Healthcare quality improvement leaders face many challenges to guiding a team through a change initiative. Julie Kliger, MPA, BSN, RN, founder and principal of The Altos Group, shares what she believes are the four primary reasons change initiatives fail and how to avoid them:
1. Politics. "Each department and service line has its own mandate and 'mini-mission,' thus potentially forcing misalignment of organization-wide efforts," Ms. Kliger says.
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To overcome this challenge, quality improvement leaders need to establish and gain buy-in for shared goals and a common mission. Developing multidisciplinary teams that meet often to discuss improvement projects can also help to eliminate silos and work toward a more coordinated, cooperative approach to care delivery.
2. Psychology. "People have different, conflicting motivations and legitimate concerns about their point of view, which can splinter consensus," Ms. Kliger says.
Aligning incentives for physicians and employees provides motivation to work toward a common goal. In addition, engaging physicians and front-line workers in a quality improvement initiative and actively seeking their perspective can ensure everyone's concerns are addressed. Ms. Kliger suggests leaders embrace constructive conflict — a process of discussing people's needs and differences to arrive at a solution. Instead of ignoring tension among team members, leaders need to acknowledge differences of opinion and have an honest dialogue about how people can work together and agree on a plan of action, she says.
3. Translation. "Moving efforts beyond pilot sites requires unit-based adaptation, which means 'starting from scratch' on every new unit," Ms. Kliger says. "To ensure specific interventions make sense given the culture, workflow and physical design of each unit, each unit must undergo this same discovery and development work as the pilot units."
Scaling up an improvement project from the pilot site to the entire organization is one of the greatest challenges in quality improvement. Leaders need to consider the impact of the environment on the project and determine how to adapt a pilot to a larger setting. Participants of the Value Incentives Learning Collaborative of the Institute of Medicine addressed this challenge in the discussion paper, "From Pilots to Practice: Speeding the Movement of Successful Pilots to Effective Practice," which includes questions pilot projects should consider during initial planning, evaluation and spread of the initiative, if it is successful.
4. Stamina. "Sustainability, which is the most challenging phase of clinical process redesign, since the very notion of redesign is by nature continuous, requires ongoing review," Ms. Kliger says.
Leaders should begin an improvement project with long-term embedding in mind to make sustainability easier. "You're not only trying to achieve a change in outcome; you're also trying to create and cement a change in behavior," Ms. Kliger says. Hospitals should hardwire new processes into the organization through clinical decision support, checklists, training, documentation in policies and other methods.
Hospitals should recognize that this process will take time, however. "Understand that improvement is a change process, which requires many different people coming together to agree upon and then develop a new set of habits. Habits take a healthy dose of time before they become 'the way we do things around here,'" Ms. Kliger says. "For this reason, improvement leaders must be patient."
Quality improvement teams also need to continually collect data to ensure improvements do not erode over time, according to Ms. Kliger. Leaders need to be flexible and adapt new processes over time, as needed, to continuously improve the delivery of healthcare.
Julie Kliger can be contacted at julie@thealtosgroup.com.
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