An Integrated Approach to Deploying Performance Improvement

The following is excerpted from Performance Improvement for Healthcare: Leading Change with Lean, Six Sigma, and Constraints Management by Bahadir Inozu, Dan Chauncey, Vickie Kamataris, and Charles Mount (McGraw-Hill; 2011) with permission from McGraw-Hill.

As it relates to performance improvement, the term deployment has come to mean different things to different people. Regardless of how it is defined, it is widely accepted that, as with any organizational change effort, a plan is essential. To some of those who do develop a deployment plan, it is little more than a training schedule; to others, it may include a list of processes that require improvement. To facilitate a successful deployment, it must be both of these and much more. The deployment plan should provide a roadmap to a successful and sustainable performance-improvement program. It should clearly address the strategy for how performance improvement will be used to facilitate the attainment of organizational goals today and in the future. It is not an easy task, but the rewards are well worth the effort.

Who Leads the Performance-Improvement Deployment?
While the deployment plan sets the path for the journey, someone must lead the way. Most successful deployments appoint a deployment champion. The deployment champion should be an executive-level leader (e.g., chief quality officer, vice president for performance improvement, etc.). At a minimum, deployment champions should have a working knowledge of performance-improvement tools and techniques. If possible, they should attend practitioner training. While it is optimal for them to complete projects as is normally required for practitioner courses, this may be waived—allowing the champion to attend much in the same manner a student may audit a college course. While not the favored approach, this may be preferred over a void in performance-improvement knowledge.

The primary duty of deployment champions is to execute the deployment strategy. This is accomplished through the executive leadership team (ELT). Many healthcare organizations have multiple entities that oversee, report, or execute improvement efforts across the enterprise—or even within departments. While this ubiquity does help to ensure a degree of focus on quality issues, it is somewhat counter to a systems approach to quality throughout the organization. For the Committee on Quality of Health Care in America, the Institute of Medicine (IOM) stated that “whatever the organizational arrangement, it should promote innovation and quality improvement.” Top-level management ought to ask, “Does the current decentralized structure promote innovation and sharing?” Additionally, the IOM found that a healthcare organization’s structure must be able to support both formal and informal ways of learning to share information. Otherwise, improvements will be suboptimized, with improvements limited to just one division or team instead of reaped throughout the organization, as Samantha Chao attests in her report, “The State of Quality Improvement and Implementation Research.”

In many cases, relegating the responsibility of quality outside the highest echelon of management serves to absolve executive leadership from direct involvement in improving quality within their organization. While the focus of these entities is usually on quality-of-care issues, the organization’s raison d’être, it fails to address opportunities in the areas of capacity, Throughput, and cost containment. These multiple quality entities are representative of the organizational silos that are widespread in healthcare.

Performance-Improvement Program Management Office
In performance improvement, initiatives undertaken to mitigate performance gaps are generally called projects. This nomenclature can be confusing when reviewing literature regarding project or program management. In some cases, they are treated synonymously. In this book, the term project is used when discussing individual improvement undertakings, and program is used when addressing the overall performance-improvement deployment.

Establishing a program office is an immediate responsibility of the executive leadership team. It is necessary to provide oversight and program management. At a minimum, this office should be responsible for the administrative tasks in support of the performance-improvement deployment. Ideally, senior practitioners should be centralized and be assigned to the program management office to work on performance improvement full time. Their role should be to provide technical oversight and deployment advice and to lead improvement efforts that affect the strategic goals of the organization. To quantify the impact of these efforts, as well as more localized efforts within work units, the deployment champion, as the head of the program office, should coordinate with the finance department to develop and implement a benefit estimation and validation process—when the JumpStart process is applied, this task is accomplished by the deployment team. JumpStart is a rapid planning process developed to accomplish a large amount of performance-improvement planning in a very short time with the executive leadership team. The use of centralized management offices is a quickly growing concept in businesses worldwide.

Depending on the maturity level of the healthcare organization, the program office may be responsible for the delivery of all training related to performance improvement. In the earlier stages of the performance-improvement deployment, the program office provides for the availability of external resources contracted to deliver the training. Regardless of its maturity level, an organization may decide that outsourcing the delivery of training remains a viable option.
In addition to being the principal of the program office, the deployment champion is also responsible for maintaining the project portfolio, which lists improvement opportunities throughout the organization, as well as management of project selection and prioritization processes. While project identification and prioritization are executive leadership functions, the deployment champion must be active in advising and coaching executives. The deployment champion continuously monitors progress toward milestones and performance relative to indicators, reporting exceptions to executive leadership.

Addressed in more detail in Chapter 5, project prioritization is a critical component of any performance-improvement deployment. One key contribution of Constraints Management to the integrated approach is the use of thinking processes tools to identify and prioritize improvement opportunities with the potential for a system-level impact. It is important to determine whether an improvement opportunity affects the system constraint or at least one of the core drivers of a top-level undesirable effect. The current reality tree (CRT) and its simplified version, the focused current reality tree (fCRT), reveal the leverage points and opportunities that yield the greatest potential for a healthcare organization to progress toward attainment of its goal. CRTs can bring the core drivers to the surface and provide the framework to discover the actions that best mitigate them.

In the approach, the linkage between core drivers and improvement opportunities cannot be overstated. In addition, agreement with strategic imperatives, as well as performance gaps related to regulatory requirements, voluntary accreditations, and annual reviews of key performance indicators, are considered. Cost, quality, and time assessments of core processes are conducted. Although financial impact is critical, estimates of expected benefits also should be provided in other areas, such as patient safety and clinical outcomes, with weights that the executive team deems as important components of project selection and prioritization.

Long-term success depends on the routine direct involvement of executive leadership in performance improvement. The execution of the strategy and guidance provided by the executive leadership team should be concentrated in a program management office. The deployment champion advises the executive leadership team on how to integrate and align the performance-improvement program with organizational strategy.

Initiating a performance-improvement deployment can be a time-consuming process. Forming the program management office is a critical first step. The next step is to form a deployment team and initiate assessment and planning as rapidly as possible.

Deployment Team
The deployment team is formed during the early phase of the deployment. Its members include management representatives from
•    Program management office
•    Executive leadership team
•    Patient care
•    Public affairs/community relations
•    Human resources/organizational development
•    Finance

The anticipated life cycle of the team as a distinct entity typically is no longer than through the initial stages of the deployment. Team members may have individual tasks stemming from the deployment plan or may be contacted to provide input on matters within their areas of expertise. Over time, these areas of responsibility will be absorbed by the deployment champion and program management office.

What Does a Mature Hospital Performance-Improvement Deployment Look Like?

There are many facets to a mature, successful performance-improvement deployment in a hospital. Governance, staffing, finance, and visibility are four crucial features of a performance-improvement deployment.

Governance of the performance-improvement program is a shared responsibility. At the strategic level, executive leadership identifies strategic goals and allocates resources to mitigate gaps. Executive leadership actively participates in the prioritization of projects focused on strategic goals or those that cross the enterprise. Next, the tactical level is the responsibility of the healthcare organization’s quality leader (e.g., vice president for quality improvement). The quality leader sets the policies and advises other executives on the progress of the performance-improvement program. Policies are to be established covering project identification, prioritization, monitoring, execution, and reporting.

At the operational level, centrally assigned practitioners aligned organizationally under the quality leader should be expected to complete between four and eight high-impact/high-visibility projects per year. These projects should be focused on areas having the potential for a high return on investment and/or a direct impact on strategic objectives. Additionally, the centralized core of practitioners provides mentoring and project oversight to decentralized practitioners. These decentralized practitioners continue to work in their normal jobs and assist their managers in identification and execution of performance-improvement events within their departments or divisions.

A single tracking system should be used to capture information related to all performance-improvement projects completed within the organization regardless of the level of sponsorship or the toolset applied. All performance-improvement projects are to be formally chartered, including a clearly articulated business case along with a validation of the operational improvements, revenue increases, and cost savings achieved after the improved process is implemented. Before long, active participation in the performance-improvement program should be regarded as an expectation for career progression within the organization.

At least one full-time practitioner is dedicated to the execution of high-impact, cross-departmental projects. Other decentralized, at-large practitioners are available for departmental projects. These at-large practitioners are expected to complete one to two projects per year, generally within their department or work unit. An ongoing program of performance-improvement training is established beginning with the executive team and progressing downward in the organization. All leaders should be trained to sponsor improvement projects. At maturity, frontline supervisors sponsor improvement efforts led by practitioners to improve processes under their operational purview. Every person who attends practitioner training and remains assigned within his or her respective work unit should lead at least two improvement events per year, such as a process value-stream analysis, rapid improvement workshop, or 5S events, which are explained in Chapter 5. An ongoing training program should result in no fewer than one trained practitioner in every department/work unit of the hospital.

The finance department, under the direction of the chief financial officer (CFO), must establish procedures for its active participation in establishing the business case for projects, as well as estimation and validation of cost savings and revenues to be achieved on completion of performance-improvement projects. Chapter 7 describes the process for estimation and validation of financial benefits of performance-improvement projects and events. Interdepartmental reports are maintained to document the cumulative return on investment (ROI) of the organization’s performance-improvement program. The results demonstrate that performance improvement is not a cost center—but rather a profit center—for the organization.

All employees should be introduced to the performance-improvement program during their orientation as new employees to the healthcare organization. Responsibility is rotated through the team so that each senior leader presents. Performance-improvement successes must be publicized and celebrated at every opportunity. In addition to regular publication in organizational newsletters or announcement via some other means, each project team prepares a storyboard and displays it in the benefitting work center. In the United States, it is common to see these storyboards maintained and used for a performance-improvement storyboard gallery each year during national quality month and/or presented at regional and national meetings such as those of the Institute for Healthcare Improvement (IHI) and National Association for Healthcare Quality (NAHQ). This should be encouraged as a means of recognizing practitioners and promoting benchmarking and sharing of best practices. One or two performance-improvement projects at a minimum are presented each month at the executive team meeting. These projects are introduced by the respective sponsor and presented by the lead practitioner. The CFO regularly presents the ROI statistics on the overall performance-improvement program. On a quarterly basis, a high-visibility project is presented to the board of directors.

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