Quality Improvement: What It Takes to Build a Cadre of Experts
This blog post is the second in a series on the basics of quality improvement and how to build a cadre of improvement experts to lead this work throughout the healthcare sector. Many thanks to my colleague Srinivas Goud for his valuable contributions to this post. Click here to read the first post in the series.
As part of our ongoing work to build capacity for continuous quality improvement within the public and private Indian healthcare system, ACCESS Health partnered with the Children’s Investment Fund Foundation and the Institute for Healthcare Improvement. Together, we launched the Improvement Advisor Professional Development Program, the first of its kind in India. The ten month program began in March 2015. The program will transform twenty two chosen candidates into effective quality improvement leaders. The improvement advisor program is organized into twelve days of classroom work, spread across three separate workshops. The program also includes monthly sessions and assignments on specific technical topics, shared over the internet. Throughout the duration of the course, each participant will carry out an improvement project at his or her own healthcare facility.
We are now four months into the program. The participants have begun work on their individual improvement projects. The first in person training workshop was held in Hyderabad from April 20 to 23, 2015. The workshop introduced participants to the science of improvement and the Model for Improvement. As the workshop began, the faculty asked the participants about their expectations from the program and what questions they would like answered through the improvement advisor program. The participants had many interesting questions:
“Given the importance of a culture of improvement to the success of quality improvement efforts, should we begin with generating this culture for improvement or should we let it happen?”
“How can we overcome financial and other constraints to ensure the success of our quality improvement projects?”
“What is the best way to introduce quality improvement to a group of people for the very first time?”
“How can you improve quality in a setting where basics necessities are not met and data are not available?”
The faculty listed all the question on a flip chart, using sticky notes. They explained how some or most of these questions would be addressed during the course of the workshop and the program. This discussion set a wonderful tone for the workshop.
Next, each participant shared his or her project charter and driver diagram. The charter directly answers the first fundamental question in the Model for Improvement: what are we trying to accomplish? The charter communicates the purpose of the team or individual involved in an improvement effort.
The driver diagram organizes the theory of improvement and provides a learning structure for the project. The driver diagram is a kind of tree diagram, a tool to conceptualize an issue and its system components. The driver diagram illustrates the pathway to achieve the desired outcome (See Figure 1). The first column, the aim, states the desired outcome of the project. The drivers list the factors that affect the outcome. The third column, interventions, presents actions that have been proven to make a difference and bring about the improvement.
After the presentations, the faculty led the participants in a role playing activity. The participants played the roles of workers, inspectors, and inspector general in a black bean factory that is not allowed to produce white beans. This activity provided an effective and interactive means of explaining the concept of flaws that are built into the system but may not be visible to the management. Management often blames employees for not performing well, without noticing these system flaws. The participants learned the importance of identifying and addressing such problems in the system before attempting to implement any quality improvement work. As the role play continued, the participants were introduced to the concept of the process map.
A process map, also referred to as a flow chart or flow diagram, is a pictorial representation of the sequence of actions that a process undergoes, with a start point and an end point. The map allows you to draw a visual illustration of the way a process actually works. This allows you to understand the existing process, identify gaps, and develop ideas about how to improve the process using the Model for Improvement methodology and the Plan Do Study Act (PDSA) cycle. (See the previous blog post in this series for an explanation of the Model for Improvement and the Plan Do Study Act cycle.) The following are the basic steps to map a process:
First, assemble the people who are most familiar with the process.
Identify a process to map, and then agree on the first and last steps in the process.
Describe the current steps in the process in sequence as they actually exist, not the ideal.
Map the process the way you would like it be (the ideal).
Understand the difference and variation in the current process and the ideal process.
Finally, identify the bottlenecks and changes necessary to bring the current process closer to the ideal.
The participants each developed a sample Plan Do Study Act cycle for the change they planned to test. This exercise provided insight and instilled confidence in the participants to develop change ideas and test them using the Plan Do Study Act cycle in their respective healthcare facilities. The exercise helped the participants develop an approach for thinking about a problem. The participants discussed their views about incorporating the planned change, based on their experiences in their organizations. The participants also learned about tools and strategies to collect and organize information: data collection forms, surveys, interviews, observation, affinity diagrams, Pareto charts, force field analyses, and cause and effect diagrams. The participants were asked to learn about and explain each tool to the other participants, using an example.
The next workshop will take place in August. In the second workshop, participants will share what they have learned and their experiences using the skills and tools acquired in the first workshop in each of their improvement projects. The workshop will provide an opportunity to hear and learn from the experiences of others in the workshop. The twenty two participants have shown a willingness and a determination to make quality improvement in healthcare central to their activities.
Among the most important assets gained from participation in the improvement advisor program were the relationships formed among the participants and the faculty. These relationships will play an important role in cross learning to support current and future projects across India. The training of these improvement advisors is the start of a significant capacity building effort within our country to achieve better healthcare outcomes for all. As these trained improvement advisors complete the course, we expect them to support each other as they go on to lead quality improvement work across India.