Planning Interventions | Quality 101 | SHM's Quality & Innovation Initiatives

Are you looking to get started on a hospital-based quality improvement project? The Society of Hospital Medicine’s (SHM’s) Quality 101 resources draw from the knowledge and experience of renowned national experts in the field of quality and patient safety. Quality 101 showcases six important points critical to the success of quality improvement in the hospital.

When defining interventions to improve quality, it is critical to reduce variation in the way care processes are implemented. The key concept is routine. Doing a complex activity the same way each time is the best way to make sure nothing is left out.

Why is routine important? Across a population of patients, one of the most common sources of suboptimal care arises from provider inconsistency. For a variety of reasons providers inevitably vary care inappropriately, whether compared to each other or compared to themselves. In fact, a graph that depicts improved system performance over time almost always shows a progressive narrowing of the range of performance data points. In a powerful way, standard processes improve care by specifically reducing this unnecessary variation in performance, from medical decision making to ordering.

The best processes, however, preserve our ability to customize care for special patient situations or circumstances. In contrast to variation that arises from provider behavior, variation from the process because of special patient situations is always acceptable. The process or interventions should make that clear.

The following is a review of some principles for effective implementation of interventions:

  1. Principle 1
    Keep it simple for the end user. There will inevitably be trade-offs between the depth of detail of guidance you want to give providers and the simplicity of the forms and the processes the end users have to go through. Most of the time, simpler is better. Minimize calculations the end user has to make or automate that process for them.

  2. Principle 2
    You cannot interrupt the work flow. Do not become shortsighted about the importance of this particular intervention. Remember that this issue may not be the focus of members of a caregiving team, and they are likely to be attending to dozens of other tasks per patient. Involve frontline workers to make sure your plans are feasible and that your processes/order sets/protocols are easy to use. Check boxes and prewritten scales can encourage rapid acceptance because they make the work easier. Get their input on how to make implementation go smoothly. Clinicians should want to use the new processes if they are constructed properly.

  3. Principle 3
    Design reliability into the process. Human beings are incapable of doing anything reliably 100 percent of the time in the complicated health care setting.

  4. High-Reliability Strategies
    • Desired action is the default action (not doing the desired action requires opting out).
    • Desired action is prompted by a reminder or a decision aid.
    • Desired actions are standardized into a process (take advantage of work habits or patterns of behavior so that deviation feels odd).
    • Desired action is scheduled to occur at known intervals.
    • Responsibilities for desired action are redundant.
  5. Principle 4
    Pilot your interventions on a small scale before attempting wide implementation. Inevitably there will some glitches with your initial order set and/or algorithm. It's best to "fail faster" by piloting on a small scale, so that you can get the glitches out of the way before you implement the process more broadly.

  6. Principle 5
    Monitor the implementation of the new intervention: expect variation and learn from it. Reduce variation over time. Rolling out the intervention is really only a beginning. You need to learn from variations in your process. The idea is to squeeze variability out of the process while retaining variation based on tailoring to accommodate the patient.

If you need additional support in leading a quality improvement effort, SHM’s signature programs can guide your team through each phase and provide individual mentoring in areas such as care transitions (Project BOOST®), Glycemic Control (GC), Medication Reconciliation (MARQUIS), Atrial Fibrillation (AFIB) and Venous Thromboembolism (VTE). We also provide resources by clinical topic to help you find exactly what you need.

No matter where you are in the spectrum, SHM can assist you in your efforts. SHM encourages you to join the QI community and view the calendar for up to date information on key events and discussions around the quality and innovation movement.

Questions or Comments, please email thecenter@hospitalmedicine.org.