Chapter Six
A Guide to Implementing and Monitoring Quality Improvement Initiatives

6.1 A Brief Introduction

In this chapter, I will touch on some general strategies that office-level health-care leaders and others can use to help them successfully implement and monitor quality improvement (QI) initiatives. Like a typical planning-based guide, I will focus on each of the key stages in the implementation process. However, I do not intend to delve into the nuanced aspects that are part and parcel of many continuous improvement (CI) discussions. For one thing, numerous authors have already written extensively on these subjects and have produced a plethora of charts, graphs, tables, and the like. Perhaps more importantly, if I created a detailed, technical how-to-guide, I would probably need to settle on one type of CI strategy such as Six Sigma or Lean. By taking this step, I would leave out readers who utilized a different system than the one I chose.

Instead, I will proffer some overall tips that office-level healthcare leaders can utilize to help them improve workplace efficiency and effectiveness. I will also instruct administrators on how to successfully engage stakeholders in the CI process. Specifically, I will discuss some techniques that these individuals can employ to help them identify problems and develop lasting solutions to these issues. I will also introduce methods that office-level leaders can use to help them convince superiors, colleagues, and subordinates to buy into (or at least to refrain from hindering) a QI initiative. Additionally, I will provide readers with some advice on how to manage stakeholder expectations. Finally, I will denote points in a continuous quality improvement (CQI) process when administrators should seek to interact with other employees in an attempt to gather valuable information and data. At the same time, I will show readers how to handle these situations so that they garner the necessary information without agitating or angering staff.

While I believe that most people will gain some key insights from reading this chapter, I feel that administrators who work for small or resource-challenged healthcare institutions will be particularly pleased with the material in this narrative. I hope to provide office-level healthcare leaders who labor in these challenging environments with specific tips that they can use to successfully implement and manage CI projects. In my opinion, business and health-care experts too often ignore these individuals; I hope to rectify that situation.

6.2 Some General Tips for Improving a Department’s Efficiency and Effectiveness

In some cases, healthcare administrators can help employees improve their quality metrics and increase their productivity levels without performing any complicated or detailed CI analyses. Below, I have listed several straightforward strategies that healthcare supervisors can employ to make their departments more efficient and effective.

  • Fix the Printer Problems: Most readers have probably worked for a company whose printers and copiers are incapable of handling the organization’s workload, which leads the systems to malfunction on a routine basis. In these instances, healthcare employees have to waste time either fixing the machines themselves (e.g., by removing paper jams) or waiting for someone else to come and repair the apparatuses. Staff often become frustrated when they have to suffer through these types of delays, thereby negatively impacting office morale. I have even seen workers become so agitated that they (sometimes with good reason) kick these photocopiers. A number of CI experts rightfully point to this issue as a poster child for wastefulness (Morgan & Brenig-Jones, 2012, p. 162; Simplicated, 2012).

    Given the amount of time that employees waste when they have to use suboptimal printers or copiers, one could argue that management should upgrade the devices when they prove inadequate for the particular company’s needs. However, many healthcare leaders choose not to do so because they lack the resources to purchase a new machine, or they erroneously assume that the costs of using an inadequate photocopier are less than the benefits of purchasing one that can handle their specific firm’s workload (Morgan & Brenig-Jones, 2012, p. 162). office-level health-care leaders rarely have a say in this matter because upper-level personnel generally control these purchases. However, when it makes sense from a cost–benefit perspective, administrators, either through the budgeting process or via another method, should nonetheless petition their superiors for permission to buy a small printer for their particular department or to upgrade the existing company equipment.

    If a healthcare administrator’s staffmembers complain about the unit’s printer and the supervisor decides to approach management about the issue, he or she should inform the employees of this action. If this individual succeeds in convincing superiors to upgrade the equipment, the department’s personnel might be able to achieve efficiency-related gains. Even if the office-level leader is unable to fix the copier problem, that person will likely still get a “win” by standing up for his or her employees’ needs. In short, some of the workers will hold their supervisor in higher regard because he or she “looked after them.” At the same time, the administrator will be meeting his or her obligations to staff (and to himself or herself) by serving as their advocate.

  • Create Digital-Based Decision Support Tools: Given the prevalence of computer-based technology in Americans’ lives, it is ironic that many healthcare employees still have to rifle through reams of paper in order to locate answers to basic job-related questions. In my experience, workers who have to thumb through a manual to find information waste signifi-cant amounts of time. As a solution to this problem, I would suggest that office-level healthcare leaders develop digital-based decision support and resource pages that enable staff members to access requisite information via computer icons, tabs, or links. If created properly, these virtual systems, when compared to paper-based alternatives, will allow workers to identify and bookmark key data with greater celerity. At the same time, an optimal site would contain a combination of video, audio, and text-based entries. This is because individuals’ learning styles vary; some more readily imbibe information when it is in text form, whereas others learn faster by way of auditory or visual cues (Kelly & Anthony, 2011, p. 168). From what I have seen, administrators who take this step will have to devote some upfront costs and time to the effort; however, over the long run, their departments will realize significant benefits—in terms of staff efficiency gains.
  • Learn Basic Shortcuts: In my experience, a large percentage of employees fail to utilize all of the timesaving shortcuts and hotkeys that are available to them. They exhibit this lack of knowledge most often when they try to switch screens, programs, or processes. A healthcare administrator can rectify this situation by training all of his or her staffmembers to find and use whatever time-saving tools are embedded within their work programs (including Microsoft-based operating systems and office tools). If possible, he or she should also incentivize workers to utilize these hotkeys. The office-level healthcare leader might sacrifice some short-term efficiency gains due to training requirements and employee-related learning curves; however, his or her department will benefit in the long run. This is because staff are more productive when they properly utilize all available time-saving techniques.

  • Reduce or Eliminate Shadow Systems: Staff can create shadow systems when they routinely use non-approved health information technologies (HITs) to complete tasks, or they eschew their corporation’s HITs in favor of more primitive systems (e.g., paper-based ones). For instance, assume that a healthcare company seeks to become paperless and asks its personnel to perform all of their jobs on its digital network. Instead of obeying this dictum, employees write everything down and then copy it to a computer system (adding a step in the work process). Alternatively, they may print out materials so they can peruse them in paper format (Fisher, 2014).

    Sometimes, healthcare staff might be able to work more effectively and efficiently by utilizing shadow systems because they employ tools, techniques, or devices that are faster and better than the ones that are supported by management (King, 2012). However, speaking just from my experiences, I have noticed that, more often than not, employees who use non-approved HITs or other tools decrease department-level productivity. These workers utilize outdated systems (or methods) because they do not want to learn how to operate the new ones. At least in clinical situations, the staff’s reliance on shadow systems might violate federal laws, such as HIPAA, or lead to an increase in medical errors (Amatayakul, 2003, pp. 16A–16C).

    I feel that office-level healthcare leaders must attempt to reduce or eliminate these shadow systems unless these people can clearly enunciate the benefits in keeping the processes in place. At the same time, administrators, whenever possible, need to eschew using coercive methods to get their employees to make the necessary changes (see Chapter 2 for reasons to support this argument). I believe that managers and professionals with de facto power should instead use logic or positive incentives to encourage staff to transition away from the use of these shadow systems. Healthcare supervisors can also try to work with subordinates to find appropriate compromises (e.g., reducing paper usage by 50 percent instead of going paperless).

  • Build in Redundancies: Although office-level healthcare leaders want to run a lean operation, they can sometimes take things a step too far. Most readers can probably recall situations in which supply or personnel shortages wreaked havoc on a department’s efficiency and effectiveness. With that fact in mind, an administrator should, whenever feasible, build redundancies into the workflow system, including training staff to handle multiple duties and slightly overstocking key office items. That way, the supervisor will be ready when an employee leaves suddenly or the unit does not receive key materials on time (Hopper, 2016, pp. 131–132).
  • Purchase or Build HITs That Are a Little Faster and a Tad Bit Better Than Necessary: Many office-level healthcare leaders have little to no control over HIT acquisitions. However, when they do have some degree of power in this area, they should opt to purchase, build, or lease systems that are a little faster and better (e.g., in regard to data needs or processing speeds) than absolutely necessary. By taking this step, an administrator will buy time for the office to upgrade HIT infrastructures in the event that the department ramps up production quickly or goes on a hiring spree.

A healthcare administrator might be able to take any of the aforementioned actions without having to develop a full listing of the costs and benefits of doing so. That is because a supervisor will often clearly be able to see the value in making the proposed changes. For instance, if a manager walks by an employee’s desk and notices that this person wastes a significant amount of time switching back and forth between two websites, he or she does not have to perform any detailed cost–benefit analysis to justify showing the worker how to use Alt-Tab or to create a split screen view.

6.3 CI at Small or Resource-Challenged Institutions: Fewer Team-Related Projects but Employee Cooperation Is Paramount

From what I have read, CI-related literature too often assumes that healthcare executives and office-level leaders have ready access to the personnel or financial resources that are necessary to perform many formal CQI initiatives. For one thing, many theorists and business experts suggest that healthcare organizations utilize teams to perform most CI-related tasks; they take for granted that the companies have the necessary human capital to devote to group projects. Other CI proponents insist that firms utilize fully credentialed practitioners (e.g., Six Sigma black belts) or train a significant amount of the workforce in specific CI techniques. Small or resource-challenged institutions might not be able to meet these goals, given the high costs involved (both real costs and lost opportunity costs) in training people in a particular CI-related discipline (Sharma, 2003, p. 16; Sheridan, 2000, p. 35).

Office-level leaders at small healthcare organizations, and even those at larger firms that face resource-related challenges, might not be able to call upon the services of credentialed CI practitioners or fully staff QI teams. However, these individuals can still utilize CI techniques to help their particular department (or company) improve its effectiveness and efficiency. This is because, at least in my experience, managers and professionals with de facto power can perform many CI-related endeavors on their own. Although they might not have to put together a formal team in order to craft, implement, and monitor CI initiatives, they do need to work closely with both superiors and subordinates to ensure their projects’ success. After all, almost every corporate activity in the healthcare field is a shared endeavor (Thompson, Buchbinder, & Shanks, 2012, p. 2). This is especially true at small or resource-challenged firms. Hence, an administrator at one of these places needs to gain the cooperation of his or her counterparts in order to successfully implement and sustain CI projects.

In the proceeding narrative, I will provide readers with some guidelines that they can use to help them successfully develop, implement, and monitor QI initiatives. Although I will discuss each of the steps in the process (as I typically go about them), I will focus most of my attention on general ideas and communications strategies. That way, healthcare administrators who work with a diverse array of CI-related tools will find the material to be helpful. Using my experiences in working for small healthcare firms as a guide, I will describe the process from the perspective of someone who does most of the legwork by himself or herself. As a result, the information in this chapter might be especially relevant to administrators at resource-challenged institutions.

6.4 Keeping Things Simple

As most readers can attest, project planning and implementation, regardless of whether it relates to CI-focused initiatives, is a diverse and complex topic. Individuals’ views on the subject will differ based on numerous factors, such as their situation, the size and scope of their particular organization’s operations, their preferred methodological system, and so forth. I have taken a few liberties in this chapter in order to keep the page length manageable and the discussion organized and on target. First, as I noted in the previous section, I will, for the most part, assume that an administrator is working on a CQI project by himself or herself. I take this point of view in part because that is how I have conducted most of my projects and partly to avoid having to spend time distinguishing between team-based and solo initiatives. Second, I do not discuss roll-out strategies because (a) doing so would add complexity to the discourse without neces sarily helping to flesh out my main arguments; and (b) people can use the information in this chapter to help them create a multistage implementation plan (they will need to utilize other sources to help supplement their learning in this area). Finally, in this narrative, I strive to provide readers with sometimes unique and valuable information that is based on my experiences as a healthcare administrator and analyst. With that fact in mind, I often gloss over areas that others have covered in depth.

6.5 IPPIM

As I noted in the previous section, I have handled a number of CI-related projects for small healthcare institutions. In these instances, I have usually worked by myself on these initiatives (with the aid of others but not on a traditional team). When engaging in one of these endeavors, I usually follow a multistage process that consists of five basic steps, which I will call IPPIM for short. These phases include:

  • The Ideas Generation Stage
  • The Presentation Stage
  • The Planning Stage
  • The Implementation Stage
  • The Monitoring Stage

6.6 IPPIM versus ICADE

My IPPIM methods correspond closely to the key CI phases that I denoted in Chapter 3, which include identifying the problem or issue, coming up with a plan of action, analyzing existing practices, designing and executing improvements, and evaluating and reevaluating the implementation process (ICADE) (Kelly, Johnson, & Sollecito, 2013, pp. 103–105; Louisiana Department of Children and Family Services, 2016; Spath, 2009, pp. 106–107, 156–161). The key difference between the two, in my opinion at least, is that my IPPIM method is perhaps better suited for administrators who work at small or resource-challenged healthcare organizations.

Additionally, my IPPIM system, like any other delineation of CI processes, is to an extent arbitrary. By that I mean to say that healthcare administrators, depending on their own unique office situations and the specific projects they have to complete, might not perform all of the tasks under each heading in the order that I have listed them here. Additionally, some of these indivi duals might be able to skip the presentation phase (more on that in a later section). Regardless, I think that most readers will find something of value in the upcoming sections.

6.7 The Ideas Generation Stage

When I decide to undertake a QI project, I always begin the process by trying to generate some improvement ideas. This is the “I” stage in my IPPIM strategy. In this phase, I want to identify important issues that are negatively impacting a certain area. I do not overly concern myself at this point with the root causes of these problems but instead focus on more general concerns. I also try to achieve other key objectives. My goals in this step of the IPPIM process include:

  • Developing a Clear Understanding for How the System Works
  • Establishing the Initial Relationships with Key Stakeholders
  • Identifying Pivotal Problem Areas
  • Coming Up with Potential Improvement Ideas

6.7.1 Clearing Up an Ambiguity: Causes versus Problems

Readers will note that, in the Ideas Generation Stage, I use the terms “problems” and “issues” but avoid mentioning “causes.” That practice is intentional. Sometimes, an administrator will take on a project that involves several departments. In my experience, this usually happens at a small company when an individual voluntarily accepts an assignment during a manager’s meeting or when that person’s higher-up orders him or her to take on the task. In these instances, the administrator must first identify the meta-issues before he or she can worry about the causes of these problems. At other times of course, the office-level healthcare leader will already know what the concern is that he or she wants to tackle. The leader can then immediately get to work trying to divine its key factors.

Following this logic, the healthcare administrator might first have to identify the problems he or she wants to tackle and then enter the presentation phase before moving on to the next steps. For instance, the administrator may initially need to posit a list of “potential problems to tackle” and disseminate this document to his or her boss or to a committee. This overseeing body—whether a group or individual—would then decide which issue is most important. Only at that time can the administrator start to discern the root causes of the chosen area of concern.

6.7.2 Get to Know the Relevant Technologies and Employee Workflow Processes

Before a healthcare administrator can begin to work on ameliorating process-related problems in a workplace, he or she must first identify the key issues that are impeding the staff’s productivity or quality levels. As an initial step, this individual should make sure that he or she is intimately familiar with every employee’s key job tasks. The supervisor must also know how to operate all of the HITs and other computer-based systems that impact the departments that are under assessment. If the office-level healthcare leader does not perform these actions, the person will have difficulty in pinpointing, let alone solving, a target area’s key problems.

Usually, a healthcare administrator will not have to do much, if anything, to achieve these goals because he or she has worked in a particular department for some time. However, on occasion, this person might not possess a good understanding of some key worker-related job tasks or HIT systems. This type of situation may occur when the office-level leader is a recent hire or when he or she handles a project that encompasses several units. In these instances, this individual must then endeavor to study up on the relevant workplace-related topics before moving on to the next step in the ideas generation stage.

As an example, I served as the team leader (which more closely equated to the assistant manager) for a small healthcare organization’s insurance billing and document services units. I left the company for a few years. During this time, the corporation’s accounts receivable area grew substantially (the firm added several departments), and it transitioned from using a paper-based patient data storage system to an electronic one. A few years later, the company’s vice president of revenue cycle management called me on the telephone and asked me to come back to work for the firm as an internal consultant. As a key task, I had to find a way to reduce the sizeable backlog of unprocessed claims.

Before I could begin to solve this problem, I had to understand all of the relevant employee-related roles and responsibilities as well as discern the ins and outs of the new HIT system. First, I visited each department (in accounts receivable but also in other areas) and observed personnel to see how they performed key job-related tasks. I then studied the electronic client database system to learn (a) how to use it; and (b) how it collected, recorded, and presented customer information. By taking these steps, I was able to develop a working knowledge of the firm’s revenue cycle system. I could therefore more easily identify weaknesses and bottlenecks in this process and pinpoint the root causes of these issues.

6.7.3 Review Relevant Data and Talk to Key Stakeholders

As the next step in the process, an office-level healthcare leader should review any relevant data and talk to employees in an effort to identify specific issues. Often, I have found that if I look at process-related information (lag times, productivity rates, types of items backlogged, etc.), I can detect important problems without having to use anything more than basic math and statistics. Sometimes, all one has to do is peruse a data set to pinpoint key areas of concern. An administrator who is involved in a do-it-alone QI project should also try to converse with coworkers to see if they can provide insight relating to process- or workflow-related issues (Strosniak, 1999, p. 44).

A healthcare supervisor who is handling a QI project should talk to relevant stakeholders, not only in an effort to acquire information but also to establish positive relationships with these individuals. An office-level healthcare leader can use these conversations to aid him or her in developing bonds of trust with pivotal frontline staffand supervisors. The administrator can also leverage these discussions to help ease any employee-related anxiety over possible job-related adjustments. Many workers do not like change, especially when they think that the alterations might endanger their continued employment with their firms (Kanter, 2012). In my experience, these people are willing to cooperate with the project leader, but only if they feel secure in their positions. In any event, the administrator needs to establish good relationships with key personnel early on in order to ensure that they cooperate with him or her throughout the CQI process (Keller, 2008).

I learned this fact the hard way. One time, I set out to analyze some workers’ job habits in an effort to identify opportunities to increase this group’s productivity and efficiency (as well as to update employee job descriptions). I went around and observed each of these individuals. As part of this process, I asked them a lot of detailed questions without fully explaining my reasoning for posing the queries. Additionally, I occasionally brushed these people aside and performed the tasks myself to see how fast I could complete them. Needless to say, I demonstrated a lack of empathy with the workers’ needs and unintentionally showed a disdain for their concerns. As a result, I ruffled some feathers, thereby causing problems for me and others.

6.7.4 For Interdepartmental Projects: Make Sure Everyone Understands and Accepts the Power Arrangements

If a healthcare administrator handles a CI project that involves more than one department, and if this individual either leads the CQI team or works alone, then that person might have temporary authority over people who would normally outrank him or her. In the space below, I delineate some of the issues that can crop up in these situations and discuss ways to ameliorate the concerns.

  • Reduce Friction: In my experience, leaders at any level often become agitated when they feel that their control is threatened. In these cases, the administrators or executives will often seek to work against anyone who they believe is taking power away from them. To set their minds at ease and thus gain their cooperation, a person who is working on a multi-department QI project needs to assure any management-level personnel that his or her authority is temporary. At the same time, the individual needs to let these employees know what the boundaries of his or her power are in regard to the project.
  • Gain Their Cooperation: Even if a project manager has temporary power over peers or superiors, he or she should only use this authority when absolutely necessary. Instead, the administrator should, through the use of logic or other noncoercive means, try to persuade these employees that it is in their best interests to perform requisite actions related to the CI process. In my experience, the office-level leader can often convince these people to go along with his or her ideas by answering their “why” questions (e.g., showing these men and women how their participation will positively impact productivity and quality in their respective areas of control). By taking this approach, the supervisor is less likely to anger or agitate his or her coworkers and is thus more likely to gain their cooperation (McIntyre-Birkner & Birkner, 2001, p. 10; Murray, 2010, loc. 541).
  • Stay Positive: In my experience, someone who stays calm, smiles often, and exhibits a positive demeanor is much more likely than more dour peers to gain the trust of people that he or she only temporarily outranks. Business leaders agree with my assessment on this topic (Graves, 2012, p. 10; Shankar, 1998, p. 7).
  • Consider the Bigger Picture: Any administrator who finds himself with temporary authority over peers and superiors needs to remember that the power is only transient. If the office-level healthcare leader abuses this control—or even exercises it too harshly for good reasons—then he or she might permanently harm key interdepartmental relationships. As a result, the individual may need to refrain from forcing coworkers in other departments to accept some types of change, even when these adjustments will improve quality or increase productivity.

6.7.5 Developing the “Problems to Tackle” List

In my experience, an administrator at a small or resource-challenged healthcare company who finds himself or herself in charge of a large QI project will, after surveying a particular area or process, denote many problems that could be solved. However, this individual will only be able to tackle one or two of these concerns at any given time. At this stage, this supervisor should use whatever tools he or she deems advisable to help to sort the issues into categories, including the following:

  • Problems that the administrator can quickly correct
  • Areas of concern that management deems to be of high priority
  • Issues that the office-level leader can solve using a moderate amount of resources
  • Problems that the administrator will only be able to fix by expending significant amounts of time or resources
  • Issues that the office-level leader does not believe can be ameliorated at this time, given the current workplace environment or available resources

Ideally, the healthcare administrator will be able to identify a problem or series of issues that fall into one of the first three categories. When creating this list, the supervisor needs to consider (and keep in the back of his or her mind) other topics that do not easily fit into a cost–benefit model, including ones related to office politics and employee morale. Once the healthcare leader has completed these tasks, he or she can progress to the presentation stage.

6.8 The Presentation Stage

During the presentation stage, an office-level healthcare leader must discuss his or her improvement ideas with supervisors or peers. If this process occurs immediately after the ideas generation phase, this administrator will usually then work with these people to decide which of the listed problems to tackle in the near term. Given the diverse array of healthcare workplace settings, a supervisor might have to prepare for any of a myriad of different interaction-related formats. For instance, a manager might verbally go over the “problems to tackle list” with a vice president or director who would then determine which of the issues he or she wants the office-level leader to work on. As another example, a department supervisor may have to present a list of potential QI projects to a group of fellow managers (and other leaders). This individual will have chosen the initial project-related targets in advance and will defend his or her decisions in this meeting. These are only two of the various types of situations that an office-level healthcare leader might find himself or herself in during the presentation stage. A person who is working on a CI project, either alone or as part of a team, might enter the presentation stage at any time during the course of the IPPIM—either to present ideas or to defend project-related choices.

Obviously, a healthcare administrator will have to adjust his or her presentation strategies to fit the particular situation. For instance, an individual who is discussing a CI-related project with coworkers might utilize techniques that are different from the ones that he or she would use when speaking to a direct supervisor in a one-on-one session. At the same time, the leader of a CQI initiative who has done most of the research and at least some of the planning would generally provide his or her superiors and peers with a more detailed, nuanced analysis than would someone who enters the presentation stage immediately after identifying potential problems.

Despite this diversity, I think there are some basic strategies that office-level leaders can use to help them succeed in any type of presentation-based environ ment. With that fact in mind, I will assume, for simplicity’s sake, that the administrator works for a small or resource-challenged healthcare organization. Additionally, I will take for granted that the individual reports to a supervisor after doing some light research and identifying potential problem areas. However, I feel that readers who are working on CI projects will be able to use much of the information that I posit here, regardless of where, when, or how they enter the presentation stage.

6.8.1 Go into the Meeting with a Clear Strategy and Do Not Forget about Secondary Goals

An office-level healthcare leader wants to go into any CI-related presentation with a clear strategy. More specifically, this individual needs to decide in advance what primary and secondary goals he or she is trying to accomplish via the QI initiative. This administrator must also be cognizant of the resources he or she will require in order to complete the project. If the meeting is informal, he or she would then develop a “talking points list” (either by writing ideas on paper or keeping them in his or her head). This person will use it to guide the discussion, defend his or her choices, and justify any resource requests. In a more formal setting, this administrator might create a PowerPoint presentation or something similar that can be used to help support his or her oral arguments.

Managers and professionals with de facto power will have more success in achieving their presentation-related objectives if they maintain good working relationships with their peers and superiors. They also want to make it a point to know as much about these individuals as possible. This is especially important when they are meeting with higher-ups or coworkers who are relatively new to the company. Most readers will find these statements to be common sense; however, too often I have seen office-level healthcare leaders ignore them.

As I noted in a previous book, administrators, especially ones who work for small or resource-challenged healthcare companies, should try to ensure that any initiative accomplishes multiple goals. Individuals who think in this way will be able to maximize their time and resources (Hopper, 2016, p. 205). Following this logic, they should undertake CI-related projects not only with an eye to achieving efficiency or effectiveness gains but also to meeting other, sometimes unrelated, objectives.

An office-level healthcare leader might seek to accomplish any number of secondary objectives during the course of the IPPIM process. For instance, this individual may desire to achieve one or more indirect goals during the presentation stage. Alternatively, the administrator might simply want to ensure that he or she leaves a meeting having secured the requisite resources to accomplish any secondary aims at later points in the IPPIM. Although an office-level healthcare leader’s indirect objectives will vary based on his or her particular situation, the person must make sure both that these goals are ethical and that they meet his or her obligations to stakeholders, as discussed in Chapter 2.

Below, I have posited three examples of possible secondary goals that help to illustrate my main point:

  • Building Bonds of Trust: An office-level healthcare leader might have a new supervisor (e.g., a recently hired vice president or director). This administrator, in an effort to incur the superior’s trust, chooses to focus on a CI project that he or she knows can be accomplished on schedule and under budget.
  • Getting a Win for the Office: A healthcare administrator’s employees are suffering from low morale. In response, this individual eschews CI projects that are lengthy and complex but nevertheless yield the greatest efficiency-related gains. Instead, the office-level healthcare leader throws his support behind a CQI initiative that the staff can quickly complete but results in fewer benefits. In this way, the manager opts to support a CI-related endeavor that can provide his or her office with a morale-boosting win, even if it does not provide the best long-term outcome.
  • Improving Office-Based Relationships: The employees in the health-care administrator’s department have traditionally not gotten along well with their coworkers in an adjacent area. With this fact in mind, the individual crafts a CI-related project that, as a secondary goal, seeks to reduce these tensions.

6.8.2 Tailor the Presentation to Offset Supervisor or Peer-Related Weaknesses

In my experience, everyone, regardless of his or her accomplishments or station in life, has biases and weaknesses. For instance, an individual might be great at seeing the big picture but have problems in conceptualizing the steps needed to get there. On the other hand, someone might excel in understanding highly technical, nuanced charts but have problems in visualizing issues from a systemic point of view. Additionally, most people have difficulty in mastering some skills (e.g., math, reading comprehension, writing, emotional intelligence, etc.).

A healthcare administrator, when possible, should take this fact into account and craft his or her CI proposals in such a way that supervisors and peers, regardless of their biases or weaknesses, can objectively judge each potential CQI project on its merits. For example, if an office-level leader plans to discuss his or her suggested initiatives with higher-ups who learn best when they are able to visualize processes, this individual should come to the meeting armed with images, charts, storyboards, and the like. The administrator can use these visual aids to support his or her verbal comments or to add context to written documents. In another instance, if an office-level leader is dealing with individuals who are biased towards seeing only the project-related benefits, that person needs to stress, to a higher degree than usual, the potential setbacks or pitfalls that might thwart or hinder the CI-related strategies.

In my experience, a healthcare administrator can benefit in several ways if he or she takes these actions. When an office-level leader ensures that his or her supervisors and peers fully understand a QI project’s advantages, costs, and barriers, he or she will get more accurate feedback from these people. Additionally, I have found that executives and coworkers recognize that they possess shortcomings and are generally thankful when an individual, in the most subtle and tactful way possible, helps them to offset these weaknesses or biases. In turn (at least from what I have seen), they are more willing to forgive any errors that the administrator might make. Finally, an office-level healthcare leader should generally want to do what is best for all key stakeholders, including himself or herself (see Chapter 2). He or she can best achieve this goal when everyone involved—and especially the higher-ups—have a clear view of a QI project’s potential benefits and disadvantages.

6.8.3 Trust Is Vital

Anyone who has overseen a complex initiative (regardless of whether it is related to CI) knows that, for it to succeed, key stakeholders must trust each other. With regard to the presentation phase, an individual who is working on a CQI project must garner his or her superiors’ confidence (Sollecito & Johnson, 2013, p. 56; Wilson, 2014). If these people do not have faith in the healthcare administrator who is handling the venture, they might withdraw their support for the plan. Alternatively, they may try to micromanage the scheme or otherwise restrict the office-level leader’s freedom, which might hinder the process and negatively impact the project’s chances of success (Fried & Carpenter, 2013, p. 138).

In my experience, administrators need to place a special focus on building these bonds of trust if they work for small or resource-challenged healthcare organizations. Executives and directors at these companies often do not have the requisite personnel and materials to accomplish all of the organization’s daily goals. They will therefore be hesitant to approve CQI projects and quick to pull the plug on the ones they do authorize unless they have complete trust in the individuals who are overseeing these ventures.

As I noted earlier in the chapter, I previously worked as an internal consultant for a small healthcare company. During my time in this position, I not only managed to significantly reduce the organization’s claims-pending backlog, but I also successfully completed a number of other key projects for the corporation. In thinking back on this time, I believe that one of the main drivers of my success was the strong bond of trust that existed between me and my direct supervisor. This executive had enough confidence in my abilities to let me handle the projects as I saw fit. He usually only intervened to ameliorate issues that would occasionally crop up between other coworkers and me. At the same time, the vice president relied on my commentary to aid him in developing strategic initiatives that impacted several departments. I rewarded his faith in me by helping him to fix systemic issues in the revenue cycle management area, thereby allowing the firm to improve its revenue streams and decrease its costs.

6.8.4 Briefing Essentials

Office-level healthcare leaders’ CI-related presentations will vary greatly depending on factors such as the point in the process when they provide the briefing, their audience, the size of their specific organization, and their particular project’s resource requirements. In some cases, an individual might need to posit a fully developed plan that includes, among other things, a detailed problem statement, a list of goals, resource requests, and a project timeline (Ashe-Edmunds, 2016; Spath, 2009, pp. 155-156). For the purposes of this chapter, I will assume that the person briefs superiors or peers very early on in the process and thereby does not need to provide them with a significant amount of detailed information.

Granted, a healthcare administrator will need to adjust his or her presentation to fit the particular situation. However, in my experience, there are certain things that the individual should include in any briefing. Below, I highlight some of the topics or items that he or she wants to bring up during the presentation stage. Some CI experts posit similar ideas (McMahon, 2009; Spath, 2009, pp. 155–157).

  • The Problems That the Administrator Wants to Tackle: When conversing with relevant stakeholders, the office-level healthcare leader needs to delineate the issues that he or she wants to handle as part of the CI project. If this individual meets with supervisors or peers early in the planning process, he or she might only have to provide them with a quick description of the target problems.
  • An Explanation as to Why One Should Tackle These Issues: During the presentation, the office-level healthcare leader not only must pinpoint the key problems that he or she wants to fix but also explain why he or she thinks it is important to tackle these specific issues. To convince supervisors or peers to support the CI project, the individual needs to persuade them that it is in the company’s best interests to devote resources to this plan as opposed to other potential initiatives.
  • The Personnel Required: During the meeting, the healthcare administrator should denote how many people he or she will need on the team. This step can be ignored if this person is working alone.
  • A List of the Departments Impacted: During the presentation, the office-level healthcare leader should explain to key stakeholders which departments will be impacted by the project (e.g., delineate the scope of the project). Sometimes, the person can skip this step if everyone already knows which areas will be directly affected by the initiative.
  • A Manifest of the Key Employees That the Healthcare Administrator Wants to Observe or Interview: In my experience, during the presentation stage, a healthcare administrator needs to provide supervisors and peers with an initial list of the employees that he or she wants to observe or interview as part of the CI project. By taking this step, the individual can identify in advance any potential issues that might arise as a result of his or her interview/observation choices. At the same time, the administrator can garner the requisite support from coworkers and supervisors to monitor certain staff members. As part of this discussion, the office-level healthcare leader should let everyone know that the number of people on this manifest might grow.
    Figure 6.1 A healthcare administrator can use a document like the one above to help convey continuous quality improvement (CQI) proposal-related information to his or her peers or supervisors. All parties can use the briefing memo to record supervisor/peer feedback.

    Figure 6.1 A healthcare administrator can use a document like the one above to help convey continuous quality improvement (CQI) proposal-related information to his or her peers or supervisors. All parties can use the briefing memo to record supervisor/peer feedback.

  • A Request for Access to Systems or Files: If the healthcare administrator needs to gain access to certain documents or data sets that are usually beyond that person’s reach, he or she should make that request during the presentation. As part of the process, this individual must explain to supervisors or peers why he or she needs to review these files.
  • An Agreement on the Next Update: If applicable, the administrator wants to work with his or her peers or supervisors to set up the next briefing date.

As I noted earlier in the chapter, a healthcare administrator might discuss a number of important topics with supervisors or peers during the presentation stage. Depending on the situation, he or she might want to write down key information or agreements stemming from these conversations. If so, this individual can use a document that is similar to the one in Figure 6.1.

6.9 The Planning Stage

A healthcare administrator, working alone or as part of a QI team, might take any number of actions in this stage. However, in my experience, the individual must, at the very least, complete three key tasks, as follows:

  • Conduct Research to Identify a Problem’s Root Causes: Assuming that the administrator has not completed this task earlier in the process, this individual must seek to identify the root causes for the problem he or she is attempting to solve. Both Lean and Six Sigma practitioners advocate this practice (Spath, 2009, p. 113; Summers, 2007, pp. 27, 54, 95). The office-level healthcare leader must then decide which of these factors to target. This person should keep both his or her primary and secondary goals in mind when making these choices.
  • Find Ways to Ameliorate or Eliminate the Root Causes: Once the office-level healthcare leader has decided which root causes to address, this individual must come up with ways of eliminating or at least ameliorating them.
  • Create an Action Plan for Implementing and Monitoring the Solutions: After the healthcare administrator has identified the problem, its root causes, and potential solutions, he or she then needs to develop a plan for implementing and monitoring these improvements.

When feasible, I usually complete these three tasks in the planning stage. My methods are often similar to the ones suggested by other CI experts (Spath, 2009, pp. 106–116). I do not think it would be helpful to readers for me to delineate specific strategies for accomplishing each of the aforementioned steps. That is because every individual will probably do things a bit differently here, depending on his or her available resources, training, the nature of the problem, and so forth.

With that said, I do want to stress two important aspects of the planning process that a healthcare administrator needs to get right. First, he or she must ensure that employees who have roles to play in the CQI project perform their tasks correctly and in a timely manner. Following this logic, the office-level healthcare leader should sit down with relevant supervisors and their respective staff members to come up with a plan for holding the key players accountable. Even if the individual is ensconced in a CI-supportive office, he or she will have difficulty motivating some of these workers. In these instances, the administrator must collaborate with management to engage the employees in the process. Second, to the greatest extent possible, the person should seek to create reliable and valid measures to help him or her assess whether the plan is succeeding. If the office-level leader’s metrics are faulty, he or she will neither be able to make proper adjustments, if necessary, during the implementation stage nor determine how well the solutions are working in the monitoring phase (Spath, 2009, pp. 29–34).

6.9.1 Cooperation from Management and Frontline Staff Is Important

Many CI experts agree that a QI team must garner the cooperation of relevant employees if it wants to successfully improve a process or system (Johnson & Sollecito, 2013, p. 584; Merry, 1991, p. 18; Sollecito & Johnson, 2013, pp. 56, 64). This is doubly true for anyone who works alone on a CI project, especially if that person’s initiative impacts several departments. In these instances, at least in my experience, the office-level healthcare leader will rely upon managers and frontline employees, at varying points in the IPPIM process, to:

  • Provide Valuable Information: In my experience, a healthcare administrator who is handling a QI project can usually obtain valuable process and workflow-related data by talking to relevant employees. When working on QI endeavors, I have often been able to get information from staff that I could not (or at least probably would not) have been able to get by way of other sources.
  • Serve as a Sounding Board: Even if a healthcare administrator works alone on a CI initiative, that individual should still seek out others to obtain feedback. Everyone has biases that preclude him or her from seeing potential solutions. The smart office-level leader realizes this fact and, when feasible, runs his or her analyses of root causes, suggested solutions, and implementation ideas by trusted coworkers or supervisors to see what they think (Fried & Carpenter, 2013, p. 124). I know that I achieved some of my best results when I asked fellow staff members for their advice on key project-related issues. Alternatively, I have performed less admirably on projects when I have tried to “go it alone,” without securing any help from other people.
  • Implement the Proposed Solutions: It goes without saying that managers and frontline employees who are impacted by a CI plan will usually be the ones who implement the initiative’s solutions. With that fact in mind, the healthcare administrator who serves as the project leader needs ensure that these people are cooperative and that they “understand the quality improvement strategy” (Fried & Carpenter, 2013, pp. 125–126).
  • Monitor the Improvements: Sometimes, the administrator cannot moni tor the implemented solutions to see if they are working properly and having their intended impact on the problem. In these instances, he or she will have to rely on relevant staff to perform the tasks. In fact, some experts suggest that employees need to take a role in the monitoring process, regardless of the administrator’s availability to perform the all of the evaluation-related tasks (Edosomwan, 1992, p. 14).
  • Update, Adjust, or Discontinue Implementation Initiatives: In my experience, the healthcare administrator who oversees a QI initiative will often have to rely upon other managers or staff not only to evaluate the improvement strategy, but also to adjust or discontinue these processes, as warranted. I will discuss this topic in more detail later in the chapter.
  • Hold Each Other Accountable: In my experience, the healthcare administrator who is overseeing a QI initiative will often have to lean on front-line supervisors and individual employees to hold coworkers accountable for correctly performing their QI-related tasks. The office-level healthcare leader will have a much more difficult time achieving this goal if he or she does not maintain good relations with all relevant managers and staff members.

6.9.2 Ways to Induce Employee Cooperation

In previous chapters, I delineated some of the aspects that are indicative of CI-supportive office cultures. As part of that discussion, I posited strategies healthcare executives and administrators can use to help them create CI-friendly workplaces. In this section, I build upon those previous conversations. Specifically, I provide QI project leaders with advice on how they can gain and maintain the cooperation of staff and peers.

I mentioned earlier in this chapter that healthcare administrators must start to cultivate strong relationships with key frontline employees and managers during the ideas generation phase. In the planning stage, the office-level leader should seek to maintain and strengthen those bonds. Ideally, the individual also needs to find a way to get the staffexcited about any potential execution-related initiatives—or at least ensure that they will not rebel if, in the implementation stage, he or she asks them to make changes to their work routines.

In my experience, healthcare administrators can accomplish these goals by taking three key steps, which include:

  • Keeping the Staff Informed: CI experts stress the need for administrators to update staff in the planning and implementation phases of their CQI projects (Fried & Carpenter, 2013, pp. 125–126). Speaking only from my experiences, I usually have been able to achieve three key things by making sure that workers are in the loop and by soliciting their advice. First, I have often succeeded in easing these people’s concerns because they are aware of what changes might take place in their departments. Second, I have learned that when I keep employees informed about any QI-related developments that might impact them, I help to maintain and even strengthen the bonds of trust between us. These relationships have proven vital to me when I have handled projects for managers and staff who were not under my direct control. Finally, by taking the afore mentioned actions, I sometimes have been able to energize these individuals, thereby motivating them to make the necessary changes to their work routines during the implementation phase.
  • Being as Transparent as Possible: In my experience, when working on a QI project, a healthcare administrator should be as forthcoming and transparent as possible with both management and staff. From what I have seen, when employees feel that the office-level leader is “hiding something,” they will often become anxious or even rebellious. Some of these individuals in turn will keep vital information from the supervisor. By contrast, if one is honest and open with workers to the greatest extent feasible, then he or she will solidify the bonds of trust with them and set their minds at ease. As a side effect, this administrator might also succeed in creating robust communication channels between himself or herself and relevant staff members. Many business experts agree with me on this point (Pace, 2010, p. 14; Smith, 2013).
  • Encouraging Staffto Provide Input and Then Using That Information: From what I have seen, a healthcare administrator who is working on a QI project wants to encourage relevant staffto provide input and then use that information when feasible. Further, this individual should take these steps even if he or she can solve the problem without help. I have found that many employees like to provide assistance when they can do so, and they feel empowered when their supervisor utilizes their advice. Hence, an administrator will have a better chance of motivating employees to take part in any implementation-related changes if he or she encourages them to provide feedback and, when possible, utilizes their suggestions (Fried & Carpenter, 2013, pp. 125–126; Rivera, 2012).

6.9.3 Some General Tips for Administrators Who Work for Small or Resource-Challenged Healthcare Companies

Office-level leaders who work at small or resource-challenged healthcare firms might face hurdles that their peers at larger and better-funded institutions do not have to deal with (or at least do not have to worry about as often). I have focused on this topic in other parts of the book so I will not delve too deeply into the subject here. However, I do want to provide a few tips that readers who work at these types of firms can utilize when they oversee a QI project.

  • Use Ideas from a Variety of Sources: As I have previously noted, an administrator at a small or resource-challenged healthcare organization will often have to work alone on QI projects. At the same time, he or she might not have any formal training in a particular CI method nor possess the financial means to obtain this education. The individual’s lack of knowledge and resources might hamper him or her in some ways. However, as a result of the situation, the manager or professional with de facto power usually has the freedom to utilize a wider range of CI techniques because the person is not beholden to any one system and does not have to deal with as many bureaucratic elements as do his or her peers at larger institutions.

    With that fact in mind, I believe that a healthcare administrator, especially one who works for a small or resource-challenged institution, should feel free to borrow techniques from whatever CI system he or she deems necessary to accomplish the targeted CQI-related goals. After all, an office-level leader’s supervisor will judge that person on whether he or she achieves important objectives and not by what CI methods he or she uses to obtain the results. Even if an administrator does have formal training in one technique, I would suggest that he or she remain open to using other methods when feasible because, to borrow an old cliché, “no one system can do it all.”

  • Be Cognizant of One’s Limitations: Everyone, especially an administrator at a small or resource-challenged healthcare organization, needs to be cognizant of which QI-related tasks he or she can perform and which ones are out of range. When an office-level healthcare leader at a small or resource-challenged institution overreaches, he or she wastes valuable resources, including lost opportunity costs, which the company might have a significant need for. If this person mucks things up too much, he or she might create other headaches for the firm, including ones related to employee morale and increased tensions between managers or among staff. Therefore, it is imperative that the administrator, particularly one who works for a small or resource-challenged healthcare corporation, carefully reviews the potential improvement initiatives and chooses one that he or she is confident can be successfully completed.

  • Standardize Things but Do Not Lose That Creative Spirit: Earlier in my career, whenever I had the autonomy to design and manage my own projects (whether CI-related or not), I often neglected to save and reuse useful templates that I developed. Thinking back on that period, I realize that I wasted a significant amount of time in “reinventing the wheel,” which resulted in lost opportunity costs relating to recreating tables, formulas, and other such things. Nowadays, I have learned my lesson, and I standardize forms and techniques, when possible. For instance, once I create a document, I seek to use it in an amended version the next time I undertake a similar initiative. I would suggest that all healthcare administrators who work on QI projects, especially ones who are employed by small or resource-challenged institutions, follow these guidelines. They will save a significant amount of time in doing so.

    Following this logic, an office-level healthcare leader needs to be willing to utilize creative solutions to problems when standard ones do not work. I have had some of my best successes when I tried “out of the box” ideas. Of course, an administrator should usually refrain from doing things that break the company’s rules, as those actions would more often represent malfeasance instead of innovative thinking.

  • Store Away Some Information for Future Use: When I work on QI projects—or for that matter, any type of initiatives—I sometimes come across information that is not relevant to the problem at hand but might help me to solve a different issue. In these cases, I make some notes for future use. This action slows me down in the short run but aids me over the long term, as I procure data that I can use in future endeavors.

6.10 The Implementation Stage

The process that a particular healthcare administrator uses to implement his or her proposed CQI solutions will vary significantly based on things such as the individual’s power vis-à-vis peers, the organization’s structure and culture, and the problem to be solved. If the office-level leader is part of a QI team where each member handles a different portion of the project, he or she might not even have much control over this part of the process. Nonetheless, I feel that one can identify some key aspects that should be part of almost any implementation strategy. These include:

  • Creating a Checklist: Anyone who oversees the implementation phase of a QI project wants to utilize some method for making sure that each stakeholder does his or her part to apply and maintain the proposed solutions. One way that an individual can accomplish this task is to use a checklist. An office-level leader can embed this feature within a project plan or create a separate document. I have been involved in QI initiatives that were fairly simple, and I only had to keep track of a few items. In those cases, I could get by with a simple checklist, such as the one in Figure 6.2.
  • Ensuring that Relevant Employees Understand Their Roles in the Process: It goes without saying that a healthcare administrator who wants key employees to perform QI-related tasks, especially when it comes to adjusting their routines, must clearly communicate the “whats” and “whys” related to these roles. The individual needs to ensure that each manager or staff member knows exactly what changes he or she needs to make to daily routines or what additional jobs he or she needs to perform. At the same time, workers must understand why these tasks are important, not only to the success of the specific QI endeavor but also to the department, the organization, and pertinent stakeholders (Studer, 2014, p. 94; Upshaw, Steffen, & McLaughlin, 2013, pp. 300–303; Wallace, 2015).
  • Holding People Accountable: Most CI experts would agree with me when I say that an office-level healthcare leader will have a much better chance of successfully implementing a QI initiative if he or she has the power to hold project-related stakeholders accountable (Sherwood & Jones, 2013, p. 493; Wallace, 2015).

  • Empowering Key Staff Members: An office-level healthcare leader will have a better chance of motivating pertinent staff to make CI-related alterations to their work routines or take part in a CQI initiative if he or she can get them to take at least partial ownership of the change process (Edosomwan, 1992, p. 14; Fried & Carpenter, 2013, p. 126). As I noted previously, an administrator must start trying to engage and empower these individuals in the earliest phase of the QI project. During the implementation stage, this person can increase workers’ ownership of the CI project by allowing them some control over how they complete CI-focused tasks or via affording them leeway in deciding how to make CQI-related adjustments to their office practices (Edosomwan, 1992, p. 14).

    Figure 6.2 An office-level healthcare leader could use a checklist like the one shown above to track the implementation of key quality improvement (QI)-related solutions.

    Figure 6.2 An office-level healthcare leader could use a checklist like the one shown above to track the implementation of key quality improvement (QI)-related solutions.

    While working on a QI project, I decided to create an electronic method for capturing and sorting certain data (the department did not currently have any system in place to collect and collate this information). I asked someone in the company’s information technology (IT) unit to help me with this task. I told the IT staff member what I needed the program to perform and let him design and build it. He did an excellent job, in part because he was engaged in the process; he was excited by the challenges involved in figuring out, on his own, how to create the requisite system.

  • Having the Courage to Make Changes to a Plan during the Implementation Process: Every healthcare administrator, if he or she handles enough QI projects, will find himself or herself in a situation in which the process does not go according to design. Perhaps the individual neglected to take an important detail into account when creating the plan or maybe the situation on the ground changed after the implementation had already gotten started. In any case, the office-level leader must adjust employees’ key tasks, include more people in the process, give staff members additional job roles, or make other alterations to the QI initiative during the implementation phase in order to place the project back on sound footing.

    Ideally, he or she would be able to make these changes with little grumbling from relevant staff members. In reality (at least in my experience), even in CI-supportive cultures, healthcare administrators often have difficulty in convincing workers to change tack midway through a QI process. This only makes sense. People who have invested time and energy in learning a new system or in performing a series of CI-related tasks do not want to make alterations that nullify what they might have struggled to master or delete the work they have already completed.

    In my experience, if a healthcare administrator who is working alone on a QI project feels that he or she needs to make changes to the plan during the implementation phase, then this person must stand firm in his or her convictions. Depending on the type of adjustments the office-level leader wants to make, he or she might receive significant pushback from superiors, peers, and subordinates. This individual should, whenever possible, utilize noncoercive means to get relevant personnel to accept these alterations. I have found that one can often use logical arguments and data-driven narratives to convince staff to go along with changes to QI initiatives. Only as a last resort should the administrator employ coercive methods (or ask his or her superiors to use these tactics) to motivate employees to make the requisite adjustments (Murray, 2010, locs. 530–559, 1382–1441).

  • Refraining from Forcing the Issue unless Absolutely Necessary: At the same time, an office-level healthcare leader should avoid making significant changes to a QI project at the implementation stage unless these alterations are necessary to ensure the success of the initiative. In my experi ence, a leader who pushes peers or subordinates to adjust preset plans runs the risk of angering these individuals. When this happens, the disgruntled employees might find subtle ways to sink the QI endeavor. They may also lose respect for the healthcare administrator. In the worst-case scenario, the unhappy staff members will do things that harm work-place morale or disrupt key interdepartmental relationships. For these reasons, I feel that the office-level healthcare leader should refrain from making wholesale adjustments to a QI project during the implementation stage unless he or she needs to do so in order to save the initiative from failing. If this person wants to make changes to a plan to improve its impact on office efficiency or effectiveness, he or she can take these actions during the monitoring phase.
  • Celebrating a Win—Even if It Is Only a Small One: When a healthcare administrator initiates office-level changes, whether CI-related or not, that person should celebrate wins, even if they are only small ones. All relevant employees should be involved in these events or announcements. This tactic can prove effective not only in helping people to accommodate themselves to adjustments in office routines and protocols but also in creating a positive workplace environment (Bolman & Deal, 2008, pp. 394–395; Sollecito & Johnson, 2013, pp. 68–69).

6.11 The Monitoring Stage

Healthcare administrators will hold differing views with regard to key aspects of the monitoring stage, including the steps in the evaluation process, the goals of this phase, and the stakeholders that should be involved in the process. However, almost all office-level leaders will put protocols in place to monitor the progress of their CI projects (otherwise, the initiatives would not meet CI standards). As part of this process, these individuals will (Spath, 2009, pp. 106–117):

  • Measure the CQI Project’s Success or Failure: Healthcare administrators should want to determine how successful they were in implementing the improvements. Following this logic, they also need to ascertain how well these solutions are working. In other words, they ask themselves: “Did the project accomplish its stated goals? If it did not achieve the desired results, why/how did it fail?”
  • Routinely Test the Improvements’ Effectiveness over a Period of Time: When working on a CI-related project, an office-level healthcare leader should not perform a one-off evaluation of the effectiveness of the implemented improvements. Instead, this individual routinely needs to check to see how well the solutions are working. By taking this step, he or she can ensure that the process-related changes have a positive, long-term impact on the targeted problems.
  • Make Adjustments as Necessary: A healthcare administrator should make additional changes to workflows or protocols when warranted in order to fix issues with the first QI-related implementation or to further improve on the process.

In short, an office-level healthcare leader will take steps in this phase to ensure that his or her improvements stick. The individual might also do things to further ameliorate the problems or to enhance the efficiency or effectiveness of the targeted process or system (Spath, 2009, pp. 106–117).

6.11.1 Making QI-Related Changes Stick: A Guide for Office-Level Leaders at Small or Resource-Challenged Healthcare Organizations

An office-level healthcare leader who participates in a QI project obviously wants whatever solutions he or she implements to stick. In large or resource-secure corporations, when the administrator is only one of several members of an improvement group, he or she may not have much control over this process. The person’s teammates might make these decisions, which accord with their particular company’s protocols and regulations. However, when he or she is part of a small or resource-challenged healthcare firm and works alone on the project, this individual may have much more autonomy in deciding how to get relevant staff members to implement and utilize suggested CI-related changes.

An administrator who works at a small or resource-challenged healthcare organization can use formal methods to help ensure that his or her employees, as well as people in other units, adhere to CQI-related workflow changes. If the office-level healthcare leader has direct control over staff, he or she can alter their job descriptions to reflect any QI-adjusted tasks (Hunt, 2009, p. 26). The administrator can also use his or her positional authority to ensure that subordinates subscribe to CI-focused changes in their daily routines. At the same time, this individual can urge managers in other departments to instruct their workers to follow the CQI-altered routines and protocols. By taking these steps, the healthcare administrator will stand a better chance of ensuring that present and future employees in the QI-impacted areas follow the new workflows and procedures (Hunt, 2009, p. 26).

Of course, an office-level leader who works at a large healthcare organization can generally perform the actions listed in the previous paragraph. However, an administrator who is employed by a small healthcare company might have an advantage when it comes to using informal methods to persuade another department’s staff to adhere to CI-related process improvements. Although smaller firms have organizational hierarchies, they are, by and large, much less bureaucratic than their larger counterparts. Therefore, a supervisor at a small healthcare corporation, with the permission of relevant managers, can often directly converse with staff in other units to encourage them to adhere to QI-related improvements. These conversations frequently take place in relaxed settings (e.g., discussions in break areas and hallways). By contrast, an administrator at a larger organization who wants to reach out to staffin another department will frequently have to utilize more formal means, such as emails (to other managers), memos, and the like (Savolainen, 2000, pp. 216, 221–222). I realized this fact early on in my career. When I worked for a small healthcare firm, I would rely heavily on the aforementioned informal methods to help encourage fellow staff members to remain committed to a particular QI-related endeavor.

6.11.2 Additional Advice for Administrators Who Work for Small or Resource-Challenged Healthcare Organizations

I want to offer up a few other tips that administrators at small or resource-challenged healthcare companies can use to help them successfully navigate the monitoring stage. They include:

  • Make Sure That Higher-Ups Understand the Value in Continuously Monitoring and Improving a Process: Administrators who work for healthcare companies that possess CI-supportive cultures might not have to worry about this one. However, an office-level leader whose supervisors are skeptical of CI needs to explain to these people the benefits of monitoring/continuously improving a process. Otherwise, higher-ups might not reward (and may even penalize) this person for trying to further improve a process once the “initial project” is complete.
  • Enlist Others to Help in Evaluating the Success or Failure of Implemented Improvements: In my experience, the typical administrator at a small healthcare company is not only busy, he or she also tends to wear a lot of hats. The individual will sometimes have to take on multiple roles in the organization depending on the firm’s needs at any given time. As such, an office-level leader who works for a small healthcare firm would be wise to enlist the aid of subordinates or peers in helping him or her to monitor the implemented improvements.
  • Have an Exit Plan in Place: As everyone knows, healthcare administrators might not occupy a certain job forever. At some point, he or she may either leave the company or transition into a new position at the current firm. In either case, the office-level leader will want to create a document that provides how-to instructions for whomever inherits his or her on going CI projects. By making this move, the individual will ensure that the person taking his or her place has the requisite information to handle these CI initiatives.

Figure 6.3 Office-level healthcare leaders can use a document like this one to help them perform a quality improvement (QI) project-related self-evaluation.

Figure 6.3 Office-level healthcare leaders can use a document like this one to help them perform a quality improvement (QI) project-related self-evaluation.

Note: Figure 6.3 is described on the following page.

6.12 Allocate Some Time for Self-Reflection

It is common knowledge that a healthcare administrator who has just completed any type of project, whether or not it is CI-related, can benefit from a self-evaluation. As part of this process, the person should identify the issues that hindered the endeavor’s progress and denote ways in which he or she overcame these obstacles. The individual might also want to reflect on other things that he or she learned as result of taking part in the project.

In my experience, managers and professionals with de facto power too often skip this step. After all, most of them are busy people. They likely find it hard to carve out the time that is necessary to do a self-evaluation. Some administrators might not even know how to begin this process. To be honest, in the past I have been guilty of neglecting to perform this type of self-reflection for the reasons I just noted.

For any office-level healthcare leader who may have trouble figuring out how to structure the self-assessment, I would suggest that he or she create a document with space for three topics that relate to the recently completed CI project. The person is free to include any type of subject under each heading as long as he or she can identify key takeaways. Using this method, the administrator can posit valuable information that he or she can use to help make future CI-related endeavors run a little smoother. Importantly, the individual can complete this self-evaluation in a relatively short period of time. Figure 6.3 represents an example of a self-reflection document.

As a case in point, assume that I just finished handling a QI project that involved three small departments. I had difficulty in convincing the unit supervisors to help me complete key CI-related tasks, but, in the end, I succeeded in getting them to take on these jobs. For one of my three topics, I might write “Ways to Overcome Manager A’s Resistance to …” In the takeaways section underneath this topic, I would identify key factors leading Manager A to resist helping me with the QI endeavor and posit ways to overcome these barriers. I would do the same thing for Manager B and Manager C.

6.13 Summing Things Up and Looking Ahead to Chapter 7—How to Make the Right Decisions When One Does Not Have the Time to Plan

In this chapter, I provided readers with information that they can use to help them plan, implement, and monitor quality improvement initiatives. I started out by positing some general tips that office-level healthcare leaders might employ to aid their departments in becoming more efficient and effective. In many cases, supervisors can implement these solutions without having to create detailed project plans or perform any nuanced analyses. I then discussed the steps that I generally follow when handling QI projects. The model, IPPIM, consists of an ideas generation stage, a presentation stage, a planning stage, an implementation stage, and a monitoring stage. I provided readers with information on every one of these phases as well as discussed techniques they could use to successfully navigate each step in the process. While I believe that most individuals will benefit from reading this narrative, I paid special attention in the chapter to the needs of managers and professionals with de facto power who work at small or resource-challenged healthcare firms.

In the next chapter, I note that the typical healthcare administrator makes numerous ad hoc decisions on a daily basis. This person must be able to execute well in these situations if he or she hopes to encourage staff to perform at optimal levels, to keep employee morale high, to meet stakeholders’ needs, and to do the other things that keep a department running smoothly. With that fact in mind, I provide readers with suggestions on how to build mental maps and internal knowledge centers. They can call upon these mind-based structures to help them make the correct choices in “the moment.” I also posit information that managers and professionals with de facto power can use to aid them in creating strategies for dealing with the most common office-related ad hoc occurrences. I then go over some of the key interpersonal skills that administrators should possess if they want to perform admirably in fluid situations. At the same time, I discuss some methods that they can utilize to help them prepare themselves to handle spontaneous interactions with staff, patients/customers, and other stakeholders.

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