SHM’s Center for Quality Improvement focuses on projects for specific clinical topics. Explore to find guides, webinars and resources on related clinical topics.
SHM's Center for Quality Improvement
View SHM's QI Enthusiast Webinar
View SHM's Center for Quality Improvement Webinar from June 18, 2019. Learn about Length of Stay reduction from two expert panelists. They discuss how they are involved in programs at their institutions to address this topic and how you can introduce the same success. By viewing the webinar recording you are eligible to receive CME and MOC credits.
SHM’s Center for Quality Improvement offers a personalized approach to quality and patient safety through an integrated, comprehensive and flexible menu of programs, tools and resources. Each can be tailored to the specific needs of your institution over a wide breadth of clinical topics and can be combined into various configurations that best suit your institution.
SHM has established methods of improving care in hospitals and developed proven solutions that increase efficiency and transform the delivery system in the process. Whether you’re just learning about the quality improvement process or already a leader in the field, SHM’s resources can guide you through your intervention.
If you need assistance on where to start, Quality 101 provides information to help you build the case for quality, engage your leaders in quality and patient safety initiatives, and assess whether your institution is ready for change.
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 8 important points critical to the success of quality improvement in the hospital.
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Gaining Institutional Engagement
Engaging leaders and peers in quality and patient safety initiatives is a key component to ensuring successful outcomes. To obtain support, you will need to:
- Clearly explain how your efforts may enhance quality and safety
- Improve processes and patient satisfaction
- Impact the hospital’s bottom line
- Develop a direct communication line to a senior administrative officer, either by a direct reporting structure or by involving a senior administrator on the team
One suggested approach is enlisting an “executive sponsor” (e.g., CEO, CMO, CNO) or administrative champion of the project. This sponsor should receive regular updates on the project (or ideally attend committee meetings) and be an advocate for the project to hospital leadership.
An executive sponsor is invaluable in helping the team focus on critical issues. However, it is equally important that the team understands where it fits in the overall quality improvement structure and priority for the organization. Teams are frequently assembled during a crisis but need a plan that keeps them connected so that improvements made are sustainable and regularly reviewed. It is useful to ask the executive sponsor to review progress and outline barriers.
Peer engagement is equally important and requires building buy-in from colleagues who can support your initiative at a grassroots level and influence others to do the same.
Assessing Team Readiness
A critical component of success is engaging your leaders and peers in conducting a readiness assessment to determine whether your institution has the infrastructure and support needed to embark upon a new initiative.
Healthcare organizations can use this survey tool to:
- Raise staff awareness about patient safety
- Diagnose and assess the status of patient safety culture
- Identify strengths and areas for patient safety culture improvement
- Examine trends in patient safety culture change over time
- Evaluate the cultural impact of patient safety initiatives and interventions
- Conduct internal and external comparisons
Forming Your QI Team
Improvement activities are often initiated by an individual or a few individuals who recognize a gap in quality of care. Recruiting additional members who have firsthand experience with the issue or content expertise to the improvement team can help to overcome challenges, enhance interaction and stimulate the brainstorming of solutions.
Who should comprise your QI team?
The leader of a team is a permanent role for the life of the team. He or she should:
- Develop a preliminary plan for each team meeting
- Coordinate and focus the meeting activity on the mission of the team
- Actively participate as a member by contributing ideas and participating in the team's processes and decisions.
- Develop the record of the meeting outcomes and actions needed
The team leader requests assistance from a team facilitator when the team is struggling with its ability to work together and use effective team meeting skills.
The most effective teams have a trained team facilitator in a permanent role to meet with them and guide their use of meeting skills and tools. If assigned, the facilitator should be present at most meetings, especially in the early stages of development when the team is learning how to work together and use the improvement tools. If a permanent facilitator is not assigned to the team, then one should be available to assist the team when members are struggling with team processes or when they need advice or skill training to effectively use problem-solving tools.
- Functions as a team adviser with expertise in the processes and tools that help teams to be effective.
- Works with the team leader to make sure that information is gathered to study the issue being addressed, that an improvement plan is developed and that the meeting record is being completed properly.
- Works as the team’s liaison with the steering committee for resources and time
- Exercises personal discipline and not contribute ideas or participate in decisions regarding the process being studied
- Coaches the team in the use of team meeting skills and tools and gives impartial feedback to the members to improve their communication and meeting process.
The involvement of the facilitator normally diminishes as the team members and team leader gain more knowledge and skills about team processes and tools.
Effective teams usually include four to six members, including the team leader. The team may be larger, but the time commitment usually increases, and the speed with which the team begins to perform is slower.
Team members are normally selected because they represent a part of the cross-functional process that is being improved. Sometimes, a team member from outside of the process is included to give the process “fresh eyes.” All members have a responsibility to participate and share their knowledge with mutual respect for other team members. Team members will also rotate to fulfill the roles or recorder or timekeeper at each meeting.
The recorder is a rotated position selected at the beginning of each team meeting based on the ground rules. The primary role of the recorder is to:
- Record content from brainstorming, consensus building and other tools and processes on a flip-chart or white board that is visible to the team.
- Write down what each team member says rather than what they interpret was said.
Sometimes it is helpful to select two recorders when a lot of information needs to be logged.
Every team member should be encouraged to fill this role and be applauded for the patience and listening skills it requires. The recorder is a full participant in the team process while they are recording. Sometimes the team leader and other members need to make sure that the recorder is participating.
The timekeeper is also a rotated position selected at the beginning of each team meeting based on the ground rules. The primary role of the timekeeper is to call out the time remaining on each agenda item at intervals the team determines is appropriate when developing their ground rules. In this way, the timekeeper assists the team in staying on task and managing its time effectively.
Identifying and including stakeholders in your project team from the beginning is critical for success. It is important to identify existing committees or teams in the hospital that are already working to improve related clinical topics or processes and determine how to link to or integrate existing efforts.
Team membership may include:
- Clinical nursing staff
- Physicians involved in the process (including residents if present at your hospital)
- Primary care physicians / follow-up specialty physicians
- Nurse practitioners and physician assistants
- Quality improvement staff
- Social workers
- Case management professionals
- Medical records
- Hospital informatics
- Home care referral coordinator
- Data analysts
- Patients who have been previously hospitalized at your institution
- Family members/caregivers
It is essential to include individuals who are invested in and see the value standardizing the process. Also, consider including patients/families as content experts on your team, as they have a perspective that is unique and critical to all the efforts of your team.
At your very first team meeting, it is key to establish the team “rules” and ensure that everyone explicitly agrees with them.
- All team members should formally sign a document agreeing to these rules to communicate and stress their importance.
- The facilitator is usually given the task of gaining consensus and enforcing the team rules.
- Download the team rules task sheet as a starting point.
- The team should modify the rules as needed and then officially record and acknowledge them. Breakdowns commonly occur when these basic rules are ignored or violated.
- Everyone on the team must be encouraged to speak up, and all views must be respected. Traditional concepts of rank must go “out the window.”
In addition to these rules, it should be made very clear that potential members should notify the leader immediately if they cannot devote the requisite time and effort so that a suitable replacement can be found. Timely minutes as well as a quick turnaround for comments/corrections should be the rule.
Establishing substantive goals is essential for maintaining focus and motivating the team.
Your aims should be specific, measurable and time-defined and should specify the population or populations for whom you want to improve care. A "stretch" goal should be established that should be aggressive enough to mandate a change in the design of your current process to achieve it. Until you have reliable metrics and a baseline evaluation, however, team-supported general aims or goals can be important for galvanizing action and establishing clarity of purpose.
- Be sure to define the scope of your efforts.
- Do you want to focus on just one ward or service? Critical care patients, ward patients or both?
- It may be reasonable to start small and then spread your improvement methods to other areas.
- While you should not take on more than what is achievable, testing and learning on a small scale can make even very large projects more manageable.
Examples of General Aims:
- General Aim 1: Reduce adverse drug events in critical care by 75 percent within one year.
- General Aim 2: Improve medication reconciliation at transition points by 75 percent within one year.
- General Aim 3: Transfer every patient from the inpatient facility to a long-term care facility within 24 hours after the patient is deemed ready to transfer.
- General Aim 4: Reduce waiting time to see a urologist by 50 percent within nine months.
As your team develops, your challenge will be to define many of the terms in your general aim, which will entail developing defined metrics and more mature, specific, time-defined aims. For example, what aspects of the process or issue do you want to improve first? What are the factors that lead to lower quality or an unsafe condition? How can you educate caregivers about these issues?
Analyzing Your Success Measures
Data collection, analysis and presentation are essential to the success of any quality improvement program. Measurement is a critical part of testing and implementing changes.
Use a balanced set of measures for all improvement efforts: outcomes measures, process measures, and balancing measures.
How does the system impact the values of patients, their health and wellbeing? What are impacts on other stakeholders such as payers, employees, or the community?
- For diabetes: Average hemoglobin A1c level for population of patients with diabetes
- For access: Number of days to third next available appointment
- For critical care: Intensive Care Unit (ICU) percent unadjusted mortality
- For medication systems: Adverse drug events per 1,000 doses
Are the parts/steps in the system performing as planned? Are you on track in your efforts to improve the system?
- For diabetes: Percentage of patients whose hemoglobin A1c level was measured twice in the past year
- For access: Average daily clinician hours available for appointments
- For critical care: Percent of patients with intentional rounding completed on schedule.
Looking at a system from different directions/dimensions
Are changes designed to improve one part of the system causing new problems in other parts of the system?
- For reducing time patients spend on a ventilator after surgery: Make sure reintubation rates are not increasing.
- For reducing patients' length of stay in the hospital: Make sure readmission rates are not increasing.
Planning Interventions to Improve Quality
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.
The following is a review of some principles for effective implementation of interventions:
- 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 must go through. Most of the time, simpler is better. Minimize calculations the end user should make or automate that process for them.
- 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.
- 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.
- 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.
Pilot your interventions on a small scale before attempting wide implementation. Inevitably there will be 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.
Monitor the implementation of the new intervention: expect variation and learn from it. Reduce variation over time. Rolling out the intervention is 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.
Further QI Education
For educational modules about quality improvement, visit the SHM Learning Portal under “Hospital Quality and Patient Safety.” Topics include:
- Quality Measurement and Stakeholder Interest
- Teamwork and Communication
- Organizational Knowledge and Leadership Skills
- Patient Safety Principles
SHM members can also share questions, challenges and successes with other hospital-based caregivers across the country through the Hospital Medicine Exchange (HMX) online forum.
Contact SHM with any further question or inquiries you may have.
SHM is your partner in Quality Improvement.
The Society of Hospital Medicine serves as an invaluable resource to help hospital leaders and clinicians in meeting the challenge of providing the highest quality of patient care amid rapid transformational change. Download SHM's Center for Quality Improvement Brochure to learn more.
"SHM’s Center for Quality Improvement is unique in that it has implemented change in performance at the front lines in hospitals across the U.S. and Canada. SHM is committed to the continued support of these clinical champions, its members and the development of additional hospitalist leaders needed to transform healthcare,”
Eric Howell MD, MHM