Change is inevitable. At a time of economic downturn, when budgets are cut and the costs of medical services to the uninsured citizens rise sharply, services from the safety-net public health agency are expected to increase with decreasing number of staff. Thus, the agency is preparing to embrace the increased workload with leaner budgets by becoming more effective and more efficient and by eliminating all non-value-added activities.
The first QI experience had taught the Cumberland County Health Department how to perform at newer levels of efficiency and efficacy. Lean skills bring about savings on staff time and service costs for the entire agency while also providing better quality services for clients and patients. When each department is trained to apply the Lean tools and the QI’s Model for Improvement effectively, then the entire agency will perform at newer levels of efficiency and efficacy. The bonus is the increased staff morale.
The change process is more effective and encounters less resistance when led by the frontline staff, who are desirous to improve their own work environment and conditions. Empowering the frontline staff with the authority to create small and feasible improvements for themselves is paramount for long-lasting success.
Staff involved in the QI process must be allowed adequate time off to learn the QI tools and to apply the QI skills in their area judiciously. All disciplines of staff in the targeted area must be included in the QI project, and their buy-in must be earned. Feedback from everyone, including patients/clients and staff, must be diligently sought, solicited, and encouraged, whether in person, in writing, using surveys or suggestion boxes, anonymously, or in public.
The QI team must ensure that the area QI staff continue to use their QI skills to sustain the positive changes and to maintain the high level of staff morale.
The QI team must provide continuous QI skills training to staff from different programs and areas to sustain the newly achieved improvements, foster the agency’s desires for further improvements, and spread the QI lifestyle and culture throughout the entire agency.
Communication is paramount:
To lessen staff resistance and ensure buy-in for success, the QI team must reassure all staff that the focus of the QI process is to change the service processes and not the people providing the services.
To prepare everyone for the upcoming changes—prior to any actual changes—the QI team must continuously and effectively communicate with staff and management and diligently explain why, when, and what will change. The QI team must communicate with Senior Management regularly to report results, impacts, and outcomes to ensure the Senior Leadership’s continuous and enthusiastic support for each QI project.
In times of doubt and when facing challenges and adversity, the QI team members must communicate with each other daily and must stand firm together and resist falling apart. The QI team must be prepared to endure and overcome indifference, resistance, criticism, and/or negativity from many sources, from staff to managers, and have strong faith in the evidence-based QI tools and in the ultimate upcoming success of the QI process.
In the agency's experiences, because this was the first QI project, the agency's initial expectations were low and its doubts high. Therefore, the successful results were unexpected and above the agency's hope and expectations. Everything went as planned and only when appropriately planned.
The QI team is composed mostly of managers who are in charge of several programs and clinics simultaneously and who at the same time provide services as frontline staff in certain areas. Due to lack of planned time devoted for the QI project, the team had failed to plan for timely data collection prior to the QI project and the Kaizen event. Therefore, for the AHC QI project, except for the daily patient complaints about the AHC’s services received by the Health Director, the pre-QI data are much weaker than the post-QI data. Staff have now learned that solid pre- and post-QI data are necessary for accurate measurements of the agency's success as well as to share its success stories. Therefore, for the next QI project, the agency will diligently collect adequate pre-QI data prior to any PDSA implementation.
Cumberland County Health Department had also failed to provide appropriate leave time for the QI staff, both for the clinic frontline staff and for the QI team members, thus creating undue stress to staff who must carry out their daily tasks in addition to the QI activities. For our next QI project, the department will make sure that everyone participating in the QI project will have adequate leave time from their areas to learn the QI tools effectively and fruitfully implement the QI skills in their areas.
Cumberland County Health Department wished it had known before beginning this project that data collection and documentation are of utmost importance.
As stated above, the department wishes it had known that all data, pre-, during, and post-QI are of utmost importance so that staff could have prepared and collected more solid data to share in the department's success story.
The department has now learned the importance of designing measurement tools and of documenting all data, especially outcomes measurements to ensure the sustainability of the QI efforts.
In the beginning of the QI project, Cumberland County Health Department had allowed indifference, doubt, resistance, and negativity from many sources, at many levels, with accusations of being another new-and-improved fad or gimmick to depress staff morale, discourage their spirit, and erode their hope and faith.
Now that the first QI project has turned out to be a huge, unexpected success, together as a team, staff have learned that their trust in the evidence-based QI magic prowess is solid and indestructible.