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What Happens When Change is Not an Improvement?


Klaus_NetherBy Klaus Nether
Executive Director, High Reliability, Center for Transforming Healthcare

Those of us who’ve worked in health care for a while know how quickly project fatigue can set in when initiatives roll out without any clear benefit.

All too often, in addition to performing increasingly demanding jobs, health care personnel are asked to improve processes and change workflows every time a new project is launched. As humans, it’s natural to resist change, even when it involves a process that’s broken and needs to be improved. Improving processes and changing workflow just for the sake of change when there’s no real improvement or benefit gets old quickly and causes employee dissatisfaction.

Furthermore, when there is no real benefit to the work that was done, employees aren’t quick to support or want to be a part of the next “improvement project” that comes down the pipeline. To some extent, it’s understandable. If a team spends months working on a project and implements solutions, but nothing improves, most people don’t want to sign on for another one.

One great example of this is hand hygiene. For many years, hospitals have struggled with ensuring that staff consistently clean their hands to reduce the spread of infections--yet still haven’t overcome the problem.

Through our work in Robust Process Improvement® (RPI®), we’ve been fortunate to identify the keys to ensuring that change leads to an improvement and not just a change for the sake of change. 

Investigating Root Causes

One way to make the best use of initiatives and, by extension, employees’ time spent on the project, is to take a systemic approach to understanding the process, identifying where the problem lies, and learning the root causes to the problem. It’s imperative to drill down to the root causes before implementing solutions. A “one size-fits-all solution” or “best practice” doesn’t always work in health care because most quality and safety issues that health care organizations face are complex and differ from place to place.

Returning to the example of hand hygiene: The problem is multi-faceted, and the work the Center did with hand hygiene resulted in three critical findings.  The first finding was that there are many root causes of hand hygiene non-compliance.  The second finding? Each root cause requires its own targeted solution. The third and final finding: The set of root causes for hand hygiene non-compliance can differ not only from one health care organization to the next, but even within the same organization. In a hospital environment, for example, root causes for hand hygiene non-compliance are different in the operating room than in the medical/surgical unit. It’s not reasonable to expect success in one clinical area to translate to another one because the root causes to the problem may be different.

When data drives decision-making, the issues gradually become apparent. Solutions can then target the real problems, and significant improvements can be achieved and sustained.

Validating Solutions for Improvement

Another key to the success of an improvement initiative is to validate that the solutions being implemented lead to an improvement and not just a change. To do this, an organization should collect a baseline measurement to understand the current process (how well is the process performing?) and collect data again once solutions are implemented to validate that the solutions show improvement.  How else can you claim success?

Finally, collecting data on your process does not end after you have validated improvements.  It becomes part of the plan to sustain those improvements.  Data on the process must continue to be collected to understand the process moving forward--but more importantly if something starts to go wrong in the process, you can quickly identify and resolve it.  How else would you know that the improvements you validated are being sustained?

Senior Leadership’s Role in Improvement Work

Today’s health care environment is nothing if not fast-paced, and administration wants everything done immediately. 

Although the health care environment is moving so quickly, senior leadership must maintain patience with their improvement teams, so the problem can be fixed the first time and we get away from the cycle of working on the same problem every few years.  

Another key role that senior leadership must play in improvement initiatives is being an agent of change. Sometimes we do not come up with the best solution because we did not take the time to truly understand the problem or the process where the problem lies, to really identify the root causes to the problem to get to that outcome we desire.  More frequently we have the best solution, but we do not get to the desired outcome because the solution isn’t accepted by the staff who needs to implement it.  Every solution implemented for improvement will be a change for staff who work in that process. It is senior leadership’s role to help in managing this change. 

Therefore, the support and commitment from senior leadership doesn’t just occur when an improvement initiative is launched but also that support and commitment is maintained throughout the project work and in sustaining the gains.

Klaus Nether leads Center solution development activities, both domestic and international. Prior to this role, Nether was a Master Black Belt in the Department of Robust Process Improvement (RPI) at The Joint Commission.  Before joining The Joint Commission, Dr. Nether held a variety of clinical laboratory positions. Most recently, he held the position of manager of the Olson Clinical Laboratories at Northwestern Memorial Hospital in Chicago, Illinois. He also received Six Sigma training from GE Healthcare. Dr. Nether received his Six Sigma Black Belt Certification from Villanova University and is also certified through The Joint Commission. He is certified as a Master Black Belt through SixSigma.US.