Making Quality Improvement Easier
Leaders need to talk to the front line of care and talk to patients, carers, and staff. They need to understand what future success might look and feel like, then work systematically through their current reality of what goes well and what needs to change. Do the systems they operate work the rubric of: “Who, What, Where, When, How, and With What?” What reliability levels does the service need to operate? Most services don't look at pathways this way. Sometimes people strive for 100% or perfection every time. In non-critical systems, 100% is extremely difficult to achieve and to achieve at an affordable cost when a “reasonable” level of reliability (say 95%) would have been acceptable. In some circumstances positive change and greater reliability requires less complexity rather than more, reducing steps, handovers of care, multiple providers, and repetitive processes. A paradigm shift needs to take place to identify and share what the patientand family-centered priorities are so that effort and limited resources are focused on key outcomes. This “keep it simple” approach for ACP is vital, as any extra and unwarranted complexity can unnecessarily make a crisis out of a drama. Case or care managers play a vital part in ACP because of the positive impact of care coordination.
Process design must make hard work easier, building in less dependence or necessity on vigilance, removing pointless steps, and stopping futile interventions that can lead to harm. Knowing where QI opportunities relate to the key functions and care delivery will help us get EOL care services right, and the quality outcomes will follow. Classic examples of positive change have been through the improvements delivered by case management, coordination of care providers, unified communication and documentation systems, and effective, efficient clinical navigation. This does not currently happen routinely and at large scale in most health and social care systems. When it does happen and care is planned and coordinated, it dramatically reduces the risks that previously drove the litigation-fearing health care behaviors. This means when treatment is futile, it is stopped and a natural death is allowed to happen, hopefully away from a potentially harmful, and costly, and intensive medical environment in a hospital. A natural death is currently more likely to happen in the United Kingdom in health social care facilities where palliative care is routine and in large care homes (nursing homes) with well-trained staff. It is possible by extrapolation to anticipate that ACP may improve outcomes for community-dwelling older people (Conroy, 2011). The figures included in this section from the IHI and their approach help keep the method simple and increase the chances of achieving QI and LSC.
Figure 20.4 summarizes the model for improvement, which is entirely appropriate to consider in ACP and EOL care. To help implement the model, the three questions noted in the figure must be asked and then answered so
FIGURE 20.4 Model for Improvement.
SOURCE: The Improvement Guide, Langley et al., p. 24.
that specific improvement aims with realistic gains can be achieved for each change or Plan Do Study Act (PDSA) cycle.
Making Quality Improvement Difficult
Change should be from the bottom up or, better described, from where the care is given. Change must be supported by committed leadership and management technique.
Don't make change difficult or, worse still, irrelevant by ignoring the patient and family. Make use of Experience-Based Design techniques with the patient and family as collaborators to initiate ACP programs and drive improvement. The case and method for change can then be properly understood. Not getting the basics right and not achieving clear communication of the benefits to patients and staff multiplies fear, and failures can occur. Usual public fears of change include the fear of the nihilistic cost-cutting exercise; or worse, still as part of a program of euthanasia; and in the extreme, linked to eugenics aimed against the poor, the disabled, the frail, and the elder.
Failure or Success?
Sometimes, despite starting out with the best of intentions, some organizations initiate programs with a “top-down” approach by imposing onto their staff and systems a process in which staff don't believe and on which they
can never realistically deliver. Imposing a process without support never works and leads to alienation and disengagement. Not paying close attention to the change process and failing to show discipline make achieving meaningful results unlikely. The lack of accountability and commitment without the guiding force of a champion and senior leadership sponsorship is again a critical failure in project management. The terminal phase of a project comes when there is an irrecoverable loss of trust when people see the approach of failure and start blaming others.
Generating success requires us to consider and use the Seven Leadership Leverage Points for Organization-Level Improvements (Reinertsen, Bisognano, & Pugh, 2008). Start by setting specific system-level aims with less but more meaningful measures monitored by the organization's board of directors. Build an executable strategy to achieve the aims. Channel attention to system-level aims and measures. Get patients and their families on your team. Engage key players often overlooked or not used effectively, such as the Chief Financial Officer, as persons in that position should be interested in what positive results the resources will bring. Engage the front line in achieving the aims, and make them own and be proud of positive change. Build improvement capacity and capability.
I have observed the worst-case scenario even in EOL care initiatives where a regional attempt to design a standardized and uniformly recognized do not attempt cardio pulmonary resuscitation form (DNARCPR in the United Kingdom or DNR in the United States), a great idea, was hijacked by political masters and given to those who are not able to perform QI. This resulted in the failure of this vital initiative when success was required. It added to complexity, with a chance of increasing patient safety risks. It has a wider future impact, as it has now made it so much harder for QI for DNARCPR or related EOL decision-making initiatives at a later date, as well as adding to the general negative sense of de-motivation, loss of will and hope, and disengagement.