Health care delivery systems that are working to improve patient experience can face daunting challenges, reflecting the need to align changes in behavior and practices across multiple levels and areas of the organization. But the process of planning, testing, and eventually spreading those changes does not have to be overwhelming. Health care organizations can take advantage of established principles and approaches to quality improvement, which are already familiar to the many providers involved in clinical quality improvement (QI).
This section of the Guide suggests a way to use the concept of microsystems to focus the QI process on the locus of responsibility for patient experience, provides an overview of the process of quality improvement, discusses a few well-known models of quality improvement, and presents a few tools and techniques that organizations can use to address various aspects of patient experience.
Three Tips for Facilitating the Quality Improvement ProcessPlace a priority on encouraging communication, engagement, and participation for all of the stakeholders affected by the QI process. Learn what is most important to the people who make up the microsystem and look for ways to help them embrace the changes and begin to take ownership of them.
Start your implementation of improvements with small-scale demonstrations, which are easier to manage than large-scale changes. Small-scale demonstrations or small tests of change also allow you to refine the new processes, demonstrate their impact on practices and outcomes, and build increased support by stakeholders.
Keep in mind and remind others that QI is an iterative process. You will be making frequent corrections along the way as you learn from experience with each step and identify other actions to add to your strategy.
One useful way for health plans and medical groups to approach the process of improvement is to think of the organization as a system, or more specifically, as a collection of interrelated "microsystems." The term "microsystems" refers to the multiple small units of caregivers, administrators, and other staff who produce the "products" of health care—i.e., who deliver care and services on a daily basis.
The concept of microsystems in health care organizations stems from research findings indicating that the most successful of the large service corporations maintain a strong focus on the small, functional units who carry out the core activities that involve interaction with customers. 1 In the context of health care, a microsystem could be: 2
Examples of microsystems include a team of primary care providers, a group of lab technicians, or the staff of a call center. In the patient-centered medical home model, a microsystem could be the patient's care team accountable for coordination of the patient's services that address prevention, acute care, and chronic care. 3
The goal of the microsystem approach is to foster an emphasis on small, replicable, functional service systems that enable staff to provide efficient, excellent clinical and patient-centered care to patients. To develop and refine such systems, health care organizations start by defining the smallest measurable cluster of activities.
Once the microsystems have been identified, a practice or plan can select the best teams and/or microsystem sites to test and implement new ideas for improving work processes and evaluating improvement. 5 To provide high-quality care, the microsystem's services need to be effective, timely, and efficient for all patients, 4 and preferably designed in partnership with patients and their families.
Measurement and performance feedback must be part of the microsystem's principles to learn and improve. 6
If a quality improvement intervention is successful for a microsystem, it can then be scaled to other microsystems or the broader organization. However, for successful scalability, organizations should adopt a framework for spread that will work within their structure and culture.
Although QI models vary in approach and methods, a basic underlying principle is that QI is a continuous activity, not a one-time thing. As you implement changes, there will always be issues to address and challenges to manage; things are never perfect. You can learn from your experiences and then use those lessons to shift strategy and try new interventions, as needed, so you continually move incrementally toward your improvement goals.
The fundamental approach that serves as the basis for most process improvement models is known as the PDSA cycle, which stands for Plan, Do, Study, Act. As illustrated in Figure 4-1, this cycle is a systematic series of steps for gaining valuable learning and knowledge for the continual improvement of a product or process. Underlying the concept of PDSA is the idea that microsystems and systems are made up of interdependent, interacting elements that are unpredictable and nonlinear in operation. Therefore, small changes can have large effects on the system.
Figure 4-1. Plan-Do-Study-Act Cycle
The cycle has four parts:
The PDSA cycle involves all staff in assessing problems and suggesting and testing potential solutions. This bottom-up approach increases the likelihood that staff will embrace the changes, a key requirement for successful QI. 9
When you are ready to apply the PDSA cycle to improve performance on CAHPS scores, you will need to decide on your goals, strategies, and actions, and then move forward in implementing them and monitoring your improvement progress. You may repeat this cycle several times, implementing one or more interventions on a small scale first, and then expanding to broader actions based on lessons from the earlier cycles.
This section discusses four key steps in the planning stage of a PDSA cycle as part of a CAHPS-related quality improvement process:
The team's first task is to establish an aim or goal for the improvement work. By setting this goal, you will be better able to clearly communicate your objectives to all of the sectors in your organization that you might need to support or help implement the intervention.
The goal should reflect the specific aspects of CAHPS-related performance that the team is targeting. It should also be measurable and feasible. One of the limitations of an annual CAHPS survey as a measurement tool is the lag time between the implementation of changes, the impact on people's experiences, and the assessment of that impact. For that reason, the team needs to define both ultimate goals as well as incremental objectives that can be used to gauge short-term progress. After defining your ultimate goals, ask "What is the gap between our current state and our goals?" Make of list of those gaps and use them to make SMART (specific, measurable, achievable, realistic, and time bound) incremental objectives.
For example, a team concerned about improving performance on the "Getting Timely Appointments, Care, and Information" composite measure in the Clinician & Group Survey may set a 1-year goal of a two percent increase in its composite score. At the same time, it could specify goals for the number of days it takes to get an appointment for non-urgent and urgent visits. Similarly, a team focusing on overall ratings may set goals for complaint rates for the health plan as a whole or for individual medical groups and then review those rates monthly.
With objectives in place, the next task of the team is to identify possible interventions and select one that seems promising. Keep in mind that all improvement requires making a change, but not all changes lead to improvement.
Section 6 of this Guide presents a number of different strategies that health care organizations can use to improve different aspects of their CAHPS performance. In addition, you may want to consult several case studies of health care organizations that have implemented strategies to improve performance on CAHPS scores.
These sources of improvement ideas offer an excellent starting point, but they are by no means comprehensive. There are many other sources for new ideas or different ways of doing things both within and outside of health care. Consequently, improvement teams should make an effort to develop and maintain systematic ways of identifying effective solutions.
New ideas and innovative solutions can be found:
One useful way to develop and learn innovative approaches is to visit other health care organizations. Resistant or hesitant staff members are often "unfrozen" by visiting another highly respected site that has successfully implemented a similar project. You can also visit a company outside of the health care industry to get new ideas. Some health plans, for example, have learned how to improve their call center operations by sending staff to visit mail-order catalog houses or brokerage firms. The Cleveland Clinic has required every doctor and senior administrator to make one "innovation site visit" a year to learn about different approaches that can be brought home and tested.
"Ideas for change can come from a variety of sources: critical thinking about the current system, creative thinking, observing the process, a hunch, an idea from the scientific literature, or an insight gained from a completely different situation. A change concept is a general idea with proven merit and sound scientific or logical foundation that can stimulate specific ideas for changes that lead to improvement."
—Plsek P. Innovative thinking for the improvement of medical systems. Ann Intern Med 1999;131:438-44. Accessed July 27, 2015.
To decide which new ideas or benchmark practices to implement, the improvement team needs to consider several factors:
Depending on the nature of the intervention, you may want to break it down into a set of related but discrete changes. For example, if the team decides to implement a new specialist referral process, you could begin by making changes to the procedures used to communicate with the specialist's office. The communication process with the health plan might then be the target of a separate change.
Although there is no one "correct" way to write an action plan for your organization or facility, it is important to have some form of written document that states your goals, lists your overall strategies to achieve those goals, and then delineates the specific actions you will take to implement the interventions you have selected to address the identified problems. One way to organize the action plan is to review the following key questions as a team and document your answers:
It also helps to lay out the calendar for all actions in a Gantt chart format, so you can verify that the timing of sets of actions makes sense and is feasible to complete with the staff you have available.
When a team establishes its goal, it typically specifies one or more performance metrics to assess whether a change actually leads to improvement. These measures should be clearly linked both to the larger goal and to the intervention itself. For example, if the goal is to speed specialist referrals, you could measure the time it takes to get a response from the specialist's office or an approval from the health plan.
Choose measures that allow you to track each of three steps in the improvement process:
Communicate with staff about why the measures are being collected and how these data will help improve their quality of work life and the patient's experience.
Seek a feasible number of measures that address the most important aspects of the improvements you are trying to achieve. Too many measures could create a burden on the staff, leading to loss of attention due to information overload; too few measures may omit tracking of important aspects of the changes you are making.
Once you have established practical measures, you will be able to produce visual displays of your performance over time by tracking the metric on control or run charts. Control and run charts are helpful tools for regularly assessing the impact of process improvement and redesign efforts: monthly, weekly, or even daily. In contrast to tables of aggregated data (or summary statistics), which present an overall picture of performance at a given point in time, run and control charts offer an ongoing record of the impact of process changes over time.
A run chart can show different data collection points plotted over time for a specific survey question, e.g., an item about patients' ability to reach the practice by phone. By measuring and tracking results to this question at regular and frequent time intervals, managers can discern how process improvement interventions relate to changes in survey results. If an intervention appears to have positive results, it can be continued and sustained; if not, it can be modified or discontinued.
Dashboard reports are another way to display performance. A dashboard report presents important data in summary form in order to make it easier to identify gap in performance and trend performance against goals. Dashboards can be a useful method for sharing consistent information across multiple levels of an organization. For example, the Massachusetts General Physicians Organization (MGPO) prepares quarterly leadership dashboards with benchmarks and targets, where relevant, at a summary level across clinical services, at the clinical service level, and at the practice level. 10
Once you have selected interventions, the next stage of the cycle is to develop and test specific changes. It helps to think of this stage as a number of "mini-cycles" within the larger improvement cycle, in the sense that the microsystem or team is likely to go through multiple iterations of testing and refining before the specific changes add up to a real intervention.
Small-scale tests of the interventions you wish to implement help refine improvements by incorporating small modifications over time. Conducting these small tests of change within a microsystem can be very powerful:
Most improvement strategies require some adaptation to the culture of the organization. Patient-centered improvement strategies have to consider the needs of patients and their families as well as the staff. Moreover, front-line staff will frequently resist new ideas if they are not allowed to modify them and test their own ideas.
Building off of the development and testing of specific changes, the final stage of the PDSA cycle involve adopting the intervention and evaluating it against the goals of the improvement project and the measures established for tracking improvement progress. For example:
This part of the improvement cycle is really the ongoing work of health care and where your teams will spend most of their time. There are no set rules about how long this part of the cycle takes. It depends in part on how frequently you monitor your CAHPS scores and other quality measures.
It is important not to let the work go on too long without ongoing measurement in order to make sure you are making progress toward achieving your aims. Most monitoring takes place on a monthly or quarterly basis. The team can use data on the impact of the intervention to see if it is making progress towards the goals and to determine whether to conduct a new set of analyses of its CAHPS performance. The purpose of this effort is to get some sense of what worked, what did not work, and what further or new interventions may be needed. To the extent that the improvement initiative was successful, the team must also think about ways to sustain and spread the improvements over time.
As part of its work, the team will need to take a hard look at the psychological, physical, and procedural barriers it has to address in order to accomplish its aim. Barriers to improvement come in many guises. Psychological barriers such as fear of change, fear of failure, grief over loss of familiar processes, or fear of loss of control or power can be significant impediments to overcome. Other common barriers include the following:
Despite the serious nature of some of these barriers, few are large enough to bring a project to a halt. Typically, they are cited as excuses for two of the fundamental barriers to change: the fear of new ways of doing things and the fear of failure.
Anticipating How the Improvement Process Affects StaffAn improvement process often requires significant changes in people's attitudes and behaviors, often requiring staff to give up their old standards and practices and adopt new ones. As a result, you can expect pushback from some staff as you introduce new processes and habits.
Many staff will "get it" early and pitch in enthusiastically. But introducing and reinforcing changes in behavior that "stick" in the form of sustainable practices will take some work and time to succeed. Over time, as less enthusiastic staff see positive progress, they too will become more engaged and supportive.
When you succeed, the payoff is significant, with benefits not only for patients but also for clinicians and staff. Many organizations have found that job satisfaction for their staff rises with improved patient experiences because the new, better practices usually reduce frustrating inefficiencies in the system that created extra work for staff.
Learn More: Aligning Forces for Quality. The Center for Health Care Quality at the George Washington University Medical Center School of Public Health and Health Services. Good for Health, Good for Business: The Case for Measuring Patient Experience of Care. 2012.
The team also needs to identify factors that could facilitate their work. Facilitators can include financial or nonfinancial incentives, such as gain sharing for staff if a specific target is met or better quality of life for the staff when a problem is fixed. Other facilitators include picking an aim that is part of the organization's strategic plan or one that will improve other goals the staff care about, such as clinical outcomes.
Sometimes, the facilitator is the ability of a change to help achieve secondary goals. For example, improvements in doctor-patient communication may decrease medication errors, or the development of shared care plans may improve clinical outcomes and reduce no-shows for appointments or procedures.
Research on the diffusion of innovation has found that social interaction plays a crucial role. Most people do not evaluate the merits of an innovation on the basis of scientific studies; they depend on the subjective evaluations of "early adopters" and model their behaviors after people they respect and trust. 11 For that reason, choosing the right team members and opinion leaders (i.e., people within an organization who informally influence the actions and beliefs of others) is critical to efforts to diffuse innovation.
Depending on the project, you may want to try to identify the opinion leaders that would be helpful to involve (assuming they are open to change and new ideas). Interpersonal communication works best when the people communicating the message are respected opinion leaders within the same staff group whose behavior they are trying to change. For example, an innovation to change the behavior of receptionists will often move quickly if it is led by a respected receptionist or office manager. But this person would probably not be as effective at getting physicians in a medical group to change their communication style with patients.
Ask people whose opinion they respect. Who do they follow when they have adopted new clinical or improvement practices? Who do your staff look to when they want advice or information about the organization?
One important step that is often neglected is the communication of successes throughout the organization—to organizational leaders as well as clinical and administrative staff. By discussing successful projects, the team helps to reinforce the culture of quality improvement, build credibility for the intervention, reward those involved, and foster the spread of effective innovations.
The organization's leaders can also:
A related practice is the communication of changes beyond the walls of the organization to members or patients. By telling people about innovative practices—whether through newsletters, emails, office computer screensavers, member Web sites, or handouts in the office—you can raise the standard of expectations.
