One of the most crucial — and often most challenging — steps in changing hospital processes is gaining buy-in from physicians and staff. For changes in areas such as information technology, the revenue cycle or governance, hospitals often have difficulty gaining buy-in because people may not believe the premise — they might think electronic health records are not needed to improve care or that a partnership with a certain organization is not wise. When gaining buy-in for quality initiatives, however, everyone typically believes in the premise — everyone wants to improve quality and patient safety; the challenge is getting support for the process.
A new approach to quality improvement
Mercy Health-Anderson Hospital in Cincinnati takes a different approach to gaining buy-in for quality initiatives: Hospital leaders empower front-line workers to develop and implement strategies to improve quality. This bottom-up approach not only ensures buy-in to quality initiatives, it can also lead to more effective and lasting changes since the workers interact with patients every day and have firsthand experience of what works and what doesn't.
Anderson Hospital began this new approach in 2009 when it joined the Transforming Care at the Bedside program, a national initiative by the Robert Wood Johnson Foundation and Institute for Healthcare Improvement to enhance quality on medical/surgical units. TCAB's emphasis on taking a bottom-up approach and conducting rapid cycle performance improvement led Anderson Hospital to make several improvements, including a reduction in fall rates and blood clot rates and an increase in patient experience scores.
Working bottom-up to improve quality
"Normally change comes from the top down; people are being told, 'This is the best way to do it.' In this methodology, people were [asking], 'Where do you think the problems are? Here are the measures we need to reach; how do you think we could get there?" says Terri Martin, RN, BSN, MBA, clinical director of Anderson Hospital and leader of the hospital's TCAB program.
For example, Anderson Hospital leaders knew they wanted to decrease the rate of falls, and they knew that there are best practices for achieving this reduction, such as doing hourly rounding. To decide how to implement the best practices, they went to the nurses and other frontline workers to listen to their ideas. "It's not a question of 'Are we going to do hourly rounding?' The team is deciding how to make it happen in their environment," Ms. Martin says.
Initially the hospital established traditional hourly rounding, during which a nurse would check on patients every hour. While this process did reduce falls, there was still room for improvement. The unit leaders went back to the front-line workers, and they discovered that one of the challenges was doing hourly rounding on weekends, when there are fewer staff members because of fewer surgeries. To compensate for reduced staff, the unit trained volunteers and new graduates to help round. "How we successfully got there was taking it back down to the unit level and having staff determine how to make it work," Ms. Martin says.
Rapid cycle performance improvement
As part of the TCAB program, Anderson Hospital used a rapid cycle performance improvement process to implement quality improvement strategies. This rapid cycle process begins with a small test of change in which staff pilot a proposed strategy in a small area. The team measures the outcomes and then adopts or abandons the strategy depending on the results. Beginning with a small test makes it easier for teams to quickly develop new strategies to replace those that failed. "People are more willing to try [new processes] when doing a small test of change, [because] they know if it fails that's okay," Ms. Martin says. "Just try it today — just today; people are more willing to do that."
Many of the small tests of change at Anderson Hospital dealt with incorporating new processes into the daily workflow and managing time. For example, staff in the medical/surgical unit instituted safety rounds for patients at high risk for falls. To determine the best method for conducting these rounds, staff tested rounding at different times and by different staff members. "You feel like you have more control as a care provider rather than someone expecting you to do [the round] every day at 9 o'clock, when that might not work with the setting," Ms. Martin says.
Changing the culture
Using a bottom-up approach and rapid cycle performance improvement changed the culture at Anderson Hospital, according to Ms. Martin. "How we make changes and how we continue to improve [is] completely different now," she says. "We know we will [meet goals] through engaging, getting feedback and testing with bedside caregivers."
Empowering front-line workers to develop improvement strategies and doing small tests of change have become not simply tools that are part of one project, but "the way we do business," Ms. Martin says. "I would never go back to the way I used to make changes."
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A new approach to quality improvement
Mercy Health-Anderson Hospital in Cincinnati takes a different approach to gaining buy-in for quality initiatives: Hospital leaders empower front-line workers to develop and implement strategies to improve quality. This bottom-up approach not only ensures buy-in to quality initiatives, it can also lead to more effective and lasting changes since the workers interact with patients every day and have firsthand experience of what works and what doesn't.
Anderson Hospital began this new approach in 2009 when it joined the Transforming Care at the Bedside program, a national initiative by the Robert Wood Johnson Foundation and Institute for Healthcare Improvement to enhance quality on medical/surgical units. TCAB's emphasis on taking a bottom-up approach and conducting rapid cycle performance improvement led Anderson Hospital to make several improvements, including a reduction in fall rates and blood clot rates and an increase in patient experience scores.
Working bottom-up to improve quality
"Normally change comes from the top down; people are being told, 'This is the best way to do it.' In this methodology, people were [asking], 'Where do you think the problems are? Here are the measures we need to reach; how do you think we could get there?" says Terri Martin, RN, BSN, MBA, clinical director of Anderson Hospital and leader of the hospital's TCAB program.
For example, Anderson Hospital leaders knew they wanted to decrease the rate of falls, and they knew that there are best practices for achieving this reduction, such as doing hourly rounding. To decide how to implement the best practices, they went to the nurses and other frontline workers to listen to their ideas. "It's not a question of 'Are we going to do hourly rounding?' The team is deciding how to make it happen in their environment," Ms. Martin says.
Initially the hospital established traditional hourly rounding, during which a nurse would check on patients every hour. While this process did reduce falls, there was still room for improvement. The unit leaders went back to the front-line workers, and they discovered that one of the challenges was doing hourly rounding on weekends, when there are fewer staff members because of fewer surgeries. To compensate for reduced staff, the unit trained volunteers and new graduates to help round. "How we successfully got there was taking it back down to the unit level and having staff determine how to make it work," Ms. Martin says.
Rapid cycle performance improvement
As part of the TCAB program, Anderson Hospital used a rapid cycle performance improvement process to implement quality improvement strategies. This rapid cycle process begins with a small test of change in which staff pilot a proposed strategy in a small area. The team measures the outcomes and then adopts or abandons the strategy depending on the results. Beginning with a small test makes it easier for teams to quickly develop new strategies to replace those that failed. "People are more willing to try [new processes] when doing a small test of change, [because] they know if it fails that's okay," Ms. Martin says. "Just try it today — just today; people are more willing to do that."
Many of the small tests of change at Anderson Hospital dealt with incorporating new processes into the daily workflow and managing time. For example, staff in the medical/surgical unit instituted safety rounds for patients at high risk for falls. To determine the best method for conducting these rounds, staff tested rounding at different times and by different staff members. "You feel like you have more control as a care provider rather than someone expecting you to do [the round] every day at 9 o'clock, when that might not work with the setting," Ms. Martin says.
Changing the culture
Using a bottom-up approach and rapid cycle performance improvement changed the culture at Anderson Hospital, according to Ms. Martin. "How we make changes and how we continue to improve [is] completely different now," she says. "We know we will [meet goals] through engaging, getting feedback and testing with bedside caregivers."
Empowering front-line workers to develop improvement strategies and doing small tests of change have become not simply tools that are part of one project, but "the way we do business," Ms. Martin says. "I would never go back to the way I used to make changes."
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