and useful. To get perspective and efficiently address barriers in the way of advancing your QI system, schedule on-going meetings with departments and programs to get their perspectives on pieces that do and don’t work.
3. Neglecting the power of cheerleaders
The cheerleaders are your champions – those who have informal and/or formal influence within the organization and can push the PQI agenda forward. Your cheerleaders understand the value of quality improvement and can explain its significance to other staff. They provide guidance and foster a culture of improvement by creating spaces for staff to get excited about data. How is this done? Adding QI to meeting agendas, providing additional context to data reports, or exploring obstacles to using data with staff.
Cheerleaders also support QI coordinators by offering tips on how to get certain busy individuals to meet their QI deliverables, or help determine when a task needs to be postponed or expedited. To implement quality improvement, you need eyes and ears on the ground to ascertain the organizational climate as the initiative is rolled out. Establishing a quality improvement system can have its challenges, especially when unforeseen hiccups occur. Champions can help you strategize how to achieve objectives and deal with underlying issues as they arise.
How do you know who your champions are? Meet QI cheerleaders, Nancy and Jesse…
Nancy, the chief operating officer, has oversight of the QI department at the organization. While the role of managing the agency’s QI system has been delegated to the QI coordinator, Nancy receives weekly updates on progress of the QI initiative. When she is informed that directors have been unresponsive to emails and meeting requests, in the next director’s meeting, she makes QI an agenda item to discuss the importance of the initiative and allow an open dialogue for questions and concerns.
Jesse, the office manager, has a warm and outgoing personality. He welcomes all clients and staff who enter the building with a smile. With his friendly demeanor and passion for helping others, Jesse knows most of the staff. He is just the person to bring excitement and energy to the PQI initiative. While he may not know all the ins and outs of QI processes, he is eager to learn and appreciates the benefits the work will bring. He asks many process-related questions about PQI strategies in the meetings that helps the team strengthen procedures and clarify responsibilities.
4. “Let’s skip the basics.”
Compartmentalize! Compartmentalize! Compartmentalize! Oh, and did I mention you should compartmentalize? Patience is key in the planning phase, but slow and steady wins the race. It’s important to start small so everyone is on the same page. You might have colleagues who are eager to start data collection and try to skip over important preparation steps, or those who want to focus on high level outcomes without first getting a solid foundation for the basics. Slow them down! Looking at basic output data may not be super exciting, but when developing a formal system, you want staff to understand (and follow) the process just as much as you want to be able to make inferences about the data generated. Data that supports what staff know anecdotally through program experience and data that contradicts it are both equally important. This is what makes an organization data-informed.
Meeting with programs to determine what indicators will be used to measure the impact of services on clients, also known as client outcomes, is an important step in developing your QI system. Once leadership approves the QI program, it’s easy to assume that all staff are on the same page in how QI is perceived and understood. This is not always the case, and it’s helpful to be prepared. Your colleagues may be confused, annoyed, excited, or anxious, about what needs to happen. You may need to train program directors, managers and staff about what QI means to the organization before you can explore the possibilities for outcomes.
Ideas for training? Provide context by talking about the history and how the organization has gotten to this point with its QI efforts. Make the training fun and encourage creative thinking with games or trivia. Use your cheerleaders to get others excited. Even if there is a desire for QI, there may be a gap in knowledge and skill that needs to be addressed. Provide clarity on the objectives to be accomplished and define key terms so that everyone is clear on the tasks and expectations. Share resources on data analytics, embracing change, and outcome measurement with colleagues so they may continually learn and challenge one another.
The end goal is to develop a quality improvement system that provides a framework to use data to support decision-making and enhance practices. The culmination of all this hard work is an organization that is able to transform data into knowledge, and strengthen its practices to better meet the needs of its stakeholders. Remember, improving practices does not mean they were inadequate before. It is using a platform to evaluate organizational performance in a thoughtfully planned manner.