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When Doris Quinn, Ph.D., worked as a hospital nurse early in her career, she came up with an effective way to make sure her patients had enough linens despite chronic shortages. She hoarded them.
Four decades and a doctoral degree later, she would rather figure out why there were not enough linens to go around.
“The goal has to be solutions that benefit everyone. Real change, not workarounds,” says Quinn, now director of MD Anderson’s Department of Process Improvement and Quality Education. “Instead of a culture where we say, ‘They should fix that,’ we should wonder, ‘How can I fix that?’”
Quinn’s group is there to help. Her team includes nurses, educators and others skilled at mapping out work processes step by step and homing in on the trouble spots.
Just as important, they can teach front-line employees and their managers how to identify inefficiencies and work out solutions themselves.
Whether the goal is to reduce patient wait times or prevent billing mistakes, Quinn believes that those with the most questions and answers are the employees who run up against the problems every day. If you want real improvement, Quinn suggests you should want your employees asking, “What is my process, and why is it making me crazy?”
Revelations of a flow chart
It takes eight pages to show the steps involved in transferring a Head and Neck Center patient out of the Surgical Intensive Care Unit. To create the color-coded flow chart laying out the patient’s transfer, Quinn’s clinical consultants have interviewed almost a dozen employees.
They include physicians (orange), nurses (pink), equipment techs (purple), pharmacy employees (blue) and medical clerks (teal). A consulting team led by nurse Laurie Kaufman, a manager of clinical quality improvement in the department, is putting together dozens of such charts for the Head and Neck patient population, using outpatient, inpatient, diagnostic, treatment and ancillary services.
These charts include the estimated times needed to perform each task. This information will allow business analysts from the Office of Finance to calculate how much a task costs when they tally up both personnel and other expenses, such as equipment and research.
This data will help MD Anderson’s Institute for Cancer Care Excellence as it develops a new model for calculating the cost of providing patient care. When negotiating payments from insurers and payers such as Medicare, the institution needs to know how much is necessary to cover expenses and offer patients a better value in an era of health care reform.
The cost-modeling project is a big one with a long-term payoff, but the process maps created for it also have more immediate uses in everyday operations, just as process maps developed for the consultants’ other projects do, from hand hygiene to faculty appointments.
In addition to bringing to light waste in the work process and obstacles to smooth patient flow, the charts can give managers a better handle on the realities employees face. They can also lay the groundwork for employee training manuals and for “what to expect” patient roadmaps.
An ‘aha’ moment
Perhaps most important, process maps can generate an interest in improvement. A doctor who writes orders dozens of times a day discovers the multiplied consequences of skipping what seemed to be a trivial step. A nurse who sees the extra time required for a workaround is motivated to seek a better solution.
“I love it when I see the light bulb go on,” Kaufman says. “There’s an ‘aha’ moment of understanding, and it’s energizing. When they can suddenly see improvement opportunities, a sense of urgency kicks in.”
Lessons from Quality College
The vice president who oversees MD Anderson’s pharmacies, Joel Lajeunesse, has an impressive view of the Texas Medical Center from his 18th floor office, but he is more interested in what his employees see every day.
After all, it was front-line pharmacy employees who fielded the phone calls from distressed patients who used to pick up pre-filled medication syringes, only to arrive home without needles.
These employees identified a solution, and outpatient pharmacies began placing neon stickers on the medications, reminding patients that needles were not included. The stickers also served as visual cues for pharmacists to tell patients where to pick them up.
Lajeunesse says grass-roots efforts such as this make a strong case for empowering employees to question why something has always been done a certain way and whether there might be a better one.
He would like them to grasp the value of process maps and to seek measurable improvements, as industrial engineers do when scrutinizing an auto plant assembly line.
To that end, last year he required his 500 employees — pharmacists, technicians, researchers, administrative assistants, IT experts and finance whizzes — to take a short video class called Plan-Do-Study-Act 101 from the Quality College, an online resource provided by Quinn’s educators.
There will be follow-up training on teamwork from the college again this year. His managers must also take a series of classes that qualify them for a “novice certificate” in the concepts of quality improvement used successfully in many industries.
“I’d like to see these concepts embedded throughout our division, and I’m trying to give employees the basic skill set they need to implement change,” says Lajeunesse, who is on the Quality College steering committee.
A well-stocked tool chest
The Quality College encourages employees who see problems to become do-it-yourselfers. This year one of the school’s most popular classes covers widely used Lean methods that eliminate waste from work processes.
Other offerings range from a nine-minute video on constructing flow charts to an advanced Six Sigma course on using statistical analysis to improve an organization’s performance.
The “dean” of the Quality College, Cylette Willis, Ph.D., says there is a misconception that making improvements is hard.
“You can do small projects, and you can do big projects,” says Willis, associate director of Quality Improvement Education and Evaluation. “You just have to pick a problem and dive in. We’ve designed our websites to be the ‘just-in-time’ source for quality education and tools that teams need for successful projects. Employees learn through Quality College and are empowered to transfer their new skills to make things better for their patients and teams. It’s a win-win process.”
Improvement you can measure
Charisse Acosta is a cytotechnologist by training, Joan Woods is a medical laboratory technician. Both now work fulltime on quality improvement for the Division of Pathology and Laboratory Medicine.
Their latest success grew out of another popular program coordinated by Quinn’s educators that targets doctors, nurses and other clinicians.
The Clinical Safety and Effectiveness course meets eight times during six months to teach quality improvement concepts to teams taking on problems in their work areas.
In addition to providing instruction from in-house quality experts and bringing in nationally respected guest speakers, the course offers an experienced facilitator for each project.
There is competition for the 85 or so spots that are open twice a year, so participants are ambitious when proposing projects for the program, which is funded by The University of Texas System.
For their award-winning project last year, Acosta and Woods set out to cut in half the number of patients who arrive at the outpatient diagnostic centers’ labs without orders. They did considerably better.
Numbers speak loudly
Working with clinic employees from various departments that routinely send patients their way for lab work, the six-member team led by Acosta and Woods discovered that each day an average of 11 patients arrived without lab orders to have blood drawn. Correcting each omission took an average of 23 minutes.
In some of the departments, employees needed to be retrained or forms reworded. In one case, the problem turned out to be that the clinic was just one floor away from the lab, so patients arrived a few minutes ahead of their orders.
A front-line employee in the clinic saw a quick fix: setting up a checkout desk at the clinic exit where orders could be entered before the patient left for the lab.
By reducing the number of patients without lab orders by 73%, Acosta and Woods’ team calculated its project will save more than $16,000 worth of employees’ time each year and — more importantly — save patients more than 800 hours of wait time.
Cathy LaComb, program coordinator for Clinical Safety and Effectiveness, believes that if employees are motivated, her program has the tools to help them.
“We can take you from what you think the problem is to pinning it down to developing an action plan to measure your success,” LaComb says. “Then we show you how to sustain that success. Improvement never stops.”
Success stories by the dozen
Whether acting as quality improvement consultants or educators, everyone who works in the Department of Process Improvement and Quality Education is a cheerleader for looking hard at processes and improving them.
More than 70 projects went on display last fall at the group’s annual Celebrating Improvement event, all projects of employees who have abandoned the “learned helplessness” that Quinn believes can cripple large institutions.
Once an assistant to quality-improvement pioneer W. Edwards Deming, Ph.D., Quinn believes the time spent trying to understand a process is time well spent.
“When you’re process-illiterate, you don’t see the problems. You don’t realize the same things happen over and over,” she says. “When you break it down to see exactly who’s doing what, so much foolishness comes to light. And that’s where change begins.”