Public health departments make improvements all the time. Improvements come in many forms; for example, staff find new venues for outreach activities, sharpen risk communication messages, form new partnerships, reconfigure their workplace to use space more efficiently, and revise staff schedules to meet client and program needs. Improvements may be driven by findings from after-action reports, program evaluations, customer or employee satisfaction surveys, or performance management activities. Improvements may also occur simply because staff decide to address a problem that hinders their ability to work efficiently and effectively.
Quality improvement (QI) is a formal, structured way to address problems. It involves using a defined improvement process (e.g., Plan, Do, Check, Act cycles; Kaizen; Lean Six Sigma) to identify the underlying cause of a problem, test solutions, and achieve measurable improvements. Anyone who has engaged in QI knows that it requires expertise, a team’s time and energy, and ongoing efforts to monitor and hold the gains. Given the demands of a QI effort, it is important to understand when QI is needed to achieve an improvement—and when it is not.
When QI Is Not the Answer
Before committing a team to undertake a QI process, it helps to determine whether an improvement can be made another way. The following are examples of when QI is not a suitable pathway to improvement:
Personnel problems exist.
A central tenet of QI is that it is about the process, not the people. What this means is that the focus of QI is on making process improvements, not “weeding out the bad apples.” If an employee is underperforming or not following established policies and procedures, it is important to directly approach the problem as a human resource issue. Individual performance plans and reviews are a valuable tool to address employee performance. When a QI process is used without addressing known performance issues, a few things can happen. For example, if someone is clearly not performing well, it could potentially undermine leadership’s assertions that QI is not about weeding out bad apples. In addition, any new process designed could accommodate underperformance and therefore fail to achieve optimal efficiencies.
Employees do not follow the same process.
One of the first steps in a QI effort is to map the process. At that point, teams sometimes find that an established process does not exist, or it does exist, but employees are unaware of it. When teams find themselves in this situation, the focus should shift to developing and documenting a process and providing standardized training for all staff. Likewise, if the team knows that an institutionalized process does not exist, then they do not need to undertake a QI effort; rather, they should work to develop and establish the process.
A plan does not exist.
In working toward accreditation, many health departments are developing strategic plans; community health improvement plans; and plans for workforce development, performance management, and QI. Generating plans when none existed is definitely an improvement; however, a QI process is not needed to do this work.
Problems have pre-determined solutions.
We have all experienced a time when a problem arose, and “the boss” unilaterally identified the solution (which is certainly the boss’s prerogative). Situations like these call for transparency from the person in charge, and the solution should simply be implemented without any pretense regarding the use or value of employee input. Putting a QI team through the motions not only wastes a significant amount of time, but it also could cause trust issues and damage employee morale.
Solutions are self-evident.
What should you do if phones are not answered in a timely fashion, a piece of equipment that needs to be centrally located always ends up in someone’s office, or customers complain because a service counter is always too backed up during peak hours? Knowing that a team needs to be involved in identifying an improvement, one may think that QI is in order. However, the aforementioned scenarios are examples of problems that most likely have a somewhat obvious cause and an easily identifiable solution. For example, staff can develop a schedule that ensures that the task of answering phones promptly is divided among them, they can agree on a better location to store equipment or institute a sign-up sheet, they can cross-train and assign staff to assist when additional “hands on deck” are required to provide sufficient customer service, or they can draft and implement a new policy or procedure. If a solution to a problem appears to be self-evident, give it a try. Staff can be engaged to brainstorm, divvy up responsibilities in a mutually agreeable way, and decide how to hold each other accountable without going through a formal QI effort.
When QI Is the Answer
QI offers a systematic, powerful way to address a number of problems, especially when data indicate that the department is not achieving desired results. QI is especially useful when the cause of a problem is not apparent, because it is designed to carefully explore a problem and identify its underlying cause, thereby avoiding the potential to treat only a “symptom” and miss the root of the problem. QI is also designed to ensure that the most efficient, effective process is designed, tested, and used by all staff members who touch the process. With a QI approach, the team members know whether the desired improvement has been achieved because they measure the results of their work and monitor the process over time. Some examples include the following:
- Specific tasks or a set of tasks are not completed in a timely fashion (e.g., processing vital records, conducting inspections).
- Many errors are made (e.g., inaccurate coding or laboratory results).
- Specific targets are not achieved (e.g., too many children are not age-appropriately immunized).
- Expenses have unexpectedly increased (e.g., those associated with inventory or transportation).
- Outcomes are inconsistent (e.g., the number of completed inspections varies significantly from quarter to quarter).
- The process is cumbersome (e.g., staff complain that too much paperwork is involved or that too many approvals are needed).
These represent only a handful of examples of issues that a QI project could best solve, and this is by no means an exhaustive list. Rather, this list is intended to help illustrate the types of situations when it is appropriate and desirable to assemble a team to conduct a QI effort.
QI can be a powerful tool to make many types of measurable improvements; however, a QI approach can sometimes be unnecessary, inefficient, and even counterproductive. Carefully considering the best approach to making an improvement will help ensure that the “juice is worth the squeeze” when you and your team decide to engage in a QI effort.
Acknowledgment: Thanks to Marni Mason, MarMason Consulting, and Becky Sechrist, Minnesota Department of Health, for sharing training materials that contributed to this document.
Gorenflo, G. & Madamala, K. Is the Juice Worth the Squeeze? Deciding When to Use QI. Wed, 03/14/2018. Available at https://www.phqix.org/content/juice-worth-squeeze-deciding-when-use-qi. Accessed 03/26/2023.
Is the Juice Worth The Squeeze?
Great article, thanks! After being a staunch advocate for formal QI for many years, I recently began hearing a growing chorus of people saying that there is no wrong way to do QI. I was becoming frustrated by this, thinking that of the 100 ways I've seen "QI" done, 99 of them were what I would consider to be the wrong way! No ability to decern whether a change actually occurred, or whether a change that did occur was actually an improvement. No way to sustain the improvement or to standardize the gains. I started to develop the sense that most people equated QI with simply solving a problem. Rather than continue to swim against this current, we decided to consider it an opportunity and took advantage of it. We created a simple tool for reporting on "QI" projects. The premise was that if you want to change the experience you are having as an employee at our health department, you are empowered to do so. And, if you think you already have the (low or no cost) solution figured out, then go ahead and try it out! Our tool asks four questions: 1) What was the problem? 2) How did you address the problem? 3) What was the result of your action(s)? and 4) How did you sustain the improvement? For marketability, we gave the tool a catchy name - the VFIT (for Very Fast Improvement Tool).
This tool has proven to be a useful way for staff to embrace QI, and it has been an important gateway for many to become engaged!
I appreciate your comment,