What Is Continuous Improvement in Healthcare?

Applicable to any industry, continuous improvement is a management philosophy designed to increase efficiency and productivity, identify and reduce waste, and increase employee, supervisor and customer satisfaction. Continuous improvement strategies take many forms, including Lean, Kata, Kaizen, Training Within Industry (TWI), Standardized Work and others.

In healthcare, continuous improvement manifests as an organizational process that leverages all team members of a health system or hospital — from CMOs to physicians to shift nurses — in planning and implementing ongoing improvement strategies and practices. The primary goal of these strategies is, of course, better health outcomes for patients; but continuous improvement can also:

  • Streamline clinical care processes
  • Reduce treatment variability
  • Reduce costs for both providers and patients
  • Help hospitals meet regulatory requirements
  • Improve the quality of customer service for patients and their families

Continuous improvement is sometimes combined with quality improvement, which refers to the results of actions taken to make a product or service better. Healthcare systems are heavily focused on quality improvement — of patient care, financial management, training processes — and will use continuous improvement strategies to achieve it. Continuous quality improvement in healthcare is an amalgamation of these two concepts, but they are technically exclusive. Continuous improvement may focus on quality improvement, but the two initiatives may be the responsibility of entirely separate departments within a healthcare organization.

If implemented correctly, a continuous improvement strategy will encourage all healthcare personnel to regularly ask, "How are we doing?" "Can we do it better?" and "How can we do this more efficiently?" In doing so, quality improvement becomes a priority and a result.

The Importance of Continuous Improvement in Healthcare

Hospitals and health systems that implement a successful continuous improvement strategy can expect to:

  • Improve the patient experience
  • Improve treatment outcomes
  • Improve population health
  • Uncover aspects of patient care that could be improved
  • Reduce costs of healthcare for providers and patients
  • Obtain a deeper understanding of their patient population
  • Translate statistics into an iterative plan for action

For example, using a TWI approach to patient care can standardize routine processes and reduce variability between staff members. This kind of optimizing can make all the difference between an overwhelming patient experience and a more manageable one. Take, for example, nurse Virginia Purvis' experience with TWI in practice:

A lot of times when patients leave the hospital, because of the massive amount of information that's given to them just before they leave, they don't grasp it all. But [the hospital staff] used TWI Job Instruction methods for their discharge instructions; they would determine the diagnosis and then educate the patient using TWI [methods] and their results were amazing. The patient's stress level was so reduced. I can tell you that being a family member of someone who's been critical, you don't comprehend hardly anything. So for [the staff] to stop and use this method was amazing in itself. And the results were astounding for patient satisfaction.

Virginia Purvis
Registered Nurse; Manager of 48-bed Oncology-Surgical-Hospice unit
TWI Certified Trainer — Job Instruction and Job Relations

What Continuous Improvement Strategies Are Used in Healthcare?

While most continuous improvement strategies can be adapted for any industry, there are some that are particularly well-suited to healthcare.

Lean
Lean's primary focus is on identifying and reducing areas of waste at all levels of an organization. Lean waste is divided into eight categories, which allows organizations to "chip away" at non-value adding activities whose eradication will, cumulatively, result in more streamlined overall operations. In healthcare, a Lean approach can:

  • Optimize workflows
  • Make patient transfers more efficient
  • Help physicians with triage needs
  • Distribute personnel more effectively across departments

For example, a Lean strategy could be used to standardize the way a hospital conducts shift changes, or to cut down on the time it takes for a patient to travel between departments. Take the following example:

We were looking at the flow for a patient who had lymphoma, and what their day looked like as far as trying to organize their care. They helped us collect data by wearing a pedometer. We captured that they were walking five miles during their treatment day because they had to go to radiology, and they had to go to the lab, they had to go to the doctor's clinic, then they had to go to the oncology intensive care unit, then they had to get a prescription filled and then… So they're just [going] back and forth, all the way through. So we tried to redesign the sequence of things and where [the patient] can get that care.

Martha Purrier
Director, Kaizen Promotion Office at Virginia Mason Medical Center

Baldrige Quality Award Criteria

The Malcolm Baldrige National Quality Award recognizes performance excellence in American business, healthcare, education and nonprofit work. The criteria of the award have evolved into a continuous improvement strategy that measures quality in seven categories:

  • Leadership
  • Strategic planning
  • Customer focus
  • Measurement, analysis and knowledge management
  • Workforce focus
  • Operations focus
  • Results

                      Image: https://www.healthit.gov/sites/default/files/tools/nlc_continuousqualityimprovementprimer.pdf

This approach emphasizes the creation of teams and ownership of responsibilities and is less focused on the specific steps needed to achieve quality improvements. In healthcare, a hospital might use the Baldrige criteria to evaluate and adjust their overall patient experience.

Plan Do Check Act

More of a step in a continuous improvement process than an overall strategy, this is a checklist of sorts to test a change to a process. The steps in a PDCA test are:

  • Develop a plan to test the change
  • Carry out the test
  • Observe and learn from the consequences
  • Determine what modifications should be made to the test

In practice, PDCA could be used to test the previously mentioned reorganization of a patient's daily treatment schedule in order to cut down on wasted time.

Institute for Healthcare Improvement (IHI) Model

The IHI model is designed to address issues that can and should be solved quickly and immediately. IHI emphasizes PDCA and can be combined with other strategies. This model is best for specific problems whose solutions can be refined over time by continuously asking three questions:

  • What are we trying to accomplish?
  • How will we know that a change is an improvement?
  • What changes can we make that will result in improvement?

For instance, by asking these questions, the IHI model could be used to identify gaps in a new patient check-in process.

           Image: https://www.healthit.gov/sites/default/files/tools/nlc_continuousqualityimprovementprimer.pdf

How Do Healthcare Systems Implement Continuous Improvement Strategies?

Any continuous improvement implementation begins at the top of an organization. Leadership buy-in is essential when adopting new processes, so it's crucial that external continuous improvement trainers are respectful of an organization's existing structure and its limitations therein. An organization may also have a department or head of improvement whose sole purpose is to research and direct these strategic implementations. One thing any successful continuous improvement process needs is the ability to iterate.

"The reality is, as an executive, when I start the year, I'm convinced these are the things we need to focus on," says Skip Steward, Vice President and Chief Improvement Officer at Baptist Memorial Health Care. "But guess what I know about that? I'm wrong somewhere. I just don't know where I'm wrong." As such, Skip says, his organization's improvement process has to adapt along with its changing needs. "Our improvement process also has to improve — so that next year, it's better than it was this year."

Whether a healthcare system wants to bring in an outside team of trainers or implement a strategy internally is entirely dependent on the organization's circumstances. The scope of improvements needed, budget and team member enthusiasm for the change can all affect this decision. It can be extremely beneficial to receive an objective assessment from an external team, but the actual day-to-day implementation and subsequent adjustments must be carried out by internal team members. In other words, the plan begins to work when the trainers leave the premises.

In either case, continuous improvement strategy development should begin with:

  • The organization's clear vision of its transformed environment
  • Identifying the changes needed to achieve that vision
  • Input from engaged team members who understand the needs of the organization and its patients
  • Alignment with the organization's mission

Steward illustrates this last item with an example.

"Let's say [a hospital is] using TWI to reduce infections. Now, that sounds like a good thing, right? And it is a good thing," he says. "But it should be connected to the company's ultimate strategic initiatives, and I should be able to find a linkage between that [and the work]. We might be doing some Job Instruction work in the ICU, and we might [also] be doing it in the ER. Strategic deployment not only helps us figure out what we want to focus on, but it also helps us create alignment, which helps us improve that process."

No matter which implementation approach it chooses, takes to the organization should:

  • Use a formal model for continuous and quality improvement (such as Lean, IHI, etc.)
  • Establish and monitor metrics for consistently evaluating improvement efforts and outcomes
  • Ensure that all staff members understand these metrics
  • Involve all providers, team members, patients and family members in quality improvement activities, whether through surveys, simulations or brainstorming

"When strategic deployment and alignment is done correctly … it helps you focus on what you [need] to focus on," Steward says. "Your natural instinct as a human is to try to focus on more than you have the ability to. Strategy is all about what you say no to. And when that is done right, that will align itself all the way to the front [lines] of work."