Why do improvement projects in healthcare fail?

Many hospital CEOs looking to improve quality of care, reduce waste and improve clinical or staff productivity have turned to process improvement or re-engineering to achieve certain operational goals. Many of these efforts have paid dividends. However, many have not, raising the question, "Why do improvement projects go wrong?"

This study was conducted in 2013 at a rural 200-bed Virginia hospital that had been engaging in Six Sigma projects for approximately four years. During that four-year span, there were projects classified as "unqualified successes" (met the goal as stated in the project charter), "disappointments" (did not meet the charter goal) and projects whose success could be categorized as "moderate" (had some success, but could have had more).

Examples of the projects chosen as "successful" include med-cart exchange between nursing and pharmacy, time to get OB supplies, patient meal tray preparation and pre-admission testing. Projects that were selected as "moderately successful" include patient central scheduling, emergency room wait time, 5S in supply closets, dirty linen processing and patient snack ordering. Projects that were considered "unsuccessful"  include 5S on a particular floor, operating room scheduling, lab testing quality with turnaround time and collaboration between first and second shift housekeeping.

The research method was to conduct a group interview with several Six Sigma greenbelts about various projects in the hospital of which they had knowledge through personal involvement (as a leader or team member) or secondhand. A Six Sigma Black Belt and I chose projects whose outcomes could be classified into one of the three categories heretofore mentioned. In an attempt to ensure valid responses by group attendees, anonymous surveys were given to each participant for completion during the meeting.

For each project under review, we specified the name of that particular project, the leader(s), the goal (s) and in which department the project was focused. Survey responses regarding each project were then recorded and collected. For "successful" projects and those that had "moderate success," the survey instrument is found in table 1. For projects whose outcomes were disappointing or considered "failures," a very similar survey instrument is found in table 2. The group attendees were asked to identify the top three reasons from each survey that could explain the success, moderate success and failure for all pertinent improvement projects under discussion. They were to identify, in their opinion, the No. 1 reason for success, No. 2 reason for success and so on for each project. Hence the alternatives for each project were force-ranked by each meeting participant. The same protocol was utilized for unsuccessful projects. All totaled, there were 14 projects from various areas of the hospital considered and a total of 154 surveys collected from those who had knowledge of the projects.

Table 1

Table 2

Results
Depending upon the type of project considered (successful or moderate), there were 10 possible survey responses for each project. When considering the projects categorized as "failure," there were 11 possible survey responses. In table 3, the top reasons for each of the project outcome categories are listed in descending order of importance. Because of a “tie” in the scoring, the top four reasons for project outcomes are reported.

Table 3

Discussion
Within this table, project success and failure anchor opposite sides of the continuum with moderate success in the middle. If you examine closely the reasons for success and failure, they both seem to be strongly related to leadership. When considering projects that were successful, project leadership, project team cohesion (which is directly influenced by the project leader, process owner and functional department) and process owner/involvement all have to do with that area's or project's leadership. The same can be said of project failure: process owner involvement, collaboration between departments (which is directly influenced by that department's leadership) and project leadership all relate directly to the area's or project's leadership. Based on this sample's collective opinion then, the balance between project and success depends heavily upon the project manager (in this case, a Six Sigma Greenbelt) and the department leadership in which the improvement initiative is taking place.

For moderate success (or projects that could have attained more but didn't), notice that no forms of leadership were selected. This section is titled "project dynamics," which could mean that even with lesser forms of leadership, if a project team has grounded itself securely with properly defined goals, a good measuring system, a manageable project and some low-hanging fruit (or low project complexity), there is a good chance of some project success. It is possible that, with enhanced leadership at the departmental and project level, these projects could have moved to the "successful" column.

Limitations and conclusion
One could argue that the culture of this hospital perhaps prevented some project success, and these responses are related to that culture. While this may be true, there have been multiple studies conducted that show the importance of leadership to project outcomes in varied industries. Additionally, ASQ advances the use of various project tools (similar to those listed here) which have also been strongly linked to successful project outcomes. Another could argue that this group somehow engaged in "group think" when conceiving their answers. While this may also be true, steps were taken to prevent that phenomenon from occurring with the individual, anonymous surveys being distributed and collected prior to discussing each project in detail.

With the dynamic nature of healthcare in the 21^st century and the need to improve patient outcomes while simultaneously reducing costs and improving the financial strength of our healthcare institutions, the need for process improvement is not going to diminish in the near future. As such, healthcare practitioners, clinicians, consultants and various stakeholders engaging in continuous improvement should pay careful attention to their improvement teams and those tasked with working with those teams. Proper training should be afforded to improvement teams to ensure the necessary tools are offered to improve the probability of project success outcomes. Based on this sample data, these factors should improve healthcare patient and process initiatives resulting in fewer project failures.

Dr. Todd Creasy, MBA, MS, Master Black Belt Six Sigma, is an assistant professor at Western Carolina University within the nationally recognized project management department and principal for Bridgepoint LLC consulting specializing in healthcare. He can be reached at rtcreasy@wcu.edu.