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Martin Thrasher
Health care delivery systems that are working to improve patient experience can face daunting challenges, reflecting the need to align changes in behavior and practices across multiple levels and areas of the organization. But the process of planning, testing, and eventually spreading those changes does not have to be overwhelming. Health care organizations can take advantage of established principles and approaches to quality improvement, which are already familiar to the many providers involved in clinical quality improvement (QI).
This section of the Guide suggests a way to use the concept of microsystems to focus the QI process on the locus of responsibility for patient experience, provides an overview of the process of quality improvement, discusses a few well-known models of quality improvement, and presents a few tools and techniques that organizations can use to address various aspects of patient experience.
Place a priority on encouraging communication, engagement, and participation for all of the stakeholders affected by the QI process. Learn what is most important to the people who make up the microsystem and look for ways to help them embrace the changes and begin to take ownership of them.
Start your implementation of improvements with small-scale demonstrations, which are easier to manage than large-scale changes. Small-scale demonstrations or small tests of change also allow you to refine the new processes, demonstrate their impact on practices and outcomes, and build increased support by stakeholders.
Keep in mind and remind others that QI is an iterative process. You will be making frequent corrections along the way as you learn from experience with each step and identify other actions to add to your strategy.
The concept of microsystems in health care organizations stems from research findings indicating that the most successful of the large service corporations maintain a strong focus on the small, functional units who carry out the core activities that involve interaction with customers.1 In the context of health care, a microsystem could be:2
Examples of microsystems include a team of primary care providers, a group of lab technicians, or the staff of a call center. In the patient-centered medical home model, a microsystem could be the patient's care team accountable for coordination of the patient's services that address prevention, acute care, and chronic care.3
The goal of the microsystem approach is to foster an emphasis on small, replicable, functional service systems that enable staff to provide efficient, excellent clinical and patient-centered care to patients. To develop and refine such systems, health care organizations start by defining the smallest measurable cluster of activities.
Once the microsystems have been identified, a practice or plan can select the best teams and/or microsystem sites to test and implement new ideas for improving work processes and evaluating improvement.5 To provide high-quality care, the microsystem's services need to be effective, timely, and efficient for all patients,4 and preferably designed in partnership with patients and their families.
If a quality improvement intervention is successful for a microsystem, it can then be scaled to other microsystems or the broader organization. However, for successful scalability, organizations should adopt a framework for spread that will work within their structure and culture.
Although QI models vary in approach and methods, a basic underlying principle is that QI is a continuous activity, not a one-time thing. As you implement changes, there will always be issues to address and challenges to manage; things are never perfect. You can learn from your experiences and then use those lessons to shift strategy and try new interventions, as needed, so you continually move incrementally toward your improvement goals.
The fundamental approach that serves as the basis for most process improvement models is known as the PDSA cycle, which stands for Plan, Do, Study, Act. As illustrated in Figure 4-1, this cycle is a systematic series of steps for gaining valuable learning and knowledge for the continual improvement of a product or process. Underlying the concept of PDSA is the idea that microsystems and systems are made up of interdependent, interacting elements that are unpredictable and nonlinear in operation. Therefore, small changes can have large effects on the system.
The PDSA cycle involves all staff in assessing problems and suggesting and testing potential solutions. This bottom-up approach increases the likelihood that staff will embrace the changes, a key requirement for successful QI.9
When you are ready to apply the PDSA cycle to improve performance on CAHPS scores, you will need to decide on your goals, strategies, and actions, and then move forward in implementing them and monitoring your improvement progress. You may repeat this cycle several times, implementing one or more interventions on a small scale first, and then expanding to broader actions based on lessons from the earlier cycles.
The team's first task is to establish an aim or goal for the improvement work. By setting this goal, you will be better able to clearly communicate your objectives to all of the sectors in your organization that you might need to support or help implement the intervention.
The goal should reflect the specific aspects of CAHPS-related performance that the team is targeting. It should also be measurable and feasible. One of the limitations of an annual CAHPS survey as a measurement tool is the lag time between the implementation of changes, the impact on people's experiences, and the assessment of that impact. For that reason, the team needs to define both ultimate goals as well as incremental objectives that can be used to gauge short-term progress. After defining your ultimate goals, ask "What is the gap between our current state and our goals?" Make of list of those gaps and use them to make SMART (specific, measurable, achievable, realistic, and time bound) incremental objectives.
For example, a team concerned about improving performance on the "Getting Timely Appointments, Care, and Information" composite measure in the Clinician & Group Survey may set a 1-year goal of a two percent increase in its composite score. At the same time, it could specify goals for the number of days it takes to get an appointment for non-urgent and urgent visits. Similarly, a team focusing on overall ratings may set goals for complaint rates for the health plan as a whole or for individual medical groups and then review those rates monthly.
With objectives in place, the next task of the team is to identify possible interventions and select one that seems promising. Keep in mind that all improvement requires making a change, but not all changes lead to improvement.
Section 6 of this Guide presents a number of different strategies that health care organizations can use to improve different aspects of their CAHPS performance. In addition, you may want to consult several case studies of health care organizations that have implemented strategies to improve performance on CAHPS scores.
These sources of improvement ideas offer an excellent starting point, but they are by no means comprehensive. There are many other sources for new ideas or different ways of doing things both within and outside of health care. Consequently, improvement teams should make an effort to develop and maintain systematic ways of identifying effective solutions.
One useful way to develop and learn innovative approaches is to visit other health care organizations. Resistant or hesitant staff members are often "unfrozen" by visiting another highly respected site that has successfully implemented a similar project. You can also visit a company outside of the health care industry to get new ideas. Some health plans, for example, have learned how to improve their call center operations by sending staff to visit mail-order catalog houses or brokerage firms. The Cleveland Clinic has required every doctor and senior administrator to make one "innovation site visit" a year to learn about different approaches that can be brought home and tested.
Depending on the nature of the intervention, you may want to break it down into a set of related but discrete changes. For example, if the team decides to implement a new specialist referral process, you could begin by making changes to the procedures used to communicate with the specialist's office. The communication process with the health plan might then be the target of a separate change.
Although there is no one "correct" way to write an action plan for your organization or facility, it is important to have some form of written document that states your goals, lists your overall strategies to achieve those goals, and then delineates the specific actions you will take to implement the interventions you have selected to address the identified problems. One way to organize the action plan is to review the following key questions as a team and document your answers:
It also helps to lay out the calendar for all actions in a Gantt chart format, so you can verify that the timing of sets of actions makes sense and is feasible to complete with the staff you have available.
When a team establishes its goal, it typically specifies one or more performance metrics to assess whether a change actually leads to improvement. These measures should be clearly linked both to the larger goal and to the intervention itself. For example, if the goal is to speed specialist referrals, you could measure the time it takes to get a response from the specialist's office or an approval from the health plan.
Seek a feasible number of measures that address the most important aspects of the improvements you are trying to achieve. Too many measures could create a burden on the staff, leading to loss of attention due to information overload; too few measures may omit tracking of important aspects of the changes you are making.
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