Week 2 Assignment

Week Two, Session One Lecture – Chapters 6, 7

“There is no substitute for teamwork and good leaders of teams to bring consistency of effort along with knowledge.” -Edward Deming

Welcome to Week Two. Lecture Session One. In our first week together, we reviewed the history of CQI and how is has diffused into health care. We looked at the work that has been done and the work we have yet to accomplish.

In addition, we began our drilldown into the model and tools that we use in the CQI process. Understanding variation and its critical role in health care, and the fact that it is a foundation piece for CQI was reviewed; along with the next steps being taken through Six Sigma and Lean to further reduce variation and waste.

This week we continue our drill down, first, on the importance of teams in the CQI process (Dr. Deming’s “People Awareness” leg of the stool). Secondly, we will exam the role of the patient in the CQI process and the importance of their contributions.

Chapter Six – Understanding and Improving Team Effectiveness in Health Care

Introduction

Understanding the role of teams in health care, understanding their vital role in the CQI process, and the factors that contribute to their success are the core components of Chapter Six.

The critical role of leadership in the team process, team participation and creating a culture that supports teamwork are all reasons why Dr. Deming chose people factors as a focus for what we call his People Awareness leg of the Three-Legged stool.

Understanding and Improving the Performance of CQI Teams

Health care, by its very nature is a team process. There is almost nothing we do in the provision of care and service that does not rely on a team of individuals coming together to provide care. In addition, the primary vehicle for improving care through the use of the CQI tools is the use of teams in the CQI process.

We have talked about health care as a number of processes, that each can be broken down into steps. And, that a number of processes linked together is a system. Here we talk about “microsystems” which are one of several subsystems in a system. We might think of these as a patient care unit, or a department, such as the lab or the admitting department. Health care is made up of multiple subsystems all working together to provide care and services. Think about your own experience, or that of a family member. When we receive care, we move through numerous subsystems: the emergency department, Radiology and Lab, an in-patient unit, surgery, nursing, discharge planning etc. Good team work makes these experiences positive – or not so positive, depending on the communication, coordination and how well the people and parts work together.

If the organizational structure does not support the teams appropriately, the results may be poor communication, staff and patient dissatisfaction and in many cases, un-safe care.

Teams are critical to the success of CQI because the members of the team understand the processes of care, and their participation is essential to assure that problems get solved in a lasting way.

Team Size and Composition

CQI teams vary in size and composition, according to the problem that they are trying to solve. Members should include a supportive and knowledgeable team leader, who can bring the right structure, tools and resources to the team. Teams also need the team members who understand the day to day work contributing to the problems to be solved, as well as those individuals who may be affected by or contributing to the problem. Lastly, teams need to be staffed by individuals who understand the process and tools, for example from Quality; and those providing resources – such as data from IT.

Creating a “safe” Environment for Teamwork

One of the key requirements for a well-functioning team is a team culture that provides a “safe environment” of all participants.

Teams include individuals who have different spans of control, from leaders to staff; as well as different functions and expertise, like managers and physicians. The least “powerful” person on the team is often the one who has the knowledge and experience to bring solutions to the problem to be solved. If the environment is not “safe”, that person my never feel safe to speak up and contribute.

The leaders and those who support the team process must address this or the team will never function at its maximum capacity. Setting team norms, expectations of respect for all members and their opinions, and the recognition of their unique talents and experience are essential for a successful team process.

Stages of Development

Teams go through a natural succession of stages – the CQI model and tools are designed to guide them through these stages more quickly and successfully. These stages include: Forming, norming, storming, performing, adjourning and mourning. These stages represent the phases that teams of individuals, brought together to solve a problem, sometimes for the first time, go through as a natural part of the process. Getting to know one another, their talents and expertise; adjusting to and respecting the norms of how the team will support and work together; using the CQI tool kit and data to identify the problems and solutions; putting a plan together to test their solutions; and then, finally put their plan in place, are key components of these stages.

Once the team has completed their work, the process may end, but the lessons learned by the team on how to work together respectfully, how to use the tools and methods of CQI, and especially the power of a good functioning team go on.

Culture

The changes that occur with a successful team process and how the team members will do their work caring for patients and working together moving forward, are a critical part of the building of a culture of excellence. Culture is defined as: the values, beliefs, assumptions, norms and goals and vision for an organization. It is sometimes called the “personality” of an organization; or how we act when no one is looking.

The goal, over time is to create that “culture of excellence” – we will talk more about this in Session Two this week.

Rewards and Recognition

Lastly, well-functioning teams need resources like time and expertise as well as rewards and recognition for the hard work they do.

Learning Organzations

Strong organizational and team leadership are key to assure good communication, decision-making and organizational learning based on the successful CQI efforts.

Effective teams: constantly look for new information to improve their performance; are open to new ideas and seek them out; include people with new expertise and different perspectives; ensure all team members are engaged in continuous training and learning; and continue to grow by reviewing past performance and lessons learned from their efforts and the efforts of others.

Conclusion

It is said that organizations continue to improve “one team at a time”. By using and sharing what the teams have learned and continuously seeking opportunities to improve – the culture of the organization is transformed.

Chapter 7 – The Role pf the Patient in Continuous Quality Improvement

“It is more important to know the sort of patient that has a disease than what sort of disease that the patient has.” -Dr. William Osler

Introduction

We have discussed the criticality of placing the patient at the center of the care process. We have also discussed how important it is to the CQI process to involve those who understand the care and service processes the we are trying to improve. So, where is the patient – the one who receives that care service, in the CQI process?

Chapter Seven presents ways we can further involve the patient in the CQI process at all levels, with evidence from actual programs that have enhanced care and made it safer. Although the patient is our primary customer, historically, they have been left out of the process when care is planned, designed and improved. The traditional role of the Board of Directors made up of community members and former patients, has been to represent the patient and the community in that process. However, we have learned how important it is to how we design and provide care that we enlist the patient’s voice in the process. From preventing errors, to designing and improving processes that meet the needs of the patient, we have begun to recognize the key role that the patient can play.

In addition, with the emergence of technology, access to information related to health care, public reporting of health care quality information, and the high-profile reporting of medical errors, the patients are demanding to play more of a role in all of our key processes. This has created an opportunity and a need to involve the patient in our CQI process.

Methods for Involving Patients in CQI

Three levels of involvement for the patient were presented:

1) Micro-level – the informed patient self-managing their care and partnering with care givers;

2) Meso-level – involving the patient in the design and ongoing improvement of care, such as involving patients in planning for new facilities and services; and

3) Macro-level – Engaging the patient in the process of identifying and helping to prevent errors – there is much work being done nationally and internationally on these efforts.

Moving away from involving patients only through after-care surveys or follow-up on complaints, a model for involving patients in a more active way was presented. This model, the M-APR model, primarily focuses on identification and prevention of medical errors, involving patient at all levels.

This model presents two dimensions:

1) Active- Proactive – directly involves the patient in identifying, confronting and addressing sources of errors prior to their occurrence. Examples may include patients on the hospital’s Patient Safety Committee as well as training patients and families to actively address errors such as asking staff to wash their hands before providing care.

2) Passive – Reactive - inviting patients to participate with the investigation and follow-up to near misses or errors after they occur as well as with the complaint resolution process. Some organizations have invited patients to share their stories, as we saw with the Josie King Story.

Examples of Patient Involvement

Examples were presented of formal processes that have been very successful in engaging patients such as:

· Kaiser Permanente - Partners in health care which engages patients with chronic illness to participate as full partners in their care processes;

· Joint Commission National Patient Safety Goals – The Joint Commission requires organizations to involve patients in the active process of identifying and preventing errors and provides training and tool kits; and

· From Partners to Owners – The SouthCentral Foundation in Alaska is directly engaging patients and the community to re-design the care process to better meet their needs.

Conclusion

With the challenges we are facing to further improve safety and care, the active involvement of patients and the community are essential components.