How to Begin a Quality Improvement Project

In quality improvement, the people who do the work need to be the ones to change the work. This usually requires an interdisciplinary improvement team, with representation from disciplines such as medicine, nursing, and administration. Health care professionals have experience working in teams, but determining the composition of a successful quality improvement team requires a different skillset (1). Stakeholder mapping and analysis are tools that may help identify appropriate team members.

Stakeholder analysis also involves consideration of stakeholder motivations that may act as facilitators or barriers. These motivations may include patient care, finances, process efficiency, staff satisfaction, or staff recognition. Different stakeholders have different perspectives on a given quality improvement initiative, and therefore, stakeholder engagement strategies may have to be individualized to build a change team and overcome resistance to change. It is important to note that stakeholder mapping and analysis are dynamic processes, with new stakeholders emerging and stakeholder influence and interests changing as a quality improvement project evolves.

After stakeholders are identified, the stakeholder map requires analysis to determine which stakeholders to approach. Analysis requires prioritization of different stakeholders, because it is not feasible or necessary to engage all stakeholders with the same level of intensity. One useful tool is a power versus interest grid ( 3 , 4 ). These grids place stakeholders on a two-by-two matrix, where the y axis is the stakeholder’s political interest in the quality problem and the x axis is the stakeholder’s organizational power or control over the system. Four categories of stakeholders result: players who have both an interest and power, subjects who have an interest but little power, context setters who have power but little interest, and the crowd with little interest or power ( 3 ). In this way, power versus interest grids help identify stakeholders who should be involved in the project and considered for the improvement team (players) as well as the intensity of engagement strategies for other stakeholder groups (greater intensity for subjects and context setters than the crowd).

A stakeholder is anyone who has an interest in a project and can influence its success or failure ( 2 ). Stakeholders are individuals and groups within (internal) or outside (external) your local setting. It is important to identify or map stakeholders who can affect your quality improvement project at an early stage when these relationships can be managed, including supporters and resistors of change. Inclusion of resistors may ultimately help to avoid conflict and administrative delays as the project evolves. There is no universally accepted strategy to identify stakeholders. In our experience, an effective technique is to brainstorm and list all stakeholders. This activity is followed by organizing the stakeholders into groups (physicians, patients, hospital leadership, etc.) and outlining the relationships among different groups. It is helpful to do this graphically using lines or arrows, with the quality problem remaining at the center of the map and the different stakeholder groups organized around it.

Improvement Team Roles and Characteristics

Stakeholder influence is not the only criterion to consider when forming an improvement team, which should consist of the following roles and characteristics (5–7).

• Team lead: The individual responsible for day to day management of the quality improvement project, who is also part of the system that will undergo change.

• Technical experts: Individuals who understand different components of the quality of care problem and are a major part of the system that needs to be improved.

• Clinical/system leader: A manager who understands the implications of changes on other parts of the system, with sufficient authority to test changes that are recommended by the team lead and technical experts.

• Improvement advisor: An individual with expertise in quality improvement methods to act as a resource and advisor for the team lead and technical experts.

• Executive sponsor: An individual with power and leadership skill within the organization who can be approached when needed to secure resources and remove barriers.

Filling these roles will help ensure that an improvement team possesses the right balance of leadership, management, expertise, and power to succeed. When an improvement advisor is unavailable, resources and toolkits, such as those provided by the Forum of ESRD Networks, may be helpful (8,9). Although these team members can come from any area of health care, the role of physicians and patients/families in quality improvement has garnered the most attention.

Among health care providers, physicians have the most influence on variation in health care outcomes, and without physician engagement, it is very difficult to improve health care delivery (10,11). However, physicians participate in <35% of quality improvement efforts, and there are many barriers to physician involvement in quality improvement (12). These include lack of time, threats to physician autonomy, financial disincentives, and lack of quality improvement skills (10,13). Physician responsibilities are often spread across several areas, and the quality of care priorities faced by hospitals and other health care organizations seem misaligned with the quality of care issues faced by physicians (11). This discrepancy may be most evident when quality of care targets are not patient centered. Despite these obstacles, physicians are clearly interested in quality of care, particularly improvement of patient outcomes and reduction of inefficiencies. Quality improvement expertise is not necessary, because the physician role can be to focus improvement activities on patient outcomes, bring credibility to a project, and inspire colleagues (14). Effective physician participation in quality improvement depends on communication and teamwork (11). Physicians must resist the temptation to lead or control discussions and instead, defer to the team lead or improvement advisor when outside their area of clinical or system expertise. Strategies to engage physicians in quality improvement exist that address the aforementioned barriers, and they are recommended on the basis of the experiences of the Institute for Healthcare Improvement and leading health care institutions in the United States (10,11). These strategies include data transparency, strong organizational commitment to quality improvement, and showing physicians how quality improvement can lead to more time in their day for direct patient care. Compensation and incentives are more controversial strategies with mixed success (15,16). One option is for organizations to provide nurse practitioner and allied health support, which frees physician time for quality improvement and patient care (11). Effective stakeholder engagement depends on making quality improvement participation easy, and these strategies involve finding common purpose with physicians on quality of care initiatives that respects their time commitment and contributions.

Users of the health care system also possess unique knowledge and experiences that can inform quality improvement efforts and help design systems around the needs of the patient rather than the staff or organization (17). However, there is much debate over how to meaningfully involve patients and caregivers in quality improvement (18). Experience from the United Kingdom suggests that projects have a clear rationale and defined roles and responsibilities for patients and caregivers (18). Roles that patients and caregivers have played in quality improvement include:

• Identifying improvement opportunities ( 19

• 21)

  Creating a sense of urgency for change with storytelling ( 20

• 20)

  Acting as an outlet to solicit other patient experiences ( 18

• 21)

  Offering change ideas to redesign systems of care ( 18

• Persuading health care providers that quality of care problems exist and need to be addressed ( 18 ).

Published experiences that involved patients and caregivers in quality improvement noted several advantages. These advantages largely focus on challenging assumptions that the current level of care is acceptable and lending credibility to system changes by showing that the proposed improvements are likely to be well received by patients and caregivers (18). In addition, patient and family involvement may energize staff and focus team members on improvement rather than longstanding organizational conflicts (20). Disadvantages include avoiding the appearance of tokenism and participation primarily to satisfy organizational requirements without concrete contributions (22). Barriers to patient and caregiver participation may have to be addressed, which include institutional culture, patient availability, and power indifferences (20,21). What constitutes a representative patient is also a matter of debate, although several published reports suggest that patient demographics are less important than the different experiences that any patient can offer (23,24). Patients and caregivers have helped to redesign several health care processes and systems across both inpatient and outpatient settings, with outcomes that include reducing missed appointments, medical errors, hospital length of stay, and costs (20,25,26). Although the literature on the role, effect, and strategies to engage patients and caregivers in quality improvement is evolving, their important stake and unique perspective on health care suggest that patients and caregivers can meaningfully contribute to an improvement team.