On Quality Improvement Action Planning --

Welcome back to what is now Part 3 in my description of Quality Improvement Action Planning®.

My last post ended with Plan 2—Plan to get data. So I'll start this one with completing Step 2—What is causing the problem?

Our team has developed a list of possible root causes and then carried out the plan to get data. At this point in the process, they analyze the gathered data to determine whether they have identified the most important root causes and what the data tells them about how to solve the problem.

This analysis involves reviewing all data, categorizing it in relationship to the problem and the possible root causes, and answering the question, “What have we learned about this problem?”

Once the team has analyzed root causes, Step 3 can be completed—answering the question, “What is the goal?”

A single problem might lead to the identification of multiple root causes. Each root cause might lead to several goals.

This is why it is so important to take your time and define the problem well. Otherwise, the whole process can become unwieldy and hard to manage. Keep the problem narrow enough so that when multiple root causes are identified, and each of those has several goals, the team can successfully implement and track its results. Too many goals is a set-up for trouble. If need be, prioritize the root causes and act on the top three, then the next set, and so forth as you are successful.

Goals should be stated clearly. This means that each goal should address only one thing the team wants to change. If necessary, you can state several goals for one root cause. Just don’t bunch several things into one goal because it will be impossible to measure.

I don’t think goals always have to have end dates, but they should be stated in such a way that you will know when you have achieved them. “There are sufficient equipment and supplies to carry out scheduled activities” is a good goal; and might also need to be partnered with a goal that says, “All staff know where equipment and supplies are stored, what is available, and how to access it;” and perhaps also a goal such as, “A cleaning and maintenance schedule for equipment and supplies will be in use.” These goals, while they do not have end dates, are clearly stated, each one addressing a different aspect of root causes of equipment availability, and it would be easy for anyone to tell whether they have been achieved.

Now that the goals are clear, the team moves to Plan 3—Plan to act. This plan answers the question of Step 4—What actions will we take to reach our goals?

Action steps are basically the bridges between the problem (where we are now) and the goal (where we want to be). Each action step must have a champion (an individual, not a group) and an end date by which the action step will be completed.

The Plan to act should paint a picture of the actions that staff are taking to reach the goal in such a way that an evaluator can come in at any point and tell exactly where the group is in the process. This part of the QIAP process is what is generally called “action planning.” As you can see, the problem identification, root cause analysis, and goal setting that come before it set the stage for an action plan that is more comprehensive and likely to yield robust results.

Finally, based on the action steps it has written, the team or leader can now develop Plan 4—Plan to validate.

Plan 4 has two distinct parts, Step 5—How will we know staff are following the plan? And Step 6—How will we know the plan is working.

• Validation is about ensuring that the action steps are being implemented and also that they are having the desired impact on the problem.
• Actions to be taken for validation should have a person assigned, and also a due date by which the analysis will be completed. Generally, data is brought back to the leader or team at some point so that decisions can be made to change the action steps or conduct more staff training, or to correct the course in some way in order to ensure that the goals are met.

This should be built into Plan 4:

• Who will review what data and when
• How the plan itself will be changed if it is not working or if staff are not able to implement it as it was planned.
• Addressing the overall effectiveness of the plan and when the plan is considered to have been successful. Often, teams set a threshold (such as, “When this goal is achieved at 100% compliance for three consecutive months”), and then refer the oversight to the CQI or PI Committee (such as “the CQI Committee will continue to monitor audits until it determines that the goals have been met”). This brings the plan into the purview of the QA or CQI committee so that oversight can be broader.  It involves leadership and often physicians in the process of oversight, further reinforcing the success achieved.

My one last piece of advice on this—notice your successes and celebrate with all staff who contributed to the solution. I’m not sure who it was who said, “Nothing builds success like success” but it is certainly true. Keeping people encouraged, letting them know what they have done to be part of a significant achievement, and involving them in celebration of success will entice them to jump in more and more as you use Quality Improvement Action Planning to create lasting, meaningful solutions to complex problems. People who use this process consistently learn that no problem is unsolvable if they invest in doing the job right.

On Quality Improvement Action Planning: How it Works

The goal of Quality Improvement Action Planning® is to produce lasting results—to get the leader and/or team where they want to be because they are achieving the results they choose. Of course, no process is a panacea, and QIAP does involve an investment of time and effort on the part of the leader and/or team. Those who have made this investment, however, are reaping great rewards. The following chart summarizes QIAP's key parts:

Here’s how QIAP works…
When a problem is identified, either through your quality improvement processes or by an outside agency, the first consideration is Plan A. This is a set of steps the facility will take immediately to reduce and minimize harm to residents. We might call these steps “quick fixes” or “band aids”—they are taken quickly and are not intended to be the final solution. This, however, is the number one error leaders and teams make in problem solving—they stop with Plan A. The results are often not satisfying because as soon as the problem seems to get better, it crops back up with different names and faces. Then more band aids are applied while the underlying causes fester. This is exactly what keeps leaders in the weeds—rushing from problem to problem in the best of worlds or crisis to crisis in the worst.

As Plan A is being carried out, the leader or team turns their attention to Step 1—What is the problem? This step requires an analysis of the situation and the creation of a well-defined problem statement. Often, the problem that is first identified gets revised as data is collected in Step 2.

Step 2—What is causing the problem? This is more than just a quick brainstorm by team members or leaders. Too often, I see people sitting around a table in thirty minutes and “deciding” what the causes are. This is something like a detective never going to the scene of the crime and sitting at his or her desk writing down how the crime happened and who did it. This method leaves out so much evidence that any decisions and actions that arise from it will inevitably be inadequate to the task. Hence, it is absolutely predictable that any complex problem approached in this way will occur again—because it has yet been really solved.

What is needed is an in-depth analysis of possible root causes. The interdisciplinary team may brainstorm possible root causes in order to decide what data it will need to move to Step 3—What is the goal? After brainstorming an exhaustive list of possible root causes, the leader or team can categorize the list. Generally I have found that teams end up with two or three main categories.

The possible root cause categories drive the design of Plan 2—Plan to get data. All actions to be carried out as part of Plan 2 must be assigned to a particular individual (not the team) and have a due date by which the step will be completed. Based on the possible root causes, a plan is developed for gathering information from residents, families, vendors, staff, medical records, physicians, and anyone else who might have knowledge to share or who will be impacted by the solutions that might be implemented.

This is where the process of organizational change begins—when people are invited into the problem in constructive ways, they often begin to change their behavior to be more in line with the goals, even before the goals are clear.

I advocate staff interviews, even of staff not often included in such analyses such as housekeepers, laundry staff, and dietary staff. For example, a team studying improving activities in their facility included housekeeping staff in interviews. They brought a whole different perspective about why residents weren’t attending—they noted that when they ask residents why they aren’t going to activities, residents reported that they were in pain or depressed. This led the interdisciplinary team into a whole new set of questions about effective assessment of depression and pain as they relate to participation in activities. This came from the housekeeping staff, not nursing.

I will take on more of the process in my next post…

On Quality Improvement Action Planning

Having put Quality Improvement Action Planning® in real-world practice for quite some time now, I’ve been able to refine the process and tools for quality and performance improvement in long-term care facilities. Although I’ve used it routinely with clients for several years, I haven’t (until now) blogged its virtues. After all, it’s my own work and I don’t want to sound self-serving. However, the fact is that people have been really noticing the positive impact that QIAP makes in their teams and facilities. So today, let me tell you a bit about QIAP: what it is, what it does, and how I came to developing it.

Closing the Execution Gap
QIAP is a deceptively simple process that builds team strength while simultaneously producing lasting improvements. I like to say it closes the execution gap—the chasm between what long-term care leaders want and what they get much of the time.

Let me explain. In my 30 years in long-term care, and in my 20+ years of management consulting in numerous organizations (healthcare and otherwise), the one constant I have observed almost everywhere is a striking gap between goals set and outcomes achieved. The same problems come back over and over (and over) again -- and people literally get burned out spending their precious time and effort reworking the same old things. This sets up a crisis-management cycle that can keep leaders spinning:  chasing problems rather than really solving them. 

Solving a Problem (Once and For Good) with an Iterative Approach
Soon after getting involved with compliance, I developed QIAP. Knowing that quality and compliance are inseparable in health care, what was needed was a way to routinely produce solid, data-based, lasting solutions. The process had to be complex enough to accomplish that result; and be user-friendly so interdisciplinary teams and bedside staff can easily understand and use it. To meet my requirements, it had to prove itself over time and be validated by someone other than me and my own experience. Most of all, it had to build the solution to the problem into the problem-solving process itself. In other words, as part of the process of designing a solution, the team that uses QIAP is taking steps to implement the solution by engaging all staff involved in thinking about the problem and how best to solve it.

What I have now observed, which has been validated by the independent monitor multiple times as well as by facility and corporate leaders, is that QIAP meets all these requirements. The process involves answering six questions by carrying out four plans. The result, regardless of the opening problem, is a broad, systematic analysis that leads to an action plan that solves the problem.

In my next post, I’ll explain each of the six steps and four plans. Stay tuned.