Sustainable QI: The People Behind the Change

Healthcare providers face a unique set of pressures as we charge full steam ahead into 2023. Staff shortages are at an all-time high, prompting everything from nursing school partnerships and extraordinary compensation packages, to importing foreign nurses to try and make up the difference. This is happening as inflation skyrockets, straining already thinning margins. Supply chain issues have been improved, but not completely solved, and making matters worse, many providers saw significant surges in demand throughout the last year.

As explained by the CDC, the emotional, economic, and workforce tolls of the pandemic have dramatically exacerbated health equity gaps, while simultaneously leading to alarming increases in situations like healthcare-associated infections. Quality performance issues are expected to persist, which will likely hurt reimbursement at a time when most providers cannot soak the hit. Healthcare executives are now eyeing quality improvement (QI) initiatives more than ever, but Chris Hayes – Connex Member, and the Chief Health Information Officer for Trillium Health – argues that providers need to be strategically cautious and mindful in how they do that.

Hayes helps lead Trillium’s digital health strategies and is working alongside their community partners to address population health. He started his career, however, in QI back in 2005. Over the years, he began to feel that the practice was losing some of its grassroots passions in favor of more rote, mechanical models that forgot the human element of change somewhere along the way.

“When you ask patients what they want, what makes them feel less vulnerable, it’s the human connection. And in the last 2 decades, we’ve stopped focusing primarily on relationship-building in favor of being activity-driven. We’re going to evaluate you on rote efficiency alone,” explained Hayes, “and that creates a harmful disconnect with both patients and staff where neither side is satisfied, and care teams don’t get that sense of purpose they need to sustain through those QI initiatives.”

The Highly Adoptable Improvement Model

By 2013, Hayes was determined to address the burden associated with implementing change and really research how both sides of the equation could be advanced symbiotically – how can providers keep pace with change and their competing demands, without overwhelming the staff expected to take on an ever-expanding list of new work and tasks?

As a Harkness and IHI Improvement Fellow, Hayes led a research team and expert panel that went on to formalize the Highly Adoptable Improvement model. The goal was to “create a practical model and toolkit to address adaptability and sustainability of QI initiatives.” Hayes’ team and panel examined 72 different evidence-based factors, and were ultimately able to synthesize QI and change sustainability down to 6 key considerations:

1. Involve people in the change that you’re asking them to undergo. The reality is most people don’t join onto an initiative that will take work and make their life harder for purely altruistic reasons; they do it to achieve and pursue things that are valuable to them. The more involved they are in the process, and the more they benefit from the outcomes, the more readily available they will make themselves.
2. Plan the change, and align productivity and team expectations accordingly. Those impacted need to know that it’s coming, and why it’s happening the way it is, so they can prepare. While it’s not always doable to fully dedicate individuals to change activity alone, try to minimize how often key elements are being performed off the side of someone’s desk.
3. Measure the inputs and allocate the appropriate resources. Hayes is adamant that this not be relegated to a theoretical pursuit: “have you seen people do the tasks you ask them to do, and really measured the resource requirements needed to do it properly?”
4. Measure the physical, cognitive, and schedule toll of the new workload being placed on employees. “You need to really observe how easy or hard it is for staff to do what you’re asking them to. Too often we roll out changes that add minutes to each patient encounter,” explained Hayes, “without realizing the strain that puts on staff.”
5. Go back through and find ways to maximize simplicity. Efficient design principles, such as LEAN, can be used to evaluate which tasks assigned are really adding value, which aren’t, and which need to be modified after go-live. “Again,” echoed Hayes, “you’ve got to make it as simple as possible for staff to meet their targets.”
6. Lastly, how are staff perceiving the efficacy of the change? “Do those you’re asking to make a shift believe that what they’re doing will actually achieve your shared goals, or are their daily experiences giving them different evidence?”

As Hayes summarized to us, this framework really looks carefully at “two core indicators: do people see personal value in the change, and do they have the resources and bandwidth to actually do it.” Hayes continued, “You have to design the change so it’s perceived as high value, and low workload – if you make change easy, and meaningful, people are willing to do it.

“It’s not that the steps taken to achieve this are novel, per se,” said Hayes, nodding towards the abundance of performance improvement models that have cropped up over the last 50 years, “but where it does differ from other change management models is it doesn’t make assumptions. Often, the default position of a change framework assumes that the change, often decided by leaders, is the right thing to do, at the right time, with the right people. The missing piece is the evidence – is that assumption correct, and how did you know if you didn’t actively measure all the steps along the process?”

“You can engage people all you want, but if your design philosophy and assumptions are incorrect, the initiative is doomed. The change becomes unsustainable and tokenistic.”

Evolving Past Buy-In

While effective change means building consensus from staff on its necessity and direction, Hayes is critical of the leaders’ readiness to frame that discussion as “buy-in”. “Buy-in is a sales term, and there are a lot of salesmen you shouldn’t be buying anything from,” Hayes half-joked. “Buying in just means that the person trying to convince you to take action has created in you an emotional desire to do so, but if the change isn’t actually sustainably resourced and managed, it’s going to lead to cognitive dissonance in your change operators.” The more caregivers lack that perception of efficacy, and the more they feel like what they’re asked to do is at odds with their core objective – caring for patients – the less likely change will be successful.

“That dissonance drives dissatisfaction, pushes your best employees to roll up their sleeves in an unwinnable situation that burns them out completely, and worst of all,” continued Hayes, “it forces them to devalue the change. People don’t and can’t live with that state of dissonance, and that’s when they begin to check out and you see an increase in sick days or head-down absenteeism.”

Undertaking a Sustainable QI Journey

Each of Hayes’ recommendations hinges on the direct involvement and consistency in the action of both the leaders driving the QI initiatives and the employees that will be executing the work. So how can that be achieved? The short answer is, it’s complicated. At its essence, he’s speaking to achieving the goals outlined in Quadruple Aim – simultaneously pursuing population health, high-quality care, and lower per capita costs, while ensuring the professionals carrying out that workers have the resources and support needed to want to engage.

Hayes had a lot to say about what that looks like, and how healthcare leaders can build that cadence of consistent action in the rest of our Fireside Chat with him – tune in here to learn more.