Hello, welcome to our next module. I'm Nikki Smith, Director for Membership Services here at MedAxiom, and I'm joined by my friend and colleague Denise. Thanks, Nikki. I'm Denise Bushman, Vice President of Cure Transformation Services at MedAxiom, and looking forward to today's conversation. One of my favorite topics. These are our disclosures. We've got four objectives we're going to cover today. Explaining the four steps of the continuous improvement process. Discussing how you might prioritize an improvement project you wish to undertake. Understanding the concept of high reliability. And lastly, how to lead change and make it stick. Let's begin with the father of quality improvement, William Edwards Deming. In particular, he's known for process control, in short, reducing variation. In particular, he was known for what's known as the red bead experiment. You can find it on YouTube. What he did in that experiment was to describe how you can take the same process, and if that process is broken, you'll get variable results. It's kind of a fun experiment to watch, but what it does is it drives home the fact that variation is really hard on good people. You've got good people in a broken process. Things are going to go wrong. That's why when talking about continuous improvement, we use what's called the plan, do, check, act cycle. By that, we mean by planning to take a subject or a problem, to understand it, and to make a plan. What do we think might work to fix it? Do, kind of the obvious, just get her done. Go ahead, take steps that you can implement those changes and see what difference it makes by then checking your data, checking your information, seeing if what you just implemented is making a difference in the process, and lastly, act. Act on that information. If it's working, go for it. Continue to do it. Keep monitoring the process. If when you go back and check it, you feel like, oh, you know, I didn't quite do what I hoped to do, then you make modifications. That's that continuous improvement because then again, once you've made those adjustments, you plan to do, oh, maybe I need to just change it a little bit, assess the situation. You do some more. In other words, you implement it again, and you recheck it, and the process just continues. That's that continuous quality improvement process. When you have a mindset of continuous improvement, that means you are always looking around. I like the phrase from Yogi Berra that said, you see a lot by looking. In other words, if you stop as a new person in a practice or a hospital setting, and you look around you, you can say, what's working and what's not? We all have a tendency to want to just say, well, I'm just going to do what works. It's like what everybody has told me to do, and I'm just going to keep doing it that way without stopping to think about if it's really working. Have you ever had a situation where you might be new in a process or in a situation, and you say to somebody, why are you doing it that way? They say, I don't know. I guess we've always done it that way. Just be aware of the tendency to just do what works. Nothing bad about that. It's human nature, but if you can stop and take a closer look at what's happening, you'll open yourself up for opportunity to improve things. When you've done that, take a step back and look for where the variation might exist. Ask how things are done. Actually go and watch it at the point at which it transpires. If you're in a clinic, go to where the work is happening. That might be at the point in care where nurses are caring for patients, where medical assistants are first greeting and rooming patients. It might be out in the customer service area where people first check in, or if you're in the hospital, it might be where patients are arriving for a procedure. Whatever that is, go to where the very contact with patients or systems takes place. We call that going to the gemba, where the work actually happens. Then what you want to do is once you've implemented that new process or understood where the variation exists and how you might standardize that process, ask people for feedback. That way you can make those iterative changes and enhancements to the process as a whole to make sure in the end you have a process that has minimal variation and optimal impact. Operational improvement really means getting it done and getting it done well. The administrative, financial, legal, and clinical activities that keep healthcare organizations running smoothly and caring for patients is what we refer to as operations. It's that stuff that gets things to operate reliably. Operational improvement, then of course, hand in hand is saying like, how can we do those very same things with a greater attention to enhancing both outcome and cost? By that, I mean cost dollars and cents as well as operational costs or even patient costs, if you will, cost to the system. Whenever you think about operational improvement, it's a give and take between aligning outcomes and the cost it takes to get those outcomes or the cost you end up with because you've gotten those outcomes, and then using data-driven decisions to achieve that. You want to be able to connect those clinical outcomes with financial and operational goals. You say, this is what I'd like to achieve for a patient or a situation or a process. What does that then mean when it comes to the cost to the organization? The more we can reduce resource use and reduce waste and activities, the more cost effective a process will be. Then of course, using data-driven decisions, using analytics, using data that you can pull to understand what the impact is on both patients and systems, and then looking for ways in which you can identify cost savings areas by either making things more efficient or by making them effective. Now the question is, how can we prioritize our improvements? Sometimes, like I said, you've done a lot of looking around and you start to feel overwhelmed with like, holy cow, there's a lot I could be doing here, especially if you're a new manager in a situation where you've not been in that environment before. You might have come from another organization and now you're at this particular clinic or new organization and you see a lot of opportunity, good and bad opportunity. Now the goal is, how can you focus on efforts that will really impact the effectiveness, efficiency, and customer and clinical team satisfaction? A really nice framework for this is by using the quadruple aim. By the quadruple aim, we mean the four things you see here on this slide. That is, how can we improve population health? Those are particular patient outcomes. How can we do that while also then reducing the cost of care? And again, by cost of care, we don't mean just dollars and cents, but we mean the cost of resource utilization. And again, those resources can be people or it can be product. It can be things that have a sort of cost to the system, that high level sort of economics. And then there is, how can we improve the patient experience? Enhancing that experience that the patient has when they come into contact with our organization. And then certainly last and not least whatsoever is improving, this says provider satisfaction. I would argue I probably should have said clinical team satisfaction because we're all in it together. And again, what is it that we can do to remove those sorts of barriers and things that get in our way to make us all hum along, work more efficiently, and actually enjoy it while we're at it? So now, if we've thought about improving a process, what might be some places to start? Again, like I said, you can walk into a system and find that you feel there's so many things you could be working on. So you got to start somewhere. Here's a few baseline assessment and monitoring metrics that you may want to start with. Some pretty classic things for an ambulatory clinic. Those would be schedule utilization. How often are the schedule full? Do you have all of the slots filled so that all of the patients need care are able to get in to see a provider or within that clinic setting during the day? What about third next available? What is the time frame in which I, as the new patient, can get an appointment with a particular provider? Is that time frame within seven to ten days as the third next open appointment? That's what that metric is looking at. And then lastly, maybe what about a no-show rate? That can be very problematic for a clinic when you've got all of these appointments at the beginning of the day and many of them end up not being fulfilled. Understand why that's occurring. So some ways in which you can start to do that is look at particular issues around each one of those. Remember what we said a few minutes ago where it's go to Gemba? Start by talking with those people who are involved in those activities. What is it that takes to make a schedule? What is it about the time frame in which we know a provider's availability of any sort? And what is it that gets in the way of patients canceling appointments? Did they forget? Did they never get a reminder? Did we make it too far in advance or maybe too soon? Ways in which we can understand a process. Now there are some factors that contribute to the efficiency of clinical operations and you see them listed here. We've got scheduling, clinical team workflow, staff mix, culture, and then even arrival times. And that means arrival times for both patients and providers. I remember I was struck recently when I had a dentist appointment and they reminded me they had a new process in place at the clinic because of some changes they had made and could I please come five to ten minutes early. That little reminder, now assuming I was able to make it five to ten minutes early, but that little reminder is to say we need you here at a particular time. Now if you're in the hospital setting those situations may be you need to be well in advance of your procedure time in order to check in and be prepared for the procedure. But any of those as you see here be it scheduling, however you might use those new patients or return patients to maximize your resources, it may be those clinical team workflows that help to reduce variation and delays to enhance patient care and effectiveness of care delivery. It may be making sure you've got the right people in the right place at the right time to make sure that patients needs are met efficiently. And of course there's always culture. If you don't have a good culture that values that efficiency and patient satisfaction it'll be hard to get things done. How about some sample metrics from the hospital side of things? You may be a new leader in a hospital department and for that instance some baseline assessment and monitoring metrics you might want to look at would be room utilization, on-time starts, and turnaround time. By room utilization we mean the amount of time or the rate the percentage of time in which that procedure room has a procedure going on an activity so that are we able to complete as many procedures as possible. You might have been in a situation before as a leader or a staff person where in the middle of the day or maybe it's lunchtime it's like crickets you know nothing's going on and it's hello in there when you talk about a procedure room where because of the way the schedule works or the number of patients that you have available you aren't using a room in that room so it's empty. On-time starts that means the time the staff and the provider is ready to go and begin the procedure. If you've got a staff there but no proceduralist you're not going to get things done efficiently or you've got a proceduralist that's there waiting for the staff to be all together and ready to go and it may even be a patient-related issue perhaps the hospital side everybody's ready to go but we're still waiting for the patient to be prepped or even to arrive. And then lastly turnaround time now this can have a variety of definitions but turnaround time really refers to the fact the time the patient comes into the room and the patient leaves the room and then what's that gap so once the patient has left the room what we many times call wheels out to wheels in now if I were to back up for a second we could even talk about turnaround time in the ambulatory setting that is to say when a patient leaves a room a clinic appointment space to when the next patient comes in that's a sort of turnaround time as well. Various factors that contribute to efficiency would be scheduling in other words block scheduling to make sure that we enhance that resource utilization in a procedure area and then we could talk about clinical team workflows it may be that the way in which that procedural team works together is such where you've got folks going in a bunch of different directions and part of the reason they go in those different directions is because equipment isn't in the right place so again it's stopping to look and see what's happening talking to people in that situation to say or make observations to say what's getting in your way and why is it inefficient understanding the staff mixed again do you have the right people doing the right jobs at the right time staff's work life is so much better if they work at the top of their license versus doing tasks that really feel as though they're not quite what they should be doing so the more you can have staff work toward the top of their license the better off they'll be and then culture again culture will eat strategy will eat operational improvement for lunch every time so making sure there is that culture of improvement a desire to be efficient and to provide high levels of patient satisfaction and again once again patient and provider arrival times making sure that everyone understands the expectation for when patients should be in the room and when the case should start to reduce those waiting times for patients providers and for staff high performance what do we mean by high performance well really it's what we want to happen that is quality so when we start to talk about quality it's what we want to have happen for patients for a system for providers for everywhere down the line some of the key areas we think of when it comes to quality have to do with mortality and morbidity mortality dead or alive morbidity bad stuff happens focus on use of evidence-based strategies in a situation will help to reduce that bad outcome from happening to patients it may be the process by which you might care for a vascular access site. It might be understanding how patients receive medication information and do they have clear understanding of when to take medications. There'd be nothing worse than for a patient to misunderstand an anticoagulant dose and as a result, take too much or too little and have a bad outcome such as a stroke or a hemorrhagic event. Another area of quality that's important to consider is the impact of the patient needing to return to a hospital either by way of a readmission or just a return visit. And that same sort of return visit may also be to the clinic itself. A readmission classically is defined as a return visit to the hospital within 30 days of an inpatient visit for that same issue or that same primary diagnosis. You may be aware of the fact that there are penalties imposed on hospitals when there are excessive numbers of readmissions for certain diagnoses. Some of the key cardiovascular ones have to do with acute myocardial infarction, heart failure and cardiothoracic surgery or open heart surgery in particular. Having that information to understand what it is that brings people back to the hospital or to a clinic setting and reduces the amount of time they can spend with quality life at home helps you understand ways in which you can further enhance that transition between hospital to clinic, hospital to home or what it is we can do to provide information that helps the patient care for themselves and reduces their time in an emergency department or urgent care center. Then there's length of stay. Length of stay is typically referred to the amount of time. We think of it in a hospital setting but that also can apply to the diagnostic testing time. It can be applied to the amount of time during a procedure or even one could apply that to the amount of time spent at a clinic appointment. Again, classically, we think of length of stay having to do with the hospital period of time but one can apply that also in the clinical setting. And then there's total cost per patient. And by that, we mean reducing the total cost of everything that needs to happen to care for that patient and optimize care pathways so that total resource utilization is optimized. And then there's high reliability. When we talk about high reliability, what we really mean is how do we make sure that what we don't want to happen occurs? In other words, we maintain patient safety. First and foremost is creating a safety culture in an organization or in a particular setting. We all know that healthcare is a dangerous place to work and complex systems have complex problems. Think of that as the Swiss cheese effect. In other words, Swiss cheese, as tasty as it is, has a few holes. And when those holes line up, there are things that can get through. So in a process, if you have lots of either variability or just even opportunity for things to go wrong and if just at the right time, those things line up, bad things can happen. Now, sometimes you can have a really good process, but it's just the way the stars align. So when you can avoid that, that is have a process that's more like cheddar, no holes, the better off we'll be. So it's having that continuous mindset of being aware of where might there be things that line up that can lead to an unsafe condition or a defect. In a highly reliable system, it's also important to provide psychological safety so that your team members feel safe in speaking up. As a leader, you can help create that culture by asking people, so what do you think about this? And then being receptive when they offer their comments. Even if you don't agree with them, listen and learn from that and say, that's interesting. I wonder if we might try either something else or that's a great idea. I'm so glad you shared that. So giving that reassurance that if a person chooses to speak up that they are heard and valued will go a long way in creating a culture of safety. And certainly part of that is reducing fears of retaliation. There's nothing that'll make your staff be quiet more quickly than a fear that someone will come and get me or I'll be punished in some way or another if I speak up. That punishment may sometimes come in the form of maybe a change in their schedule or a perceived lack of pay improvement or something along those lines. Whatever it may be, you want to minimize that fear of retaliation if you wish to have a culture that supports patient safety. And then sometimes things do go wrong. And when things do go wrong, it's important to stop and pause and understand what happened versus what should have happened. As well as then in that should have happened scenario, what were the little glitches in the process, the variation, the circumstances, the things that got overlooked, what were all those pieces that led to the issue occurring? We call that that root cause analysis to understand why that unsafe situation occurred. High reliability and creating a safety culture is really something that helps to reduce threats and errors and shifts from being a reactive state to a more proactive state. When you're purely reactive, that'll really stall progress. Always anticipate. Pause when needed to understand what the impact of your actions or someone else's actions might be. And then stop that blame game. Again, like I just said, a punitive response will always shut down that culture of safety. Reducing unnecessary variation. We've already talked about this. Standardizing your care, your workflows, your patient care protocols will reduce the variation that can lead to unsafe situations. Things like checklists can really be helpful. Create for your staff a list of things that should happen in a process until it becomes second nature to them. Or create a checklist because there's just so much to remember. Even if it is second nature, healthcare is complex and it's easy to forget things along the way. And then employing tactics that use reliability science. Understanding that, like as we've said, human behavior and human nature is really error prone. And the more complex a situation is, the more likely we are to have glitches that happen or errors. So the more we can make a system consistent and predictable and being good at those things that are predictable, the more we'll be prepared for those unpredictable situations. That's referred to as a preoccupation with failure. Always think about what could go wrong. Not to be the doom and gloom person, but just to know things can go bump in the night and when they do, you'll be ready. A few improvement science strategies one should keep in mind is first of all, just to overcome inertia. It's really hard to make change. And sometimes that inertia is just a comfortable place to be. Healthcare is known for being historically slow to adopt changes in technology and practice. In fact, studies have indicated that it can take up to 17 years for full implementation of new guideline-based strategies. That's pretty scary. I think 17 years ago, it was a different world and it was a different healthcare world for sure. So we don't want to get caught in that trap. You'll see here as several different ways in which you can overcome that inertia that tends to set in in healthcare. Everything from looking at the opportunity as we pointed out, exploring root causes, identifying particular ways in which you can address an issue, designing interventions that fit the situation, not just the comfort of what you'd like to have happen, making sure you continually adjust and monitor a situation and then sustain those efforts, communicate what's going on, how we're doing, implement things in that continuous quality improvement approach. And then whenever you can, reduce friction in a situation. If you've got a process that's always creating issues that you have to, let's take a simple thing here. You've got a staff person that's in a patient room and they need to go get additional equipment and then bring it back and they get back and no longer do they get back to the room and it's like, oh, I've got to go get one more thing. If you can stop and say like, is there a way to keep everything there or maybe the night before you've restocked a room, how can you reduce that irritation, that kind of constant grinding in your workflow or maybe in an administrative task? If you've ever had to fill out a form, for instance, and you feel like, didn't I just click on that or didn't I just fill that out? How come it didn't pull forward? Looking for ways in which you can streamline a process and use technology whenever possible. Artificial intelligence is a great example of how you can sometimes use information in a more compact and streamlined fashion to improve communication, to improve routine tasks and reduce friction. I'm going to hand it over to my friend Nikki now for more information on change management. Thank you, Denise. So who likes change? Change is inevitable. It's surprising how many of us admit to not really liking change. In fact, some of us avoid it. That's true in our work environments too. Some of us like the newness that improvements bring. Some of us don't. The healthcare industry has been an environment where change has come to be expected, even demanded. Technologies, new treatments have pushed us forward, as Denise said, in the last 17 years, things have changed. But in recent years, we've seen the speed of change and the types of change increase exponentially. Industry leaders and strategists tell us that we're not done yet. There's more to come. So why so much change? The same strategists say that there are five forces that are leading most of this in healthcare. Technology is the first. It's changed many aspects of healthcare from how we access our care to how we interact with our providers. The workforce needs and expectations are evolving. As new employees enter the workforce, they're asking for and expecting an environment that fits their needs. Persistent financial challenges are requiring us to change how we function. And parent-provider partnerships are requiring lots of changes of us as well. The complex social issues are now at the forefront of healthcare, creating new thoughts and initiatives. So how do you and your role prepare for this and manage the changes? Changes will come to you and your team through your organization, a business need or a patient requirement. Some changes will be small. Some changes might not impact many of your team at all. Other changes will be very large and they'll impact all of your team. And then there are those that are in between. There are numerous ways to approach change management, but there's one resounding theme that runs through all of them. Clear communication. Change can be challenging. So as the leader, remember to tap into your self-awareness. Do you like change? Is this impacting your leadership style through the process? Be empathetic to those who react differently than you and embrace the messiness of the change. One of the most helpful ways to move and lead through change is to use a tool, a change management model. This will help to align your work with the actions needed to move through the process to get to the goal. For our purposes, we're gonna focus on the ADCAR change management model. It's one that you will most likely come in contact with in healthcare. However, the COTR change management model is frequently discussed and used often as well. So be sure to check out some of the recommended articles and books in your syllabus on this topic. ADCAR is a framework that was introduced in 2003. This model is focused primarily on how best to support the humans involved in change at both the individual and organizational levels. ADCAR is an acronym for the five outcomes that are required for a change to be successful. A is for awareness. This is the first phase of change, which is making everyone aware of the need for change. They need to understand the why behind it so that they can get behind it themselves. Communication is crucial in this phase and often takes the form of leadership communication, presentations, and meetings. D is for desire. The focus in this stage is to create the desire to participate and or support the change. During this phase, motivation and willingness are built to support the change. This is where team members are pulled in and asked for input and success stories are shared. K is for knowledge. This is when the knowledge is shared on how to implement the change. So education, training, and resources are shared with your team, the things that are needed for the change to take place. Tools such as workshops, trainings, and manuals and mentors are often used. The second A is for ability. During this phase, the ability to apply new skills and behaviors are tested. Knowledge is applied to the process and resources are provided so that the team has the ability to overcome obstacles and barriers to the change. R is for reinforcement. This last phase is focused on strengthening the new change and anchoring it to prevent a relapse. So monitoring and follow-up occur as well as recognition and reward for a job well done. This support is essential to sustaining the change. Having a change management model to use is good. Knowing how to use it is great. Application or operationalization of this model looks like step one, analyze and diagnose. So assess the need for change and identify why it's needed and communicate the need and the change to all involved. Step two, develop the plan. Develop your plan for the change based on the ADCAR components. Determine what tools and resources are needed for each phase. Step three, implement the change. Implement the plan. Begin with creating awareness and build desire. Then move on to providing the knowledge or training and developing the skills. Cement the change with support, reinforcement and reward. And step four, evaluate and adjust. Monitor the progress of the change. Is it working as you intended? Are there adjustments needed? Modify your strategy to accommodate what you've learned through assessing the feedback. Again, change can be hard, but it doesn't have to be impossible. Understanding that not everyone reacts the same to change is key. And using a tool such as a change management model can be the difference between a well-orchestrated and sustainable change and resistance and failure to a movement forward. Well, thank you. I hope that you enjoyed this module. And if you have any questions, please reach out to us at academyatmedaxium.com. Thanks for joining us.

continuous improvement

high reliability

quality improvement

Plan-Do-Check-Act

change management

quadruple aim

psychological safety