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Focus on the fundamentals

Kids playing basketball

Round the back, under the legs, and...It's a miss!

Don't you love March Madness? Go Cougars, Ducks, Beavers, Lobos, Bruins, Trojans, Rebels and Utes (if your team is missing, please add them somewhere in between the Cougars and the Utes).

I love to play and watch basketball. From ages 13-15, I would get up at 6 a.m. nearly every day to practice the fundamentals of shooting foul shots and layups at the hoop outside my home. With the ultimate goals of scoring and winning the game, the fundamentals are the best way to ensure that the ball will go in the hoop.

I love quality improvement too. You set your aim and goal; create your plan; use outcome, process and balance measures to guide the effort; put it in practice; and study the outcomes. When it works, you save people from mistakes, help them realize how to manage their care better and catch people before they fall through the cracks.

I recall playing against kids who had some fancy basketball moves. They would bounce the ball between their legs, throw a tricky behind-the-back pass or do a layup from under their legs. This stuff was fun to watch, but it rarely worked in a real game. Often, the young players who focused on these trickster moves found it hard to make a basic foul shot. Helping these kids return to the fundamentals helped their game.

In the same way, health care organizations may have advanced dashboards and sophisticated methods for improving quality, but if they don't follow the fundamentals, they may find those methods lacking.

The Plan, Do, Study, Act (PDSA) or Plan, Do, Check, Act (PDCA) cycle is among those fundamentals, though I feel it sometimes ignores two critical elements of quality improvement, namely, the aim and the goal. If you achieve your goal, it moves you closer to achieving your aim, and if you achieve your aim, you win the game.

Here is my list for ensuring that your quality improvement initiatives move forward.

Plan. Make sure your plan has:

  • An aim to guide your actions, with a clear clinical purpose and direction in health care.
  • A goal with specific measures that you hold yourself accountable for. Example: "We will reduce readmissions by 40 percent by the 31st of next month by doing X, Y and Z." Your goal could be to get somewhere in a day, a week, a year or 10 years from now, but stick with your original plan, even if you don't achieve it.
  • Quality measures: Use outcome, process and balance measures related to your aim and goal, so you can determine whether or not what you're doing is working. I consider it an act of bravery to find a good balance measure that might upset the apple cart if you take something too far. You don't always have to use standardized measures; you can create your own measures that add value. For more on the basics of measurement, take a look at the Institute for Healthcare Improvement's explanation.
  • Assignments for everyone on the team, defining who does what and setting deadlines.
  • Workflow evaluation: Create lean processes in the test environment for any changes in workflow that may be required.
  • Cadence: Bring up the topic in regular meetings. This may seem like a strange thing to mention, but cadence in quality improvement initiatives creates checkpoints and ensures integrity of the effort.

Do it! Make it happen with assignments, accountability and deadlines. My colleague Janet Tennison is an expert in making things happen. In clinic settings where I've worked with her, Janet uses effective language to commit individuals and organizations to make changes.

Study the outcomes. Look at your data to determine what worked, and look at your balance measure to make sure you're not upsetting the apple cart in some other important area.

Act. Decide to continue or discontinue what you did. If your idea worked, share it throughout your organization and with others. If it didn't work, determine whether a particular component of the effort caused it to fail. Retry it or discontinue it altogether.

Finally, consider the benefits. If your quality improvement effort created a favorable clinical or health-related result that reduces your revenue, inform your insurance companies. Let them know of the benefits and consider payment reform incentives that may help you stay in business or make more money to compensate your organization for the value provided.

Bringing it back to basketball, when players focus on the fundamentals, it brings clarity to what can be a confusing game. In all the confusion of health care, sound principles can guide you in the right direction. Then when you look at the final score, you'll find that the fundamentals have carried you to a win.

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