International Journal for Quality in Health Care; Volume 19, Number 4: pp. 237 –243 Advance Access Publication: 15 June 2007
10.1093/intqhc/mzm021
Case study
Introduction of a quality improvement program in a children’s hospital in Tehran: design, implementation, evaluation and lessons learned S. MEHRDAD MOHAMMADI1, S. FARZAD MOHAMMADI2, JERRIS R. HEDGES3, MORTEZA ZOHRABI1 AND OMID AMELI4 1
Tehran University of Medical Sciences and Health Services, Center for Academic and Health Policy, 2Tehran University of Medical Sciences and Health Services, Eye Research Center, 3Oregon Health and Science University, School of Medicine, Department of Emergency Medicine, and 4Management Sciences for Health
Abstract Background and Objective. Reports addressing continuous quality improvement (CQI) methods in developing countries are scant and there are questions about the applicability of quality improvement methods in such settings. The structure and output of a formal quality improvement program implemented in a teaching hospital affiliated with the Tehran University of Medical Sciences is presented. Objective Method. During a nine-month period, a multi-stage quality improvement program was implemented. It comprised: (i) training workshops; (ii) a steering committee; (iii) weekly consultation and facilitation of improvement projects; and (iv) a day-long demonstration and recognition meeting. Four cycles of workshops were held in which 132 employees were trained in the basics of CQI. Results. Thirty improvement projects were initiated. Twenty-five of the projects were completed. In an evaluation survey more than 70% of respondents assessed a ‘positive impact’ on organizational culture, work efficiency and quality of services. More than 90% believed that the changes were sustained, and more than 60% reported that they have implemented additional improvement projects. Conclusion. Our quality improvement package supported rapid implementation of multiple projects. The underlying ‘change structure’ comprised the improvement teams, top management and the university’s quality improvement office; it integrated project management, support and facilitation functions by the respective participant. Organization-wide change was more limited than anticipated. To institutionalize the program and ensure sustainability, a local structure for change should be organized, management coaching should be sustained, local facilitators should be developed, incentives should be established and physician involvement should be emphasized. Keywords: change in behavior, continuous quality improvement, hospital, structure for change
Introduction Some state that healthcare organizations in developing countries have little experience with continuous quality improvement (CQI) methods [1] and the reports on such initiatives are scant [2]. Several questions have been posed in this regard: What specific process models and principles of
design make the most sense in these countries? Which management approaches work in cultures very different from those in which quality improvement was first described? What permits quality interventions to work or prevents them from working? How should successful quality improvement efforts be reinforced, disseminated and supported over time [3]? In addition, authorities asserted that Western advocates
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[email protected] International Journal for Quality in Health Care vol. 19 no. 4 # The Author 2007. Published by Oxford University Press on behalf of International Society for Quality in Health Care; all rights reserved
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of quality could learn from the innovation of colleagues and challenges in the non-Western world [4]. This paper reports a formal quality improvement program in the Children’s Medical Center, a teaching hospital affiliated with Tehran University of Medical Sciences and Health Services (TUMS), which was led and facilitated by the TUMS quality improvement office. We provide a description of the entire program and present a profile of the improvement projects undertaken (including process measures of pre- and post-intervention and the respective corrective actions). The results of a follow-up evaluation survey are presented. We also analyse the structure for change, discuss the role of facilitators and examine the overall success, limitations and long-term viability of the program.
Method Setting TUMS is a public organization whose mission is higher education in the health sciences, medical research, administration (regulation and provision) of health services in its catchment area and provision of specialized hospital services for referrals from other regions of the country. TUMS has 8 schools, 15 hospitals and 186 primary healthcare centers and oversees 18 private hospitals and 3170 other healthcare facilities. The TUMS chancellor requested the quality improvement initiative to be undertaken ( piloted) in one of its affiliated units. The impetus was to determine what could be achieved by such a quality program. The Children’s Medical Center was chosen due to the prevailing supportive attitudes and
preparedness of the managers of the hospital towards improvement. The hospital provides both general and specialized services. This children’s hospital, with around 175 staffed beds, 87% bed occupancy, nearly 450 employees, and 80 physicians, is a major referral center in Iran. The participants of the program were nurses, doctors and administrative department heads. Intervention The intervention, known as the Quality Improvement Training Cycle, was a multi-stage program comprised: (i) Training Workshop; (ii) Consultation and Facilitation; (iii) Demonstration and Recognition Meeting; (iv) Evaluation Survey; and (v) Retraining. Stages 1 through 3 were implemented during a nine-month time course (February 2002 – November 2002). The evaluation survey was administered in September 2004. The ultimate goal of the program was behavioral change of the employees and enabling the process of change within the organization. The phases of the course along with the methods and approaches used in each phase are summarized in Table 1. (The retraining phase emphasized the cyclical and continuous nature of the process.) Each workshop was organized as four 6-h days (24 h total) of training with 30 trainees. Almost half of the time was dedicated to didactic education and the other half to team exercises and experiential learning. TUMS’ quality improvement office consultants, who were physicians with advanced training in quality improvement philosophy and tools (including the courses by the national quality improvement committee), provided the training. As mentioned in Table 1 above, workshop content was a process improvement
Table 1 Quality improvement training cycle Phase
Name
Description or content
Time
Associated human resources training terminologya
............................................................................................................................................................................. b
One
Training workshops
FOCUS-PDCA methodology
In a weak (4 days)
Two
Consultation and facilitation
One day a week, 6 months
Three
Demonstration and recognition meeting Evaluation survey
Giving instructions, follow-up and answering questions along the nine-step methodology in the hospital Lecture presentations, poster (storyboard) presentations, recognition ceremony Trainees/participants assessment of effects on culture and hospital performance, sustainability of improvement efforts and obstacles to change Beginning PDCA cycle and experimenting anew
Four
Five a
Retraining
In one day
Lectures, educational pamphlet, questions and answers, group discussions Coaching (positive reinforcement and encouragement), case study
Seminar method, opportunity for reporting results of efforts, recognition, monetary rewards
A year and a half following phase three
For a comprehensive list of human resources training methods, the interested reader may refer to the Lussier’s book on management [36]. FOCUS-PDCA refers to a generic nine-step method for process improvement projects involving the use of 11 quality improvement tools by teams [5]. PDCA stands for: Plan, Do, Check, Act, respectively; and FOCUS for Find, Organize, Clarify, Understand and Select. b
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methodology known as FOCUS-PDCA. This managerial package includes: brainstorming, block diagram, flow chart, run chart, affinity diagram, cause and effect (fishbone) diagram, nominal group, multi-voting, decision matrix and planning sheet techniques [5]. (A sample improvement project along with the tools used is detailed in an appendix available on http://tums.ac.ir/cahp/qiprog_sampleproj.html)
deviation (SD). Mean of the trainee multiple-choice test score administered prior to workshop improved from 1.67 (SD: 0.22) to 3.25 (SD: 0.17) post-workshop (maximum score: 5).
Structure and leadership
Being very interested in the program, the University’s top managers (chancellor and vice-chancellor for logistics) supported it symbolically and through their actions. The chancellor believed that the best way for showing the value of the quality improvement approach is through example. The vice-chancellor for logistics gave an opening speech for all workshops. The process was supported financially in various ways. The top managers awarded bonuses and citations in the closing meeting. Hospital managers participated in the workshops and were involved in the improvement projects implementation and facilitation. The second phase involved consultation and facilitation of improvement projects. Overall, 187 consultation sessions were offered on a weekly basis on 16 separate dates. Ideas for 30 projects were formed; 25 were started and facilitated in the five-month period; and 20 went through all the nine formal steps. Table 2 lists the projects. The conception of improvement projects was not just based on solving a perceived problem; some were conceived just to study and ‘improve’ an existing process. Seven projects were initiated but not completed, i.e. DCA or CA stages of FOCUS-PDCA were not followed through. In all, a corrective action was formulated but it was either not implemented (four instances) or its effect was not measured post-action (three instances). The reasons were: impracticality of the recommended action, group dynamics problem or lack of a need for another measurement. A representative quality improvement project is detailed in an appendix available on http://tums.ac.ir/cahp/qiprog_ sampleproj.html. Analysis of individual projects is beyond the scope of this report. Phase 3 was implemented as described in Table 1. An evaluation survey was conducted a year and half after the formal closing of the program (i.e. following the demonstration meeting). All 29 distributed questionnaires were collected. More than 70% of the respondents believed that the exercise had a ‘positive impact’ on organizational culture development, work efficiency and speed, quality of services, patient satisfaction and number of patients (including bed occupancy). The survey scale used ‘positive impact’, ‘indifferent’, ‘negative impact’ and ‘no comments’ levels. In more than 90% of instances, respondents believed that the changes were sustained; and more than 60% of the respondents reported that they have implemented additional improvement projects after the program’s formal closure. The impact on employees’ satisfaction scored the lowest; only 35% believed that the impact has been positive, and 45% described it as indifferent (Figure 1). Lack of sufficient resources (budget, staff and equipment) and an ineffective incentive payment system were the two most frequently cited obstacles against improvement initiatives. The employee comment of ‘what’s
The Management Consultancy and Quality Improvement Office that reports to the TUMS chancellor managed and facilitated the program. The office’s mission is: ‘To provide consultancy and training services in the areas of improvement and management for the managers and employees of TUMS and to give advice to TUMS’ management leaders regarding organizational development policies.’ Its activities range from holding training workshops, facilitating quality improvement projects and guiding strategic planning workshops to facilitating problem solving projects. Measurement and evaluation Performance measures of the intervention were number of the workshops delivered and number and percentage of personnel participating, trainers’ performance, trainees’ multiplechoice test, number of improvement projects (initiated and completed) and attitudes of the participants towards the program and institutionalization of improvement activities. Trainer’s performance score was based on a four-criteria test, namely, scientific competence, chain of topics, eloquence and trainee participation with each criterion being measured on the three-tiered scale of good (2), fair (1) and poor (0). Participants scored the trainers after every session. Participant satisfaction was measured in the areas of session timing, logistical issues, volume of material, level of participation and overall satisfaction, again on a three-tiered scale at the course conclusion. Participants’ satisfaction and judgment about the quality improvement training cycle effect on organizational culture, work efficiency and hospital performance (quality of care, patients’ and students’ satisfaction, and occupancy) were questioned in the evaluation survey. The extent of institutionalization of the improvements and whether the participants have undertaken fresh initiatives later were also evaluated. Participants were asked to enumerate the obstacles they encountered and their suggestions for future improvement activities. A sample of 29 people were surveyed. Analogous to Kirkpatrick’s four-level model, we aimed to evaluate the impact of training at the levels of reaction, learning (knowledge), behavior (skill) and results [6].
Results Four workshops were held in which a total of 132 (of the some 530 hospital personnel) were trained (76% were female); 62% were nurses, 17% paramedics, 7.6% physicians and 13% other staff. Mean trainer performance score (based on the fourcriterion test; maximum score: 8) was 5.1 with a 0.75 standard
Observations regarding the University’s and hospital’s senior management involvement and support
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Table 2 Target processes for quality improvement and projects team composition No. Title
Team composition (staff mix)
....................................................................................
1.
2.
3. 4. 5. 6. 7. 8. 9.
10.
11. 12. 13.
14. 15. 16. 17. 18.
19. 20. 21. 22. 23.
Transferring the stable infant from the neonatal ICU to the ward when admitting an unstable one Transferring patient from surgery ward to the operation theater in the morning shift (elective operations) Distributing food to patients in wards Embedding tissue in paraffin in pathology specimens preparation Lending books in the library Washing hands in the pediatric ICU Delivering medicine to outpatient patients Distributing sugar and tea in the hospital Transferring cerebrospinal fluid specimen from the wards to the clinical lab Infectious diseases ward admissions of the patients for whom isolation is indicated Connecting patients to ventilators in pediatric ICU Hydrotherapy in the physical therapy unit First visit of the (insured) patients in the specialized clinics following discharge Admitting neonates with respiratory distress in the neonatal ICU Providing service to non-emergent patients in specialty clinics Placing intravenous lines for the patients The ward X’s daily visits Admitting non-emergent patients in the morning shifts from the time entering the ward Y to the time resting on the bed Submitting blood tests from the surgical wards to the clinical lab Service provision for the outpatient referrals at the sample taking room Copying service in the library Transferring an icteric infant from the emergency department to the ward Z Implementing CT scan orders for the hospitalized patients
Nurses
No. Title
Nurses
Support staff Paramedics Support staff Nurses Paramedics, support staff Support staff Paramedics, support staff Nurses
Nurses Paramedics, support staff Nurses, paramedics, support staff Nurses Nurses Nurses Nurses Nurses, paramedics
Paramedics Paramedics, support staff Support staff Nurses Paramedics
Team composition (staff mix)
....................................................................................
24. 25.
(continued )
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Table 2 Continued
Doing work at registration/sorting office Patients’ visit by the surgical fellow in different shifts
Support staff Nurses
An extension to this table (Table 3) provides more information on the projects, i.e. quality measure used, pre- and post-improvement statuses of the measure (mostly in the form of median and range) and the corrective action implemented. It can be accessed at http:// tums.ac.ir/cahp/qiprog_projdata.html.
in it for me’ was common and represented the main inherent challenge to change.
Discussion A variety of approaches for quality improvement, including process improvement, quality assurance, re-engineering and participative management, are available. In our program we adopted a CQI and project-by-project approach. The specific method for improvement and problem-solving taught and used by the teams was a package of analysis, teamwork and planning tools acronymed FOCUS-PDCA (see above). Many empirical papers report its application in dealing with specific projects in US academic healthcare centers [7–12] or on an organizational basis [2, 13, 14]. Others have reviewed the utility of the method [15, 16] and still others suggest modifications [17–19]. CQI has been found efficient in hospital settings [20–23]. Francois et al. evaluated a decentralized approach for quality improvement in a hospital and concluded that implementing CQI in hospital departments is a viable alternative to organization-wide implementation strategies [20]. Project-byproject quality improvement is a conventional option and through culture building, in the long run, it may bring about organization-wide improvements. In our case, program implementation was led in an efficient manner (considering the number of projects finalized, mean trainer’s performance scores, satisfaction scores and post-test trainee scores, and the uneventful delivery of the successive stages of the package). Further, top management’s support was present throughout. Although we do not have detailed observations characterizing the improvement projects outcomes and behavioral change in the participants, we did survey the attitudes of the participants. Given that 60% of the respondents reported having conducted further improvement projects, we infer that favorable behavioral change has occurred. Given that more than 70% of participants rated a positive impact on a variety of outcomes, beneficial organizational changes can be inferred. More importantly, the exercise provided an opportunity for teamwork, two-way communication between staff and managers, and led to organizational learning.
Quality improvement program in a children’s hospital in Tehran
Figure 1 Evaluation survey results. Quality improvement participants judgment of the outcomes of the program. It has been reported that the introduction of quality management systems has positive effects on the staff ’s work satisfaction [24], although in our evaluation, despite a positive assessment in all other areas, the impact on employee satisfaction was relatively low. This can partly be attributed to less than optimal feedback and incentives; the roles of these factors have been emphasized elsewhere [25, 26]. This perspective was articulated by our participants as ‘what’s in it for me?’
Quality improvement in a developing country setting Some state that hospitals in developing countries have little experience with CQI methods [1] and the outcome of quality improvement initiatives may not be similar to those of the developed countries. Developing country conditions that may impede such programs include relatively lower employee income and morale, little competitiveness (arising from low or absent external incentives, low peer pressure from organizations and limited mechanisms for management accountability), more frequent unfair management practices, management turnover, lower consumer expectation, overwhelming working conditions, lower training, lack of local expertise and leadership, and a higher ratio of patients to providers [3, 4]. Similarly, it is reported that the compliance with case management and clinical practice guidelines is not high in developing countries [27]. We found scant evidence in the literature for comparative analysis of quality improvement programs in developing countries but some suggest that properly adapted improvement methods may be even better suited to the developing world than to the developed nations [28]. In developed
countries, quality improvement often encounters old-style, control-oriented management, a leadership system far more focused on finance and revenue than on improving operational processes, a strong sense of professional hierarchy and entitlement, and a lack of integration of the health care system with community resources [3]. In developing nations, the ‘crust’ of old-style management may be thinner or even absent, leaders may already be focused on the task of getting the best they can out of current resources, teamwork among health care workers may seem more familiar and community structures may be more accessible as part of health care [3]. In addition, it is expected that systematic quality improvement would optimize resource allocation and use and can break through to new performance levels [3] and might enhance development of management skills and processes in a practical manner in such countries.
Structural considerations Structure is critical if total quality management (TQM) is going to work [29]; quality improvement office views improvement in TUMS as a concerted participation of three players: the operational unit (hospital staff and improvement teams), top management and the institutional quality improvement office. Quality improvement was in fact a product of collaboration and synergism between these elements which, respectively, performed the functions of project management, support and facilitation—thus making quality improvement/ change (as an outcome) a ‘systems property’ [30]. From the perspective of organizational power, the quality improvement office’s responsibility and role with respect to improvement has been one of ‘staff authority’, i.e. to assist and give advice
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[31]. The quality improvement office is outside the chain of command and lacks ‘line authority’ to make decisions and issue orders down the chain of command. The office’s ‘expert’ status and ‘connection’ (to the university’s chancellor) power helped it influence the staff and effect change [32]. In the evaluation survey, respondents cited the absence of a long-term support [resources (budget, staff and equipment)] and incentive payment system as major barriers to improvement activities and their sustainability. A formal intramural support and an evaluation structure (including local facilitators and improvement project champions) should address these factors; a specific procedure for improvement activities should be defined that clarifies the following elements: how improvement projects are identified and formulated, how teams are organized, how facilitation and technical support are to be provided, how they are to be followed-up and how they are rewarded. Attention to these steps should institutionalize quality improvement activity within the working of an organization, i.e. make them routine and intrinsic (see below).
Ensuring involvement of the staff and ultimately enabling change within the system needs: opening of communication channels and listening to the employees, a continuous push or encouragement toward higher standards, coaching, recognition of accomplishments, removal of favoritism and an atmosphere of teamwork (instead of power and politics). These are significant leadership challenges. Only with sustained motivation can the quality improvement process be sustained. Externally the organization and its management should receive incentives from a market-driven competitive environment or through quasi-market policies adopted by the regulators or higher-level management. CQI is an organizational culture and largely the product of the organization’s leadership and motivational system. Building a culture takes time. Although CQI is a long-term effort, we should not wait until the ideal culture has evolved. Results themselves build culture. Although our improvement initiative was successful in many ways, the employees’ perceptions suggest cultural change is incomplete. This transformation and behavioral change may require the establishment of support systems and financial incentives [25].
Project ownership and facilitation Considering the type of involvement and participation, implementation of an institutional quality improvement program can be achieved in two primary ways: (i) expertowned—a consultant- or quality-specialist-driven program employed on an ad hoc basis and (ii) self-owned—a program owned and driven by the staff, but potentially supported by outside consultants or specialists. Beckford [33] suggests that the latter approach is preferable. From the Children’s Hospital’s perspective, quality improvement office members are considered external consultants but from the perspective of TUMS top management, they are internal change agents assisting a program within the entire organization. Regardless of the perspective chosen, the quality improvement training cycle was established to enable the process of change through behavior modification and empowerment of the employees to take charge of their own operations. The role of facilitators cannot be over-emphasized as they help organizations apply improvement principles and tools and help them manage change [34]. Since our quality improvement office members were exposed to extensive quality improvement experience, they could transfer their experience between improvement projects and teams. Thus, each team benefits from lessons learned elsewhere and the insights are shared across the organization. Institutionalization Sustainability of quality improvement initiatives is always a concern and even the applicability of CQI approaches to healthcare for long-term changes has been questioned and evaluated [26, 29]. Godfrey observed ‘It’s easier to begin than to keep going’ [29]. We had a similar experience. Although the evangelical fervor of TQM can help initiate projects, tangible incentives are needed to sustain the momentum or to prevent initiative fatigue.
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Physician involvement Relatively few physicians were involved in both workshops and projects. Time constraints, limited interest and accountability and the perception that physicians’ involvement was— at least at this stage—not necessary might explain this limited participation. This low level of physician involvement was an obstacle for several of the improvement projects and was a source of complaint and grievance among the nurses. There is a large, relatively untapped opportunity for quality improvement in medical processes; relevant projects could culminate in the development of clinical practice guidelines or critical pathways. Previous reports have also highlighted the difficulty of achieving physicians’ involvement and importance of physician involvement [35]. Quality metrics In most of the projects, the quality metrics used (i.e. as performance indicators of the processes) were a time measure— e.g. time taken for completion of a task, time delays until a task is initiated, etc. (see Table 2 legend). There are other quality measures (e.g. characteristics of the interaction with the patient by the healthcare workers, patient comfort or pain control, and patients’ perception of the technical excellence), which are more directly related to patient satisfaction. Time measures are relatively easy and ready for operationalization, but quantification of other measures in a reliable, valid and practical fashion can be challenging.
Acknowledgements We are thankful to Ms. A. Khadem, as the local program coordinator and to our assistants, Ms. Z. Ghomian and Mr. R. Dehghan, for their contribution in the evaluation survey.
Quality improvement program in a children’s hospital in Tehran
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