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Five Ways to Reduce Unwanted Variations in Clinical Processes

11/13/17

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Eric Burch, MBA, RN, FACHE, Associate Principal, Clinical Advisory Solutions

Unwanted variability in clinical processes is a pervasive, intractable problem in virtually every hospital and is adversely affecting outcomes, patient satisfaction, operational efficiency, performance measures and costs. Consider these studies that have shown:

  • The lack of widespread adoption of best practices was a significant factor in adverse events that researchers found occurred in one-third of hospital admissions
  • Medicare patients experienced injuries because of their care in 27 percent of hospital admissions
  • Unnecessary variations in care account for about 30 percent of health care spending

In a recent webinar, my colleague and I shared how hospitals can systematically and significantly reduce unwanted variability from their clinical processes. The overarching goal of such efforts is to become a high-reliability organization that performs consistently well on clinical processes that have the most impact on quality, outcomes and costs.

Here are five action items to put your hospital on the path to successfully eliminating variations in care.

Prioritize and benchmark actionable data. With so many metrics to consider, an effective strategy to reduce clinical variations must be highly focused on key performance and process data. A good starting point is to identify areas that are not meeting the benchmarks, and prioritize them based on harm, patient outcomes and other criteria most important to your organization.

Hospitals then need to assess which actions (or inactions) are having the most effect on outcomes, and which processes they want to make sure occur every time with every patient. Funnel charts or a fishbone diagrams, for example, are useful cause-and-effect tools that can show that, if you’re doing this, this is the result.

A key to process improvement is selecting measures that move outcomes, making them your leading indicators and continually benchmarking to see whether interventions move the needle. Hospitals also need actionable data that should help them identify opportunities for improvement and be used as a valuable learning tool to drive desired practice changes throughout your organization.

Select and engage the right stakeholders. People in high-reliability organizations understand that the people closest to the work are the most knowledgeable and most important stakeholders. Other key champions are clinicians who can influence processes, remove barriers and communicate effectively with those involved in practice changes. And don’t forget to tap into the knowledge of process improvement and subject matter experts within your organization.

Establish written standards of care. Let’s start with the definition: Standard work is a clear, concise and written description of how to perform a particular process or set of tasks so that the outcome will be safe, efficient and of the highest quality.

Surprisingly, the “written” part of this is often ignored. Remember, if a process is not documented, it doesn’t exist – all you really have is tribal knowledge. This document also should be the No. 1 aid for training or re-training, and be used for all types of PDSA (Plan-Do-Study-Act) or group problem-solving activities.

Standard work establishes a well-defined difference between “normal” and “abnormal” and guides people to respond immediately and appropriately to the latter. In the previously mentioned CLABSI case, for example, the standard of work included protocols and checklists focused on keeping dressings intact and ensuring that hubs were cleaned before access and flushes were properly completed. Compliance to these changes resulted in about a 90 percent reduction in CLABSI infections.

Also keep in mind that if you have no standards, you have no problem. Why? Because if you have not documented what your intended outcomes should be, you can’t have any “failures” to provide the proper care – which, of course, is your biggest problem that won’t ever be resolved.

Mistake-proof your processes. Mistake-proofing is the process of identifying potential causes of errors and implementing a systematic approach to preventing them through awareness, detection, alerts and/or automated prevention mechanisms.

At its most basic level, mistake-proofing is creating widespread awareness of what’s right and wrong (normal or abnormal), usually through instruction or visual aids or visual controls. Alerts that signify an error has occurred is even better, but the most effective approach is to design a product or process in such a way that makes it impossible for mistakes to happen.

A good example of effective mistake-proofing in the OR is that it’s virtually impossible to connect nitrous to a patient’s oxygen line because the fittings won’t connect. The combination of barcoding with medicines packaged in single-dose plastic bags is another powerful way to prevent dosing errors.

Continually evaluate and adjust to sustain progress. As part of an inter-dependent, multidimensional system, clinical processes are always a work in progress. High-reliability organizations systematically use data, observation and other techniques to seek out vulnerabilities in their processes and put mechanisms in place to prevent these from causing unwanted variability.

Vigilant monitoring and constant communications to key stakeholders are essential to sustain high performance. A3 status reports are great tools to help everyone continually evaluate compliance to interventions and whether they are resulting in the desired outcomes.

Standardizing and mistake-proofing clinical process best practices can lead to fewer errors and give personnel more time to interact with patients. It is one of the most powerful strategies for lowering the total cost of care while improving quality and outcomes.

For more information on leading strategies and practices in reducing clinical variations, click here to read a recent white paper.

About the author. A registered nurse, Eric Burch uses his more than 25 years of health care experience to focus on innovative health care delivery models, clinical quality processes and structures, case management/care coordination, value-based care strategies and accreditation/regulatory compliance. Before joining Vizient, Burch was the chief operating officer and chief nursing officer for Oklahoma State University Hospital and the chief operating officer for Hillcrest Medical Center in Tulsa, Oklahoma. Some of his key achievements and accomplishments include improvement in pay-for- performance outcomes, improving patient and staff satisfaction, reducing length of stay, optimizing capacity management and implementing successful cost reduction strategies. Burch is a fellow in the American College of Healthcare Executives and has served as adjunct faculty at the University of Oklahoma School of Nursing. 

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