Process Improvement

Every outcome is the result of a process. This is a simple fact, just as night follows day. Every outcome for every patient every day of the year is the result of clinical care processes supported by hospital operations and accomplished by a variety of clinicians (not always working together and communicating). Performance relates to how well:

• A process might be working
• Multiple processes are integrated to work in concert with each other
• Clinical process(es) are supported 24/7 by hospital operations
• Clinicians perform individually and working together as a team.
• Patients and their families understand and participate as needed.

Performance improvement always occurs within an existing process. This means that performance within a process is limited to the capability of the process itself. If the process is a bad process, outcomes will also be bad – even with good performance. Unfortunately resources are often spent trying to improve flawed processes with little change in outcomes leading to staff frustration. It is wise to establish what the current process is (current state) before efforts are made to improve. Mapping the clinical care process may be daunting at times – but always yields good insight into the nature of the process itself. This leads to PDSA, small scale testing – and how to measure progress.

Plan, Do Study, Act (PDSA) has been accepted worldwide as a basic approach to improvement. With little effort, PDSA can be used to more fully understand current processes – and attempt meaningful change without upsetting the apple cart. PDSA offers a way to test changes to existing processes in a small way with a high degree of agreement form various clinicians. Measurements of the small scale test provide insight into the process itself.

Much of the measurement in healthcare today employs measures of central tendency: the mean and median. When data seems out of line with the experience of the clinician, the data is declared to be an “outlier� and often not included in the dataset. Furthermore, hospitals are being run more and more on a quarter to quarter basis with business goals becoming pre-eminent. In this context, an improvement in the mean or median leads to a bonus to the executive in charge of the business unit. All of this may work – at least for a time – in performance improvement. But it can be contrary to true change and process improvement. Here is why…

The mean and median may work well in normally distributed populations. But most of our clinical work occurs in the real world – and the population we serve is not normally distributed as you may find in research. In fact, the term “outlier� is a defined statistical term that occurs ONLY in normally distributed populations. Outliers are really patients whose care did not mean an expected outcome. They are not outliers. They are variances! Instead of focusing on measures of central tendency and throwing out data that does not meet goal, it would be much more productive for healthcare to consider measures of dispersion – and try to understand variation that occurs in a process – and eliminate it. Control charts and run charts work well when describing clinical processes.

Control chart analysis is not difficult. But it does require some level of understanding. The upper and lower control limits reflect variation in a process. When improving a process, one goal is to minimize variation. When this occurs, the measure of dispersion (distance between upper and lower control limit) decreases. Remarkably enough, this can actually cause an increase in the mean and/or median. After much of the variation is eliminated, then the process operates at a new level – and at that point, the mean makes a quantum change for the better. This cycle typically takes 16-18 months. That means that the CEO is waiting for six quarters to show improvement in the mean – and does not get his bonus! With such perverse incentives to improvement, it becomes easier to understand why performance improvement often trumps process improvement in healthcare.

The Colloquium does not claim to have a solution to this difficulty. However, we do at least create an awareness that it exists. We promote mapping of clinical care processes – and encourage true process improvement in our accreditation process. We believe that not all change is improvement. But all improvement is change.