Process improvement in health
Process improvement in health related fields are mostly driven by financial and reporting requirements of an organisation, often to enhance the ability to maximize funding or meet pre-determined performance indicators and in more recent times to mitigate risk and decrease litigation. Clinicians now embrace a patient centered care approach to health, and are often driven more by the desire to improve methods and patient outcomes, irrespective of financial or governance issues.
Key performance indicators
A key performance indicator or financial penalty will often provide the first measured evidence of process failure, particularly at a higher strategic level. Investigating the process thoroughly will discover hearsay and innuendo about why a process is not working as it should, or is possibly not being adhered to. Walking through the process provides opportunity to review each stage Most importantly those conducting the evidence gathering, must listen to what is being said by those performing in the role, at each identified step and then deciphering the messages. Evidence, both quantitative (numbers) and qualitative (experience), must be collected and corroborated with data and key information. When hard facts about the process and failure points are clearly identified it is difficult to challenge or argue against.
Identifying process improvement
Identifying where in the process improvement is required is essential. Often a process is complex and reliant on many peoples’ contributions. If a part of the process is falsely identified as requiring redesign or improvement, a poorer end result might occur. It is instrumental in the success or failure of process improvement to identify where a process is failing to be met or completed. Evidence will determine the fail point or points. This can be complex because failure at an early part of a process will have flow on effects as the failure perpetuates, potentially hiding where the actual failure point is occurring.
Stakeholder identification - who needs to be at the table?
A more diverse group will capture all of the areas involved in the improvement process. Engagement and inclusion of the right people and consistency of attendance during planning and implementation are vital in process improvement. The best executive, accountant or clinician is not often the best stakeholder. Stakeholders need to have expertise within their fields and respect from within the organization. They also require excellent communication skills, should be easily approachable and have a keen interest in the improvement that is being proposed, part of their role will be to inform and market the desired improvement.
One of the biggest challenges when trying to introduce process improvement is that often the improvement has been discussed, planned and critiqued at a board, executive or senior management level. End users are often involved marginally and are often fearful of speaking their minds and articulating their concerns when the boss or bosses are present, and can often feel that they are not appropriately represented at the “coal face” where process improvement occurs
Each level of user will have a different reason for why a process should be improved. Executives may be looking for better ways to maximize funding and meet required performance indicators. Middle managers may look at process improvement to improve work flow and create efficiency within a workplace whilst meeting departmental budgetary requirements. End users will look at how process improvement will affect and have a positive impact on their day to day routine. Involving all relevant levels of the organisation during the identification and the planning process will ensure that involvement and ownership occurs, participants will be responsible for their decisions in the planning, education and evaluation of process improvement. Acknowledging, identifying and appealing to the motivations of those involved will ensure success of the process improvement.
Process improvement is often 'problem-centered’ rather than ‘content-oriented’. By identifying the process to be improved and working together toward solutions it is more likely that suggested improvements will be maintained and adhered to consistently. If process improvement is focused in isolation it is unlikely to be sustainable as the relevance of the improvement is lost to the greater audience.
Relevance of the improvement is required to support process improvement and will be dependent on the audience the improvement is being aimed at. A hospital executive may see the benefit of an improvement as an opportunity for the organisation to enhance patient’s safety and decrease possibility of litigation. A manager may see it as an opportunity to improve use of resources required to deliver process improvement and a clinician may see the improvement as a way to provide more time delivering actual care to patients, as opposed to “wasting time” completing paperwork or administrative duties.
The end user: The patient
Process improvement should always clearly indicate how improvement will benefit all stakeholders involved and outline benefits for the organisation and the end user, whether that be financial, governance compliance or personal improvement in work process or treatment outcomes. The end message should champion an improvement in patient care with a patient centered approach.
The process improvement should be clearly articulated and disseminated to those involved and based on foundation of the desired improvement. This provides the basis for learning activity and resource support as required. Setting of responsibilities and adherence to clear targets and timelines, will assist with monitoring and evaluating progress and delivering the desired outcome. Noncompliance or failure to complete tasks provides opportunity to review process and see whether the issues are due to one person or departments of people. This allows for development of strategy to overcome the concerns or a review of the process being used for process improvement.
Process improvement can be confronting, it challenges historical theory, current practice regimes, experience and education. Process improvement that is not inclusive of all key stakeholders is a challenge to implement. Outcomes are determined by those implementing the process improvement at their particular level of involvement Without including end users it is often felt that change is enforced upon them, often with little involvement or information to support and enhance the opportunity for end users to be the driving force for improvement.
Evaluation and monitoring
Ongoing evaluation and monitoring after process improvement has been implemented is essential. It can indicate the success or failure of a particular improvement, show where further improvements can be made, and where implemented improvements have delivered results. Monitoring and evaluation can also assist and inform other similar processes that may benefit from similar improvements.
Strong leadership during process review and improvement is vital. Ultimately everyone needs to believe that all parties concerned are working towards the same goal, irrespective of what the initial motivation is and promote a “we are all in it together” approach. Everyone should have a stake and the outcome is reliant on how well we can work together and in isolation to deliver the desired outcome - process improvement that leads to organisational improvement and better patient care.
Stuart Turk - Nurse Unit Manager Anaesthetics and Recovery at Bendigo Health
Stuart is a registered nurse with special interest in critical care. More recently Stuart has worked on the development of the New Bendigo Hospital Project the largest regional hospital redevelopment in Victoria Australia responsible for developing a Model of Care and Functional brief based on a wellness model with the clinicians and consumers. Stuart is passionate about patient centered care and improving health care access with a keen interest in the development of E health solutions that provide positive outcomes for consumers and clinicians.