As the number of QI interventions continues to rise, and as hospitals become increasingly subject to financial pressures and penalties for hospital-acquired conditions (HACs), we believe it is important to consider the impact of the pressure to improve everything at once on hospitals and their staff.
We argue that a strategy that capitalizes on “small wins” is most effective. This approach allows for the creation of steady momentum by first convincing workers they can improve, and then picking some easily obtainable objectives to provide evidence of improvement.
National Quality Improvement Initiatives
Our qualitative team is participating in two large ongoing national quality improvement initiatives, funded by the Agency for Healthcare Research and Quality (AHRQ). Each initiative targets a single HAC and its reduction in participating hospitals.
We have visited hospital sites across six states in order to understand why QI initiatives achieve their goals in some settings but not others.
To date, we have conducted over 150 interviews with hospital workers ranging from frontline staff in operating rooms and intensive care units to hospital administrators and executive leadership. In interviews for this ethnographic research, one of our interviewees warned us about unrealistic expectations for change: “You cannot go from imperfect to perfect. It’s a slow process.”
While there is much to learn about how to achieve sustainable QI in the environment of patient care, one thing is certain from the growing wisdom of ethnographic studies of QI: buy-in from frontline providers is essential for creating meaningful change.
Frontline providers often bristle at expectations from those they believe have little understanding of the demands of their daily work.
Requiring health care providers to improve on all mandated measures at once, in an atmosphere of reduced reimbursements and frequent staff shortages, is a goal that risks burnout, discouragement, and apathy — all signs of initiative fatigue.
Frontline workers we interviewed found the required amount and pace of improvement work daunting. One respondent described how health care providers already felt overburdened: “We have people wearing five or six hats and add another thing to their plate…it’s just difficult.”
One nurse told us that her attempts to encourage hand washing were met with mockery and push back: “After awhile you just give up. You know it’s like…you do. You can only tell them so many times.”
Risk of Initiative Fatigue
At the system level, there is a risk of initiative fatigue. “They are asked to do so many projects and their staff has to do so many projects and if the culture isn’t there — adding more projects is just not a good thing to do. I think there is a lot of competing priorities that they have to do now, unfortunately,” said one respondent.
The literature in organizational studies suggests that one danger of initiative fatigue is that a policy or protocol for reducing HACs can be decoupled from its implementation on the frontline.
Encouraging frontline workers to focus on small innovations that are relevant to their institution is particularly productive and helpful for avoiding the disconnection between a policy and its implementation.
For instance, one respondent in discussing how his team creates visual reminders about safety initiatives cautioned, “When we re-do our posters, there is always fifteen more things we want to add so you kind of have to keep the balance there…to make it so people will actually do it…still make it relevant.”
Part of keeping QI relevant and feasible for frontline workers is embedding it in their workflow, a practice that transforms QI into an exercise of team ingenuity rather than an additional administrative burden. For example, giving staff protected time to attend patient safety meetings and participate in patient safety projects shows a commitment of the hospital administration to QI, as opposed to viewing it as another activity that staff must add to their already stressed days.
This helps frontline staff take ownership and feel empowered by the safety changes that they themselves suggested. In some cases, making providers’ work easier to perform increases compliance and smoothes implementation.
Small successes develop trust and increase motivation for quality improvement work. Small wins, early on, develop trust and create an environment that can embolden more radical change. In one case, when one hospital team developed a QI forum, they were able to get hospital administrators to replace mixing valves that had left operating room scrub sinks without hot water for months, thus opening the door for wider safety initiatives.
The success of the initial quality improvement project leads to greater participation among frontline staff in quality improvement meetings as they begin suggesting additional safety changes to the unit. As a result, frontline providers see that the quality improvement project team is capable of producing results that improves work conditions and the safety of their patients.
The desire for simultaneous improvement in multiple areas is certainly understandable, especially since we know that any given patient is at risk for a number of potential harms. We need to keep in mind, however, the inescapable reality that hospitals are complex organizations forced to meet competing goals, often with limited resources.
An approach that aims to improve everything at once aligns poorly with the work environment necessary for the sustainable improvements in patient care that it seeks to achieve.
As we have outlined above, burnout, loss of morale, and general apathy in the face of unrealistic expectations are some of the measurable and unintended consequences of QI initiative. However, attempting to improve on so many core measures at once has the potential to become a symbolic action to reassure ourselves and others of a commitment to change.
The Surgical Time-Out
One example of a tool that might be used symbolically or as part of a genuine safety practice is the surgical time-out. Most teams we visited had adopted a checklist for the surgical time-out at the beginning of each case, prior to incision. Many hospital administrators we interviewed were proud of their use of time-out checklists to ensure patient safety.
This is one of many initiatives and tools to which everyone from frontline staff to the administration refer to in order to demonstrate their commitment to patient safety and quality. However, the manner in which the time-out checklist is used varies by team.
In some places, a team member recites the time-out checklist quickly, almost mechanically, and often while they (and others) are doing other pre-operative tasks. In other hospitals, the time-out is embraced by the entire team as a helpful tool for ensuring and guiding better quality of care.
While the former teams use the required WHO surgical checklist, which quickly becomes routine, the latter teams work on making the ritual “fresh” by engaging team members who make eye contact with one another and stop all other tasks. Continual engagement is bolstered by the fact that these teams revise the time-out checklist repeatedly following collective discussions of what needs to be changed.
In both types of hospitals, surgical teams describe using time-out checklists as a measure of patient safety but execute it differently. If QI interventions are to be meaningful, then the use of tools like the time-out must be based on experiential knowledge: namely the recognition that real change is hard, usually slow, and rarely achieved without setbacks.
Quality improvement and patient safety initiatives in health care are vitally important for reducing harm and keeping patients safe. In order to implement QI initiatives most effectively, our research suggests that we reconsider a regulatory culture that seems to reflect a belief that a greater amount of QI in a hospital will always yield a greater quality and increasing safety for patients.
To prevent burnout and failure in the case of too many QI initiatives operating at the same time, we suggest choosing QI priorities. For optimal QI success, there must be a sense of teamwork and partnership among executive leadership, administration, and frontline workers that includes celebrating successes and inviting frontline staff to play a large role in identifying problems and solutions.
Joanna Brooks, Ph.D. is currently a Robert Wood Johnson Foundation Scholar in Health Policy research at Harvard University.
Ksenia Gorbenko, Ph.D. is a postdoctoral researcher at the University of Pennsylvania since 2012.
Catherine van de Ruit, Ph.D. is a postdoctoral researcher at the University of Pennsylvania and is an affiliate to the Armstrong Institute for Patient Safety at John Hopkins University.
CHARLES L. BOSK, Ph.D. is a Professor of Sociology and Anesthesiology and Critical Care at the University of Pennsylvania. He is a visiting professor at the Armstrong Institute for the 2013-2014 academic year. Dr. Bosk was elected into the Institute of Medicine’s class of 2013.
Brooks, J. et al. The Dangers Of Quality Improvement Overload: Insights From The Field. Health Affairs Blog, 7 March 2014. Copyright ©2014 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.