Do We Make QI Too Complicated?

Karen Baldoza, MSW, is an IHI Executive Director, Improvement Advisor, and lead of IHI’s Improvement Science and Methods portfolio. She describes below her perspective on the past, present, and future of building individual and organizational capability for improvement.

What does it mean to build improvement capability?

For me, it’s about making sure people know how to do their job and how to improve their job. That looks different in different parts of an organization, but it’s ultimately about having the capability and capacity to plan for improvement, improve, and maintain those improvements over time, always striving toward your ultimate mission and goals.

Why is it so important to build improvement skills?

Having the opportunity and ability to improve a situation gives us power, energy, and optimism ― i.e., joy in work. There’s nothing more demotivating, more frustrating than working in a broken process, having ideas about what would make it better, and not being able to act on those ideas. Improvement gives us concepts, methods, and tools to tap into those ideas and into the full range of talents, skills, and motivations people bring to work that, in the end, allow us to best serve those we strive to serve and achieve results that matter.

What is it about improvement that is sometimes daunting?

We often overcomplicate improvement. Sometimes people think these skills are all about a mysterious language and set of tools. It can seem inaccessible, but improvement is innate. We all do it in our daily lives. We just don’t necessarily call it “improvement.” For example, when we try a recipe and it doesn’t work out quite the way we wanted — say it was too salty or too watery — we tweak it a little bit the next time we make it. Or when it takes too long to get out the door in the morning with two kids, we try different ways to organize our morning routines. We innately do these things to make something better.

The challenge is how to tap into that natural tendency at work. It’s hard because you’re often working with many people in complex systems that are often invisible. That’s where improvement tools, methods, and concepts can be helpful.

Improvement can sometimes be intimidating, so I don’t tend to worry about whether or not people use the correct term or use a tool exactly the right way. If people are engaged, improving, making the system visible, or tapping into their intrinsic motivation to make things better, it’s all fine to me. Once we start and people begin to learn and understand, we can then introduce more sophisticated concepts and tools, but always based on the aim, where people are at, readiness, and need.

What were common challenges organizations faced in the past when they were developing QI competency?

Ten to 15 years ago, QI [in health care] was still relatively new. We had early adopters in some organizations. We had improvement projects and scattered pockets of excellence, and we were starting to think more about scale-up and large-scale improvement.

We were discovering the importance of leadership in planning for and supporting improvement and ensuring sustainability. We were starting to focus more on the role of leaders and boards in raising the profile of quality. We were focused a lot on patient safety.

We lacked data. Now we have a different set of challenges around data. Now we have trouble getting the right data out of the EHR. Or we have too much data and aren’t sure what’s useful.

We were beginning to think about the idea of setting goals as an organization that has a portfolio of projects in support of those goals. We were talking more about building improvement capability to support an organization-wide quality strategy.

We were still primarily focused on the technical side of change. The human side of change is embedded in improvement science, but we focused more on the tools and methods. Patient-centered care and involving patients in improvement was still rare. We weren’t saying enough about the link between improvement and equity and joy in work.

One thing I think we did better 10 years ago was starting with the result, like the 100,000 Lives Campaign. “We’re going to use improvement to save 100,000 lives.” These days, we tend to say things like, “We’re going to build improvement capability.” That’s great, but we must keep asking, “To what end?” To train people for the sake of training them doesn’t create results and sometimes creates some dissatisfaction among staff who say, “Okay, that was great. That was the latest flavor of the month.” When you focus on results, then you’re always building capability toward that end, and not just for the sake of doing it.

What’s different about how you teach improvement science now compared to the past?

I teach in IHI’s Improvement Coach Professional Development Program, so I’m constantly thinking about the human side of change ― working with people to create change for the better. People feel moved to join fields like health care, and then we crush that out of them through the complexity and the hassle of their day-to-day work. How do you tap back into people’s intrinsic motivation to keep improving? How do you use the expertise they’ve developed by doing the work every day to improve the work? You see some organizations who are superb at this and others who are struggling with it.

I’ve also learned by working with our equity colleagues that you can’t talk credibly about quality if you’re not talking about equity. You’re not producing quality care that’s safe, timely, effective, efficient, or patient-centered if you’re leaving entire groups of people behind. You have to segment your data or analyze your work in different ways to make sure your improvement efforts are not leaving populations of people out or making things worse for them. It’s time to stop leaving equity out of our work on quality.

Why is building improvement capability important to you?

I’ll never get tired of seeing someone’s eyes light up when they fully engage in an improvement effort. I see it when people are natural improvers and, all of a sudden, a lightbulb goes off. “Oh, my gosh. I’ve always just thought like that. I’ve always mapped out my processes. I didn’t realize that was an improvement tool.”

It’s also rewarding to see people understand something that was eluding them. They knew the work wasn’t going well. They knew it was hard or harder than it needed to be. You see them create a process map or look at their data a new way, and they make visible something they couldn’t see before. They say things like, “I had a sense in my gut that something was going on and now I see it in black and white. Now I can share this information and do something about it.” It’s an amazing feeling to see people learn how to improve care and make their own work lives better.

Editor’s note: This interview has been edited for length and clarity.

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