CASE STUDIES IN CLINICAL PRACTICE MANAGEMENT
Systems Redesign: A Quality Improvement Initiative at a Tertiary-Care Veterans Affairs Medical Center Christine M. Rehwald, MD, Arindam Tripathy, PhD, Puneet Bhargava, MD DESCRIPTION OF THE PROBLEM Quality improvement projects within the health care field have become an integral means of streamlining and improving the quality of patient care. However, making lasting qualitative changes can be difficult. Moreover, these projects can take on an intimidating scale when complex problems, involving multidisciplinary teams and multistep processes, are tackled. The radiology department is no stranger to quality improvement projects. Indeed, the radiology department’s intimate relationship with a variety of multidisciplinary teams often makes quality improvement initiatives intricate and involved. At our institution, for example, we noticed that our biopsy procedures are fraught with delays. From the correct order being placed by the referring provider, to laboratory work being ordered and completed in a timely manner, to patient arrival, check-in, and preprocedure processes, any glitch along the way results in delays. At the US Department of Veterans Affairs (VA), a relatively new quality improvement model has been implemented to address just these sorts of problems. The model is called systems redesign, and it involves making systematic changes to patient care practices and health systems to improve the
842
quality, efficiency, and effectiveness of patient care. The goal is to enable sustaining quality improvement changes at the hospital level through a transformational strategy. The systems redesign model incorporates recommendations from the Institute of Medicine, the National Academy of Engineering, and industrial engineering [1,2]. It offers a systematic approach to removing barriers, eliminating variation in processes, and, ultimately, restructuring the system to improve performance [3]. Key components include assembling a team comprising frontline staff members, collecting data to identify and focus on the most important aspects of the problem at hand, “redesigning” and making smallscale changes, then monitoring progress, expanding successful changes, and continually reviewing and adjusting progress to ensure sustainability [4]. Our goal was to delve into the systems redesign model, learning the details to understand how it can be applied to the radiology department to address complex problems, improve workflow, and patient care.
WHAT WE DID Understanding the VA System Redesign Model The VA model has the acronym VA TAMMCS, which stands for Vision,
Analysis, Team, Aim, Map, Measure, Change, and Sustain, with the overarching goal of eliminating waste within the system and making sustainable improvements in patient care. The primary focus of this approach is to improve veterans’ access and transitions in care. Examples of successful changes include faster imaging turnaround times for inpatients, establishing a nursing academy, and improving the safe administration of medications, among others [5]. n
The first step in this model is to come up with a vision: identify a problem that needs to be addressed and envision the ideal outcome. The vision is not intended to be detailed or specific. Rather, it should be a simple statement that addresses the following questions: Where are we currently? Where do we want to be? Where should we focus our efforts? The vision sets the desired direction of the project and helps formulate a more specific, detailed aim later in the process (described later). Next, the specific problem is articulated, for example, system issues that might delay CT-guided biopsies. Patients need to have the orders in correctly, have their laboratory studies performed on time, and arrive ahead of schedule to check in at the Same
1546-1440/15/$36.00
n
ª 2015 American College of Radiology http://dx.doi.org/10.1016/j.jacr.2015.01.020
n
n
n
n
n
Day Unit to ensure that the procedure is done in a timely manner. If the orders are placed incorrectly, if the laboratory results are not available in a timely manner, or if the patient is late, a delay in the procedure occurs, resulting in continued delays for the remainder of the day and sometimes cancellations. Systems redesign is able to break this overwhelming array of potential problem areas down into key components, by identifying the important, “rate-limiting” steps that lead to delays. One way to do this is to use mapping tools, a strategy that is interwoven throughout the systems redesign process and one that allows a pinpoint assessment of a particular problem. An observation worksheet is one way of mapping a problem. Here, the entire process starting from when a patient enters to the point when the patient exits is “mapped” and timed. How long does the patient spend at the registration desk? Was the laboratory work ordered correctly? If not, how long does it take to correct the order? How long does it take for the blood to be drawn? How long does it take to get the final laboratory results?
The crucial, “rate-limiting” steps are easily revealed in this mapping process, and the key problem areas come into focus. Once the critical inefficient steps are identified, further work needs to be done to assess why these delays are occurring. Here again, a mapping tool can help outline the process, by clearly demonstrating the necessary steps, the wasteful steps, and any barriers in the process. A flow map is also a useful tool for this task. This
map details the “flow” of the process, characterizing each step along the way, that is, the decision points, necessary steps and redundant steps, and issues or problems noted through the process. With complicated problems, a map provides a way to visualize all the components involved in the process, commonly involving interdisciplinary teams, and multiple different departments, including radiology. Once the specific details of the process are outlined, the improvement process begins. Forming a team is a crucial part of this process. A team works together to remove the barriers and redundant steps and to streamline the necessary ones. Ideally, the team should be small and comprise both administrative and frontline staff members. The latter point cannot be emphasized enough. One of the key factors leading to failure of sustainable quality improvement changes is when the staff members carrying out those changes are not included in the decision-making process. This causes lack of team cohesion, a poorly understood conception of the process, and an inability to make the changes proposed [4,6]. Thus, every team should involve members responsible for the necessary daily actions of a process. A team leader is also assigned, typically an administrative staff member who understands the process and is enthusiastic about the proposed changes. The next step is to formulate a goal or “aim.” This is a more detailed “vision,” a specific statement that lays out an explicit, achievable goal. Good aim statements include a “what” and “by when.” When deriving an aim statement, it is important to incorporate budget restraints and resources available. If the aim of the project is not within an allowed budget, then the aim should be revised to ensure that it is
Journal of the American College of Radiology Rehwald, Tripathy, Bhargava n Case Studies in Clinical Practice Management
reasonable and attainable. Once this is achieved, mapping out an ideal process is a good way to begin before implementing changes. Implementing the proposed changes can be an exciting, yet daunting task, especially if a process is riddled with barriers or wasteful or difficult-to-improve steps. To ensure success in this area, a PDSA cycle is established. This stands for “plan, do, study, act,” and the key to its success is the nature of the size of change implemented. If a multistep process needs multistep changes, start with 1 PDSA cycle on 1 change. Plan out the change, perform the change, measure the outcome, and act accordingly. The “study” component of PDSA is a crucial one. This is the assessment of the change: has it been successful? Was it reasonably easy to implement? To assess the change in a meaningful way, the change must be measurable. This is not intended to be a hard number or even an exact science. The measurement should be able to diagnose the current problem and support the general aim [5]. Once a specific change has been shown to be an improvement—or, conversely, if it has not been shown to be an improvement—further PDSA cycles are then conducted until the entire process is completed and the aim achieved. This takes time, devotion, continued analysis, and adjustments. The final systems redesign step is the most critical, and, often, the most difficult. This is the “sustain” step, whereby the changes are made to last. Sweeping changes carry a certain momentum early on, but this tends to fade with time, allowing old habits and methods to resurface [4]. The key to sustaining change is to memorialize the changes made: modify job descriptions, enact new policies, use new training, and try reward systems [7]. It is important to continue to analyze 843
and readjust, always keeping the entire team involved in the process.
DISCUSSION The possibilities for quality improvement involving radiology are numerous, as the radiology department has complex intradepartmental and interdepartmental components. Within the department itself, radiology depends on coordination of patient care (scheduling examinations, performing biopsies, etc), competent technicians, busy radiologists, and complex technology that requires reliable support staff members [8]. A breakdown in any one of these support systems can cause delays and compromise patient care. Interdepartmental processes are often more complex, requiring higher level coordination, review of orders, consultation with referring providers, and expedient, yet accurate interpretation of examinations. CT-guided
biopsies are one such example, in which coordination of care and a smooth workflow are key to timely, efficient patient care. Systems redesign can be an especially helpful model to use for this complex problem, with mapping tools to break the process down into more easily digestible steps and using small-scale changes to work toward the end goal.
ACKNOWLEDGMENT The authors thank Sarah A. Hart, health systems specialist, systems redesign, VA Puget Sound Health Care System (Seattle, Washington) for her guidance.
3.
4.
5.
6.
REFERENCES 1. Institute of Medicine, Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, District of Columbia: National Academies Press; 2003. 2. Reid PP, Compton WD, Grossman JH, et al. Building a better delivery system: a
7.
8.
new engineering/health care partnership. Washington, DC: National Academies Press; 2005. The Center for Policy Design. About system redesign: brief overview of concepts, terms and definitions. Available at: http://www. centerforpolicy.org/system. Accessed August 1, 2014. Hagg H, Workman-Germann J, Flanagan M, et al. Implementation of systems redesign: approaches to spread and sustain adoption. In: Henriksen K, Battles J, Keyes M, et al., eds. Advances in patient safety: new directions and alternative approaches, vol. 2. Rockville, Maryland: Agency for Healthcare Research and Quality; 2008. US Department of Veterans Affairs. VA TAMMCS: improvement framework guidebook, version 2. Washington, District of Columbia: US Department of Veterans Affairs; 2011. Counte MA, Meurer S. Issues in the assessment of continuous quality improvement implementation in health care organizations. Int J Qual Health Care 2001;13: 197-207. Veterans Health Administration. Systems improvement framework guidebook, version 1. Washington, District of Columbia: US Department of Veterans Affairs; 2010. Bruno M, Nagy P. Fundamentals of quality and safety in radiology. J Am Coll Radiol 2014;11:1115-20.
Christine M. Rehwald, MD, and Puneet Bhargava, MD, are from the Department of Radiology, University of Washington School of Medicine, Seattle, Washington, and Diagnostic Imaging Services, Veterans Affairs Puget Sound Health Care System e Seattle Division, Seattle, Washington. Arindam Tripathy, PhD, is from the Milgard School of Business, University of Washington e Tacoma Campus, Tacoma, Washington. Dr. Bhargava is Editor-in-chief, Current Problems in Diagnostic Radiology, Elsevier Inc. Puneet Bhargava, MD: Veterans Affairs Puget Sound Health Care System e Seattle Division, Mail Box 358280, S-114/ Radiology, 1660 S Columbian Way, Seattle, WA 98108; e-mail: [email protected].
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Journal of the American College of Radiology Volume 12 n Number 8 n August 2015
Systems Redesign: A Quality Improvement Initiative at a Tertiary-Care Veterans Affairs Medical Center Christine M. Rehwald, MD, Arindam Tripathy, PhD, Puneet Bhargava, MD DESCRIPTION OF THE PROBLEM Quality improvement projects within the health care field have become an integral means of streamlining and improving the quality of patient care. However, making lasting qualitative changes can be difficult. Moreover, these projects can take on an intimidating scale when complex problems, involving multidisciplinary teams and multistep processes, are tackled. The radiology department is no stranger to quality improvement projects. Indeed, the radiology department’s intimate relationship with a variety of multidisciplinary teams often makes quality improvement initiatives intricate and involved. At our institution, for example, we noticed that our biopsy procedures are fraught with delays. From the correct order being placed by the referring provider, to laboratory work being ordered and completed in a timely manner, to patient arrival, check-in, and preprocedure processes, any glitch along the way results in delays. At the US Department of Veterans Affairs (VA), a relatively new quality improvement model has been implemented to address just these sorts of problems. The model is called systems redesign, and it involves making systematic changes to patient care practices and health systems to improve the
842
quality, efficiency, and effectiveness of patient care. The goal is to enable sustaining quality improvement changes at the hospital level through a transformational strategy. The systems redesign model incorporates recommendations from the Institute of Medicine, the National Academy of Engineering, and industrial engineering [1,2]. It offers a systematic approach to removing barriers, eliminating variation in processes, and, ultimately, restructuring the system to improve performance [3]. Key components include assembling a team comprising frontline staff members, collecting data to identify and focus on the most important aspects of the problem at hand, “redesigning” and making smallscale changes, then monitoring progress, expanding successful changes, and continually reviewing and adjusting progress to ensure sustainability [4]. Our goal was to delve into the systems redesign model, learning the details to understand how it can be applied to the radiology department to address complex problems, improve workflow, and patient care.
WHAT WE DID Understanding the VA System Redesign Model The VA model has the acronym VA TAMMCS, which stands for Vision,
Analysis, Team, Aim, Map, Measure, Change, and Sustain, with the overarching goal of eliminating waste within the system and making sustainable improvements in patient care. The primary focus of this approach is to improve veterans’ access and transitions in care. Examples of successful changes include faster imaging turnaround times for inpatients, establishing a nursing academy, and improving the safe administration of medications, among others [5]. n
The first step in this model is to come up with a vision: identify a problem that needs to be addressed and envision the ideal outcome. The vision is not intended to be detailed or specific. Rather, it should be a simple statement that addresses the following questions: Where are we currently? Where do we want to be? Where should we focus our efforts? The vision sets the desired direction of the project and helps formulate a more specific, detailed aim later in the process (described later). Next, the specific problem is articulated, for example, system issues that might delay CT-guided biopsies. Patients need to have the orders in correctly, have their laboratory studies performed on time, and arrive ahead of schedule to check in at the Same
1546-1440/15/$36.00
n
ª 2015 American College of Radiology http://dx.doi.org/10.1016/j.jacr.2015.01.020
n
n
n
n
n
Day Unit to ensure that the procedure is done in a timely manner. If the orders are placed incorrectly, if the laboratory results are not available in a timely manner, or if the patient is late, a delay in the procedure occurs, resulting in continued delays for the remainder of the day and sometimes cancellations. Systems redesign is able to break this overwhelming array of potential problem areas down into key components, by identifying the important, “rate-limiting” steps that lead to delays. One way to do this is to use mapping tools, a strategy that is interwoven throughout the systems redesign process and one that allows a pinpoint assessment of a particular problem. An observation worksheet is one way of mapping a problem. Here, the entire process starting from when a patient enters to the point when the patient exits is “mapped” and timed. How long does the patient spend at the registration desk? Was the laboratory work ordered correctly? If not, how long does it take to correct the order? How long does it take for the blood to be drawn? How long does it take to get the final laboratory results?
The crucial, “rate-limiting” steps are easily revealed in this mapping process, and the key problem areas come into focus. Once the critical inefficient steps are identified, further work needs to be done to assess why these delays are occurring. Here again, a mapping tool can help outline the process, by clearly demonstrating the necessary steps, the wasteful steps, and any barriers in the process. A flow map is also a useful tool for this task. This
map details the “flow” of the process, characterizing each step along the way, that is, the decision points, necessary steps and redundant steps, and issues or problems noted through the process. With complicated problems, a map provides a way to visualize all the components involved in the process, commonly involving interdisciplinary teams, and multiple different departments, including radiology. Once the specific details of the process are outlined, the improvement process begins. Forming a team is a crucial part of this process. A team works together to remove the barriers and redundant steps and to streamline the necessary ones. Ideally, the team should be small and comprise both administrative and frontline staff members. The latter point cannot be emphasized enough. One of the key factors leading to failure of sustainable quality improvement changes is when the staff members carrying out those changes are not included in the decision-making process. This causes lack of team cohesion, a poorly understood conception of the process, and an inability to make the changes proposed [4,6]. Thus, every team should involve members responsible for the necessary daily actions of a process. A team leader is also assigned, typically an administrative staff member who understands the process and is enthusiastic about the proposed changes. The next step is to formulate a goal or “aim.” This is a more detailed “vision,” a specific statement that lays out an explicit, achievable goal. Good aim statements include a “what” and “by when.” When deriving an aim statement, it is important to incorporate budget restraints and resources available. If the aim of the project is not within an allowed budget, then the aim should be revised to ensure that it is
Journal of the American College of Radiology Rehwald, Tripathy, Bhargava n Case Studies in Clinical Practice Management
reasonable and attainable. Once this is achieved, mapping out an ideal process is a good way to begin before implementing changes. Implementing the proposed changes can be an exciting, yet daunting task, especially if a process is riddled with barriers or wasteful or difficult-to-improve steps. To ensure success in this area, a PDSA cycle is established. This stands for “plan, do, study, act,” and the key to its success is the nature of the size of change implemented. If a multistep process needs multistep changes, start with 1 PDSA cycle on 1 change. Plan out the change, perform the change, measure the outcome, and act accordingly. The “study” component of PDSA is a crucial one. This is the assessment of the change: has it been successful? Was it reasonably easy to implement? To assess the change in a meaningful way, the change must be measurable. This is not intended to be a hard number or even an exact science. The measurement should be able to diagnose the current problem and support the general aim [5]. Once a specific change has been shown to be an improvement—or, conversely, if it has not been shown to be an improvement—further PDSA cycles are then conducted until the entire process is completed and the aim achieved. This takes time, devotion, continued analysis, and adjustments. The final systems redesign step is the most critical, and, often, the most difficult. This is the “sustain” step, whereby the changes are made to last. Sweeping changes carry a certain momentum early on, but this tends to fade with time, allowing old habits and methods to resurface [4]. The key to sustaining change is to memorialize the changes made: modify job descriptions, enact new policies, use new training, and try reward systems [7]. It is important to continue to analyze 843
and readjust, always keeping the entire team involved in the process.
DISCUSSION The possibilities for quality improvement involving radiology are numerous, as the radiology department has complex intradepartmental and interdepartmental components. Within the department itself, radiology depends on coordination of patient care (scheduling examinations, performing biopsies, etc), competent technicians, busy radiologists, and complex technology that requires reliable support staff members [8]. A breakdown in any one of these support systems can cause delays and compromise patient care. Interdepartmental processes are often more complex, requiring higher level coordination, review of orders, consultation with referring providers, and expedient, yet accurate interpretation of examinations. CT-guided
biopsies are one such example, in which coordination of care and a smooth workflow are key to timely, efficient patient care. Systems redesign can be an especially helpful model to use for this complex problem, with mapping tools to break the process down into more easily digestible steps and using small-scale changes to work toward the end goal.
ACKNOWLEDGMENT The authors thank Sarah A. Hart, health systems specialist, systems redesign, VA Puget Sound Health Care System (Seattle, Washington) for her guidance.
3.
4.
5.
6.
REFERENCES 1. Institute of Medicine, Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, District of Columbia: National Academies Press; 2003. 2. Reid PP, Compton WD, Grossman JH, et al. Building a better delivery system: a
7.
8.
new engineering/health care partnership. Washington, DC: National Academies Press; 2005. The Center for Policy Design. About system redesign: brief overview of concepts, terms and definitions. Available at: http://www. centerforpolicy.org/system. Accessed August 1, 2014. Hagg H, Workman-Germann J, Flanagan M, et al. Implementation of systems redesign: approaches to spread and sustain adoption. In: Henriksen K, Battles J, Keyes M, et al., eds. Advances in patient safety: new directions and alternative approaches, vol. 2. Rockville, Maryland: Agency for Healthcare Research and Quality; 2008. US Department of Veterans Affairs. VA TAMMCS: improvement framework guidebook, version 2. Washington, District of Columbia: US Department of Veterans Affairs; 2011. Counte MA, Meurer S. Issues in the assessment of continuous quality improvement implementation in health care organizations. Int J Qual Health Care 2001;13: 197-207. Veterans Health Administration. Systems improvement framework guidebook, version 1. Washington, District of Columbia: US Department of Veterans Affairs; 2010. Bruno M, Nagy P. Fundamentals of quality and safety in radiology. J Am Coll Radiol 2014;11:1115-20.
Christine M. Rehwald, MD, and Puneet Bhargava, MD, are from the Department of Radiology, University of Washington School of Medicine, Seattle, Washington, and Diagnostic Imaging Services, Veterans Affairs Puget Sound Health Care System e Seattle Division, Seattle, Washington. Arindam Tripathy, PhD, is from the Milgard School of Business, University of Washington e Tacoma Campus, Tacoma, Washington. Dr. Bhargava is Editor-in-chief, Current Problems in Diagnostic Radiology, Elsevier Inc. Puneet Bhargava, MD: Veterans Affairs Puget Sound Health Care System e Seattle Division, Mail Box 358280, S-114/ Radiology, 1660 S Columbian Way, Seattle, WA 98108; e-mail: [email protected].
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Journal of the American College of Radiology Volume 12 n Number 8 n August 2015
