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UsingLeanSixSigmatoIncreasetheEffectivenessofanEvidence-BasedQualityImprovementProgram.pdf

Using Lean Six Sigma to Increase the Effectiveness of an Evidence-Based Quality Improvement Program

Patricia Lavin, MS, RN, NEA-BC; Mary Jo Vetter, DNP, RN, AGPCNP-BC

ABSTRACT Background: Evidence-based quality improvement (EBQI) is an established methodology for identifying nursing practice changes that improve health care quality and safety. However, EBQI itself does not provide a framework for navigating the barriers to practice change. Local Problem: An EBQI program in an orthopedic specialty hospital fostered many successful quality improvement projects. However, program participants frequently encountered barriers to project implemen- tation. Methods: Lean Six Sigma (LSS) principles, tools, and strategies were incorporated into the EBQI program to help participants overcome organizational barriers to successful implementation. Interventions: LSS interventions included stakeholder alignment, process analysis, change management, project management, structured check-ins, mentoring, and organizational recognition. Results: The addition of LSS principles gave EBQI project leaders new tools for gaining executive support, securing resources, and overcoming organizational inertia to facilitate effective practice change. Conclusions: Lean Six Sigma can increase the effectiveness of an EBQI program. Keywords: evidence-based practice, evidence-based quality improvement, Lean Six Sigma, project management, quality improvement, total quality management

In 2010, an urban orthopedic specialty hospital created a program to teach nurses the princi-

ples of evidence-based practice (EBP) and facili- tating practice change. The new EBP Academy reflected the hospital’s longstanding commit- ment to base the care delivery model on EBP standards. It also aligned with the hospital’s par- ticipation in the American Nurses Credentialing Center’s Magnet Recognition Program, which requires that nurses be educated about EBP to explore the safest and best practices for their patients and the practice environment.1 As the EBP Academy evolved, it adopted an evidence-

Author Affiliations: NYU Langone Orthopedic Hospital, NYU Langone Health System, New York (Ms Lavin); and New York University Rory Meyers College of Nursing, New York (Dr Vetter).

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com).

Correspondence: Patricia Lavin, MS, RN, NEA-BC, NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY 10003 ([email protected]).

Accepted for publication: March 22, 2021

Published ahead of print: May 10, 2021

DOI: 10.1097/NCQ.0000000000000567

based quality improvement (EBQI) methodology based on the merger of EBP and performance im- provement paradigms.2 EBQI is an established methodology to increasing health care quality and safety.3

The EBP Academy is a clinical-academic part- nership initiative conducted by the hospital and an affiliated College of Nursing. It is led by the hospital’s senior director of nursing quality and outcomes and a nursing college faculty mem- ber (core program leadership team). The EBP Academy is structured as a yearlong program, typically beginning in the first quarter. It con- sists of a 2-day classroom component followed by monthly coaching sessions. The coaching ses- sions are led by the core program leadership team and a quality nurse specialist who man- ages the monthly meetings and deliverables. All 3 leaders meet separately each month to review each project team’s progress and coordinate next steps. The program accepts 10 to 20 participants annually. Participants are nurses from all levels of the organization interested in EBP; prospec- tive participants nominate themselves with the approval of both their nurse manager and director.

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The educational content of the EBP Academy is based on the Iowa Model Revised: Evidence- Based Practice to Promote Excellence in Health Care.4 The content focuses on formulating a problem-intervention-comparison-outcome (PICO) question and assembling, appraising, and synthesizing the body of evidence. Pro- gram participants are introduced to a dedicated data analyst and a librarian. The data analyst provides support with biostatistics, financial analysis, and other unique data needs. The librarian supports teams in conducting a litera- ture search for the highest level of evidence to inform the project intervention. A nursing re- searcher is available for circumstances where the evidence review indicates a gap that necessitates a research approach to generate new knowledge. From the start of the program, participants re- ceive guidance on project implementation from the core program leadership team—moving from the definition of the problem to baseline data collection through pilot project improve- ment strategies, evaluation, modification, and dissemination.

In the years following the EBP Academy launch, the program generated many successful care improvement projects. However, project se- lection was based on participant interests, not on the importance of a potential improvement to the organization’s overall strategic priorities. As a result, program participants frequently encoun- tered barriers to project implementation. This issue came to the forefront in 2016 when 2 out of 5 of that year’s EBP Academy projects failed to be adopted and did not yield results. In assessing these failed projects, the core program leader- ship team theorized that one contributing factor was a lack of alignment with hospital executives’ priorities, which led to a lack of administra- tive stakeholder support and resource allocation, such as protected time for project completion. At the same time, program leaders realized that par- ticipants were learning how to identify evidence for practice change, but not how to overcome organizational obstacles to executing change. The leaders concluded that the EBP Academy needed mechanisms to align projects with or- ganizational strategic priorities and manage the organizational factors that determine success or failure. To achieve this goal, Lean Six Sigma (LSS) principles, tools, and strategies, as well as change management techniques, were incorpo- rated into the program.

AVAILABLE KNOWLEDGE The value of EBP is firmly established in the nursing profession. Research shows that adop- tion of EBP can increase care quality and patient safety, improve outcomes, and decrease costs. Also, nursing leaders have found that EBP princi- ples can be combined with quality improvement (QI) methodologies to drive better care and outcomes.5 Nursing teams have also found that clinical-academic partnerships can facilitate EBP goals.6 Despite the volume of studies on EBP and QI, little research specifically addresses the challenge of aligning EBQI projects with orga- nizational priorities and overcoming barriers to implementation.

RATIONALE FOR LEAN SIX SIGMA INTERVENTION Lean is a process improvement methodology that has been applied extensively in health care over the last 20 years.7 In general, Lean methodol- ogy focuses on improving processes by removing steps that do not add value; value is determined from the perspective of the customer.8 Nurs- ing leaders have found that EBP and Lean are complementary and combining the 2 approaches benefits QI initiatives.9 Six Sigma is a process improvement approach that generally focuses on reducing process variation.10 LSS combines tools and approaches from both methodolo- gies. Nursing teams in similar practice settings have had success in blending LSS with EBP to achieve care quality improvements.11 The EBP Academy core leadership team theorized that LSS principles would help program participants learn how to overcome organizational barriers to project implementation and generate more value, as defined by executive stakeholders in the organization.

AIM OF THE PROJECT This project aimed to increase the EBP Academy’s effectiveness by using LSS interven- tions to give participants the tools to overcome organizational obstacles to project implementa- tion and sustainability.

METHODS The EBP Academy began to implement LSS tools and strategies in 2017. During this year, program leaders applied LSS in an ad hoc manner, using LSS concepts as needed to address specific issues. Starting in 2018, the EBP Academy embraced

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LSS explicitly. The core program leadership team revised the educational content to emphasize LSS concepts and formalized LSS strategies in project management and implementation.

The hospital had previously adopted LSS as an institution-wide quality strategy, and by 2018, it had developed a strong culture of Lean man- agement. When the EBP Academy moved to em- brace LSS, it tapped preexisting support for this approach. It should also be noted that many LSS tools and strategies overlap with concepts from other implementation science models—for ex- ample, the Knowledge-to-Action Framework12

and Promoting Action on Research Implemen- tation in Health Services (PARIHS) model.13 As program leaders revised the EBP Academy’s con- tent, they were aware of these other models and were influenced by them.

Specific changes to the EBP Academy Changes made to the EBP Academy empha- sized LSS strategies for securing stakeholder alignment, analyzing processes, and managing projects effectively. While program leaders em- braced LSS philosophy broadly, 3 concepts stood out as the most important for the EBP Academy: working from the perspective of what is valuable to the customer, identifying a problem and main- taining focus on it, decreasing process variations, and removing barriers to project implementa- tion. These concepts informed several specific program changes.

Stakeholder alignment Previously, EBP Academy projects were selected based on individual participants’ clinical in- quiries, which helped ensure participants were engaged in their projects. However, executive stakeholders were not involved in project selec- tion, which ultimately affected the support for any proposed practice change. The core pro- gram leadership team vetted potential clinical practice inquiries with the clinical leadership be- fore the annual program launch to remedy this situation. These discussions also helped deter- mine identification of program participants. As a result, selected EBP Academy projects reflected the priorities embedded in the organization’s quality and safety performance improvement plan and/or the strategic nursing plan. Also, EBP Academy project reports became standing agenda items for the hospital’s EBP and Nurs- ing Research Council meetings. These changes

aligned the program’s project selection process with the clinical priorities and organizational tar- gets established by executive stakeholders.

Under this new system, all EBP Academy projects were endorsed and supported by a se- nior executive champion who was invested in the project’s success. As a result, all projects (even relatively small ones) aligned with a high-level strategic goal and could provide executive stake- holders with evidence of action toward that goal. This helped unlock resources for project teams. It also established accountabilities for project outcomes.

Protected time and resources During the first several years of the EBP Academy, participating nurses had manager ap- proval to participate in the program, but hours were not formally set aside for project work. As a result, participants did not have protected time to work on their projects between standing monthly mentoring meetings. With the adoption of an LSS approach to project management, the value of protected time to attend program meet- ings and work on their projects was recognized and allocated by nursing leadership.

Analytic tools EBP Academy participants were instructed in the principles of value stream mapping, the LSS tool for analyzing the patient’s journey across the continuum of care and their interactions with the health care system.14 Value stream mapping iden- tifies both the current state and future state of a process, which enabled program participants to rigorously evaluate how care is delivered across service lines. This helped ensure that proposed practice changes deliver value to patients and their families and that projects integrate highly reliable care into the organization.

Change management During the initial years of the EBP Academy, the program’s focus was teaching participants how to use evidence to determine what nursing practice should be. With the integration of LSS, the focus was expanded to teaching how to use change management skills to implement a new practice within an organization. Essential change management tools included problem validation, stakeholder identification, and the Awareness, Desire, Knowledge, Ability, and Reinforcement (ADKAR) framework for sustaining change.15

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The program also introduced the A3 project management tool, a Lean management tool that provides a simple template to guide problem- solving and requires identifying the broader organizational goal of the QI initiative.16 In sup- port of the new emphasis on formal change management skills, both the Senior Director of Nursing Quality and Outcomes and the quality nurse specialist took on a project sponsor role, removing obstacles to project implementation as needed.

Strengthened check-ins From the start of the EBP Academy, the program included loosely organized monthly check-in meetings to gauge progress and provide support to project teams. With the full adoption of LSS, program leaders introduced more structure to monthly check-ins. Specific deliverables were as- signed for each meeting. For example, project teams were required to provide a table of ev- idence at the first check-in, a problem-solving analysis at the second, a stakeholder analysis at the third, etc. During check-in, each project group was given approximately 30 to 60 minutes to report on their progress and receive feedback from program leaders and other participants. In between check-in meetings, program leaders pro- vided mentoring as needed to help participants stay on track with deliverables.

Year-end grand rounds As noted, an essential part of this effort was aligning the EBP Academy with executive stake- holders’ planning process for quality, safety, and strategy. To “close the loop” on that effort, completed projects were presented to senior ex- ecutives at an annual Ground Rounds event, which was initiated in 2018. This event sup- ports the program by providing recognition to participants while enhancing accountability and visibility of program results. It also rein- forces executive stakeholder support for the EBP Academy, which benefits future participants.

RESULTS All projects sponsored by the EBP Academy, both before and after the LSS intervention, are presented in the Supplemental Digital Content Table (available at: http://links.lww.com/JNCQ/ A860). There were a total of 41 projects imple- mented in the 10 years of the program, and more than 100 nurses participated. Only 2 projects

were initiated in 2020 due to disruptions caused by the COVID-19 pandemic.

Following the introduction of LSS into the EBP Academy, program participants were edu- cated about principles of both EBQI and LSS and integrated use of tools and strategies for overcoming organizational barriers to practice change. These tools helped participants gain ex- ecutive support for QI projects, secure needed resources, and overcome organizational inertia to facilitate effective practice change. Several other outcomes indicate that LSS increased the organizational impact of the EBP Academy. Fol- lowing the adoption of LSS, several nurses from affiliated hospitals asked to participate in the EBP Academy, anecdotal evidence that the pro- gram’s reputation was growing within the health care system. Also, the enhanced program was ac- cepted as the template for a graduate-level course for nursing students. The course will be offered at the affiliated academic institution in summer 2021 in a completely online format taught by the EBP Academy core leadership team.

DISCUSSION EBQI methodology can help nurses achieve im- provements in quality and patient safety. How- ever, EBQI itself does not provide a framework for navigating the barriers to practice change. This program redesign demonstrated that the ad- dition of LSS principles and tools to an EBQI program could help participants overcome im- plementation barriers.

Interpretation This change to the EBP Academy demonstrates that EBQI and LSS principles and tools are com- plementary. EBQI provides tools for identifying nursing best practices but not implementing change and aligning projects with essential qual- ity and safety goals. LSS provides tools for en- suring goal alignment and implementing change, but it does not offer a process for incorporating evidence into change management. When used in combination, EBQI and LSS create an end-to- end process for the sustainable implementation of evidence-based change aligned with organiza- tional goals.

This experience also shows that adding LSS to an EBQI program supports actual clinician-led practice improvement. LSS gives frontline clin- icians a framework for knowing what projects are essential to the organization. It helps focus

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the clinicians’ work on what matters most to the organization and thus to patients. LSS also gives clinicians an enhanced understanding of a health care organization’s operations and processes for setting priorities and eliminating barriers to change. It also provides clinician-led practice improvement with a structure for accountabil- ity. The combination of LSS and EBQI supports a culture where frontline nurses are bedside change agents who improve outcomes associated with evidence-based care in alignment with or- ganizational strategic goals. The EBP Academy empowers nurses to identify and bring forth opportunities for improving patient outcomes and the professional practice environment. It fa- cilitates the development of a Magnet nursing culture across all levels of nurses, particularly regarding transformational leadership and struc- tural empowerment to promote QI and practice innovation.

Limitations This program redesign was implemented at an urban specialty hospital that is part of a more extensive academic health care system. Smaller hospitals with fewer resources may find this approach challenging to replicate. Conversely, more complicated health systems with very com- plex reporting and governance structures may find the approach challenging to execute. Also, EBQI and LSS were already firmly embedded in the culture of this health care system. An organization starting from scratch with either EBQI or LSS may experience a steeper adoption curve for this approach. Finally, this program redesign was energized to some extent by the hospital’s participation in the Magnet program; non-Magnet hospitals might not have the same impetus to succeed with this approach. Health care organizations that adopt this approach face several potential challenges to sustainabil- ity. First, both LSS and EBQI require institutional commitment. If top-level priorities change, any LSS-EBQI program could lose support and re- sources. In addition, this approach is primarily a coaching model, so it depends on program leaders’ coaching abilities to succeed and remain viable.

CONCLUSIONS To the extent that this approach can be repli- cated, it can lead to sustained outcomes from EBQI projects and enhance project teams’ ac-

countability within the organization. By clearly defining the operational definitions for each project and tracking progress, this approach can help an organization ensure that EBQI projects stay on track and deliver the improvements in patient care outcomes needed to meet regulatory, value-based management, and Magnet require- ments. It can also help hospitals ensure nurses’ continuous professional development in EBQI, improve patient outcomes, and recognize nurses for their contributions in addressing an organi- zation’s strategic priorities.

This program redesign embedded LSS struc- tures and skills into the EBP Academy and integrated the EBP Academy into organiza- tional strategy. Facilitating change at multi- ple levels of the organization will help en- sure this approach is sustainable in the long term. Also, this effort is rooted in a clinical- academic partnership, which creates a powerful self-sustaining dynamic.17 The creation of a graduate-level nursing college course focused on evidence-based health care improvement using an LSS framework will reinforce this approach in the nursing workforce, supporting further sustainability.

The program was implemented in a partic- ular context, limiting its application to other settings. However, LSS is successful in many health care settings, and LSS expertise is rela- tively widespread. Even in settings where formal LSS expertise is not available, this approach’s basic principles can be used successfully by any nursing leader.

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