Improvement initiatives (QI projects) are key to transformation. They contribute to transformation in at least three ways.
- First, these initiatives, such as clinical redesign, improve operations. Those with sustained impact progress beyond short-term improvement to build into routine work new practices that are visible, easier to perform, more reliable, and more efficient than old practices. It is unlikely that improvements will be sustained after project resources are removed unless the system itself is changed.
- Second, improvement initiatives actively engage staff across disciplines and hierarchical levels in problem solving around a concrete, meaningful, urgent problem. Such engagement results in skill development, a newly-honed sense of inquiry and problem solving, and more rigorous use of data. Equally important, engagement in problem solving generates a palpable sense of enthusiasm and accomplishment.
- Third, successful initiatives build momentum for further change and improvement. They contribute to culture change when the clinical focus for improvement is aligned with the organizational mission and strategic direction, is an area needing improved performance, and have scientifically-valid evidence on which to base redesigned practices. Projects focused on improving clinical care for patients engage clinical staff because of their unmistakable clinical importance and because of the momentum built by incremental, short-term gains.
Leaders in Site F, for example, found that improvement changes did not stick once special project resources were removed unless the system itself changed. In a surgical infection project, the site initially improved prophylactic antibiotic use through the use of guideline-based reminders and education, but changed its approach after performance plateaued. To reach a zero-defect level, the site re-engineered its practices to provide patients with antibiotics at a specific moment in the preoperative process signaled by explicit physical cues. As a result, the site attained consistently high performance without additional resources.
One person in Site F said regarding staff engagement through improvement initiatives,
“It was very rewarding to see how excited staff and physicians were about making these changes. It became a competition; it was fun and we celebrated successes, in part by posting the successes… It is part of the ‘pull.’ Doctors, respiratory therapists, etc. travel to all units and communicate ‘what’s doing’ to other units. If it is good, people say ‘why can’t we have that?’”