Often, quality improvement in healthcare settings is treated as a one-time effort, with people coming together once in awhile to focus on quality improvement and then returning to their daily jobs. That is a recipe for relapse, according to Richard Scoville, PhD, an improvement advisor with the Institute for Healthcare Improvement.
"When the team takes their eye off the ball and goes back to thinking about their daily operations and daily work, we backslide. And we end up with the same old dysfunctional system," Dr. Scoville said during a presentation at the IHI National Forum on Quality Improvement in Health Care in Orlando, Fla., in December.
Interviews with organizations and review of literature revealed the key to sustained improvement in healthcare: sustained attention. "You can't sustain improvement unless you can sustain attention to the process on a continuing basis…Improvement alone is not enough," Dr. Scoville said.
An IHI whitepaper spells it out in more detail: "The key to sustaining improvement is to focus on the daily work of front-line managers, supported by a high-performance management system that prescribes standard tasks and responsibilities for managers at all levels of the organization."
Huddles are the key
Through testing at multiple hospitals and surgery centers, IHI researchers and organizational leaders found daily huddles that bring together front-line staff, managers and even executives to be the fundamental element in achieving quality control, as huddles help keep attention on quality improvement goals.
Jeff Rakover, an IHI research associate, likened daily huddles to being the "engine" of quality control. Huddles provide an opportunity for staff to raise concerns in real time and talk about any problems they encountered on their previous shift, review tracked problems and discuss any anticipated issues for the upcoming day.
Daily huddles are part of the following six factors IHI researchers identified as being important for sustaining attention and, therefore, quality control:
1. Standardization. Staff and front-line managers' daily tasks need to be well-defined. Standardization is achieved when "people know what to do and how to do it," said Dr. Scoville.
2. Accountability. The daily work of front-line staff should be monitored in a way that allows for recognition of well-completed work and the ability to make corrections if necessary. Huddles involving staff and supervisors are a great way to achieve this.
3. Visual management. This can be achieved by displaying unit-specific data prominently on posters or computer screens. Displaying data allows workers to track progress and also identify surfacing problems.
4. Problem solving. Problems will likely be identified on a daily basis during huddles and can also be resolved by staff in the moment or after an investigation.
5. Escalation. If a problem needs inter-department coordination or substantial process redesign to be solved, a formal escalation process should kick in.
6. Integration. This refers to the notion that quality-related objectives and metrics should be aligned throughout the organization, so the organization can operate as a coordinated whole.
Success stories
Greater Baltimore Medical Center in Maryland saw success after implementing lean daily management, which Lisa Griffee, GBMC's director of lean operations, described as "daily disciplined process of looking at your metrics" and seeing if improvements could be made.
Each unit in the hospital identified the metrics it wanted to work with and then displayed them on an LDM board, which is updated daily. When goals are met, they are denoted in green, while red on the board means progress still needs to be made. Ms. Griffee said most boards in the hospital will have a lot of "red" because units are encouraged to pick metrics that need focus and work. "We're not doing problem solving if we have a board full of green," she said.
Then, five-minute huddles that include members of the GBMC executive team occur daily, sometime between 9 and 10 a.m. Executives break into groups and walk routes in the hospital, covering each unit. During this time, the unit reports out on its metrics, how they did the day prior and reflect on what they learned. Then, the executives relay their own metrics and learning, and close the walk by asking about any barriers experienced at the unit level. "This is a chance to escalate," Ms. Griffee said.
After implementing this process, GBMC has seen catheter-associated urinary tract infections and surgical site infections fall dramatically, and the hospital has gone over three years without a serious pressure ulcer.
Daily huddles also led to quality improvement at the Andrews Institute Ambulatory Surgery Center in Gulf Breeze, Fla. Each department, including the business office, has a visual management board highlighting metrics they want to focus on, and each department huddles independently each day. They then report up to administration about what was discussed during the huddles.
After implementing the huddles and visual management boards, ASC employees scored the organization higher in terms of safety culture. Additionally, the ASC saw lower rates immediate use sterilization and higher compliance with time-out procedures prior to surgery.
Daily huddles should be first priority for provider organizations looking to sustain quality improvement, Kevin Little, PhD, an IHI improvement advisor, said during the presentation.
"Daily huddles really are the place to start," Dr. Little said. "It empowers staff…it gives everyone a voice."