Start Small to Win Big in Healthcare Quality Improvement

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"At the heart of improvement is small testing for change," says Julie Kliger, MPA, BSN, RN, founder and principal of The Altos Group. Ms. Kliger has learned the value of conducting small tests of change as a leader of quality improvement in healthcare. From 2008 to 2010, she led nine hospitals to reduce sepsis mortality by more than 50 percent; she later created the Integrated Care Leadership Network and The Altos Group to train and assist quality improvement leaders.

What are small tests of change?

Julie KligerSmall tests of change are mini-interventions that allow healthcare teams to try out new ideas quickly and cost-efficiently. Plan, Do, Study, Act cycles are one model of small tests of change. The core concept is healthcare teams brainstorm improvement strategies, implement them on a small scale, measure the results and then act based on those results. If the intervention fails, the team learns from the failure, adapts strategies and then tests a new intervention. If the intervention succeeds, the team works to expand the process to other areas of the organization.

For example, one hospital Ms. Kliger worked with aimed to reduce medication errors. Their hypothesis was that reducing distractions to clinicians administering medications would reduce errors. To test this hypothesis, the team created cardboard placards that asked people not to interrupt the nurses administering medication. However, the font was so small that people walking by would stop the clinician to read the placard, driving up interruptions instead of reducing them. Learning from this outcome, the team changed the sign to more clearly communicate that the nurse should not be interrupted.

This example shows how testing an intervention on a small scale can teach front-line clinicians about what types of changes are effective in the organization. Furthermore, it illustrates the importance of embracing failure as an educational tool and a timesaver for future efforts in quality improvement. Normalizing failure as part of the quality improvement process encourages people to try new things because they know that if they fail, they "have the freedom to try various ideas until success is achieved," according to Ms. Kliger.

What are the benefits of small tests of change?

Creating change agents
Putting front-line clinicians in charge of small tests of change is valuable not only for achieving a specific goal, such as ultimately reducing medication errors, but also for teaching front-line workers a process for improving quality. Small tests of change can be applied to a range of problems in healthcare, such as mortality from sepsis, falls and healthcare-associated infections.

Ms. Kliger suggests quality improvement teams perform small tests of change regularly to promote continuous improvement. For example, teams can run tests every two weeks, with the week in between designated for meeting to discuss the results and plan for the next test. Establishing this cycle of testing, measuring and retesting builds a habit of working to improve quality, according to Ms. Kliger. "Even though that sounds time intensive, what is developed then is a cadre of change; you created change agents where before you didn't have any. Now those agents are skilled at problem-solving in general, and you can throw them all types of problems," she says.

For example, after the hospital solved the medication error problem, it moved onto focusing on reducing sepsis mortality and reducing length of stay on its medical/surgical units.

Saving money
Another benefit of small tests of change is that they are cost-efficient. Implementing a change in a limited setting limits the capital outlay that is required. In the medication error reduction example, the team needed only some cardboard and string. Even when the intervention is more complex and requires costlier equipment, testing it on a small scale creates only a marginal cost, according to Ms. Kliger. "If I fail, I fail small," she says. In contrast, some projects that come from the top down instead of from the front-line may be implemented organization-wide without testing small first. If these projects fail, the cost in time, money and employee satisfaction can be significant, she says.

Furthermore, if the small test of change succeeds, once scaled up, the organization has the potential to save a significant amount of money. Preventing medication errors and sepsis mortality, for example, can generate huge cost savings. Ms. Kliger's sepsis mortality reduction project generated a 56 percent return on investment, for instance.

Spreading successful tests of change

When a small test of change succeeds, the quality improvement team can scale up the test to additional units as appropriate. While expanding a pilot project is challenging, being prepared from the beginning to spread the process can ease this transition, according to Ms. Kliger. She suggests the improvement team include representatives from different units so they can begin thinking of how an intervention can be adapted for their unit's environment and culture.

In addition, the improvement team should establish a core set of goals that will be constant across units. While specific aspects of an intervention may vary depending on the unit, the overall goal and principles should be the same, Ms. Kliger says.

Julie Kliger may be contacted at

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