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52 and 52: An Effort at Rapid Improvement to Impact Staff and Patient Experience
| Part of the Influence Factors of Patient Experience inquiry conducted with support from Siemens Healthineers
- We have an opportunity in healthcare to move beyond long-cycle process improvement to efforts at the front lines that can impact staff and patient experience.
- By engaging staff in the opportunity to elevate ideas for improvement, we underline a sense of ownership, accountability, possibility and pride that raises morale and elevates leadership.
- Efforts such as this require rigor, a commitment to process steadiness and clear and unwavering leadership buy-in, support and visual presence and engagement to ensure success.
Experience Framework Alignment
- Culture and Leadership
- Infrastructure and Governance
- Staff and Provider Engagement
- Quality and Clinical Excellence
About this Case
This Influence Factors case study interview was conducted with Dan Kwak, formerly Administrative Director of Imaging Services/Radiology for Stanford Health Care and now with Kaiser Permanente. Stanford Health Care seeks to provide patients with the very best in diagnosis and treatment, with outstanding quality, compassion and coordination. With an unmatched track record of scientific discovery, technological innovation and translational medicine, Stanford Medicine physicians are pioneering leading-edge therapies today that will change the way health care is delivered tomorrow. SHC is a premier academic medical center with 613 licensed beds and is one of only 20 hospitals in the nation to earn top honors for exceptional performance in specialized, complex patient care. SHC is nationally ranked in 12 specialties by US News and World Report. Imaging Services operates in 12 different locations comprising 300 FTEs and completing about 450,000 patient exams annually.
What was the opportunity, issue or challenge being addressed?
As part of Stanford’s system-wide improvement effort “52 and 52” (52 projects in 52 weeks), now in its second year, the imaging team wanted to focus on staff empowerment and staff engagement and provide a platform and an opportunity to effectively solve problems that impact the patient experience. While there was an established framework for performance improvement and the groundwork had been set to create a culture of performance improvement, Kwak shared the team was looking at “how we could drive [improvement efforts] more locally and provide staff the opportunity to more quickly resolve some of these issues that are impacting their work, their engagement and most importantly, patient experience.”
What process was used to develop a solution?
“We were fortunate enough to start with the quality improvement team that existed in our department,” Kwak said. “We brainstormed together with our physician partners who help lead this group to address the question, ‘How do we create this smaller, quicker platform [for change]?’”
The committee brainstormed and decided to structure an effort around very quick two to eight-week projects that can quickly tackle the process improvement process. The committee addressed the parameters, how success would be determined, and if there wasn't the ability to address an item in the short time frame, how could more resources be aligned, or was it something that actually needed to be put in a parking lot. The group discussed structure, timing and targets and then as Kwak added, “We said, let's put an aggressive goal to it and try to do 52 projects in the 52 fiscal weeks of the year."
What outcomes were you looking to achieve?
Kwak offered, “We anticipated we were going to need to create a structured process where people have a [clear] reporting structure, and that we could help them [take] accountability for their own project.” At the same time the team worked to develop process improvement thinking in all team members. As Kwak described, “Some of these [people] were front line staff who never stood up in a presentation before, never spoke up and said, ‘Oh, I think I want to tackle something myself’ and talk with their leadership about it. So, honestly, we weren't sure what was going to come out of it.” They just recognized the need to put both the structure and process together. The expectation was to put a weekly format together, assign people to help do this work, and provide coaches to help support front line staff as well as to get the word out. The bottom line in this effort was not simply one specific improvement, but the capacity to identify and drive improvements across the organization at all levels with thoughtfulness, speed and intention.
What specific steps did you take to address the problem?
Getting the Word Out
Kwak reinforced, “We had some team members who had performance improvement experience, but really our first job was to get the word out.” They started by informing people of the effort and reinforcing the goal of the endeavor, as Kwak described, “to support staff in being able to identify areas of improvement, areas of opportunity, whether it's for a patient or for your own, and raise it to your supervisor.” The goal was to elevate issues, rapidly put a project together and then work to guide individuals through the improvement process.
Establishing a Structure for Accountability and Ongoing Support
The effort started with a few projects coming in and then just continued to grow. To sustain the momentum the team established a weekly huddle structure every Wednesday at 1:00 PM. During the meeting people report out to the group, to their peers, and to leadership. Individuals were also provided improvement coaches to support them on their project journey.
Kwak shared, “Our VP started including VPs from other areas and even brought our Chief Quality Officer down to see the great work being done.” Key to the program’s success was this accountability structure where leaders were in place to identify barriers. Kwak continued, “We also needed to make sure that we were all in, we're engaged, and that we're asking thoughtful questions to challenge them or make them think about something in a different way. I feel as leaders, we are accountable for supporting the staff and making them feel like they're making a difference, because they are.”
What resources, if any, did you engage to address the problem?
The resources to successfully implement this effort come down to each individual project and what their needs are. This is not to overlook the fact that there are resource needs to support people’s time in addressing the issues they choose to tackle, the coaches engaged in supporting the process, meeting times and leadership engagement. From there, it is truly dependent on the issues that are raised to be addressed.
As Kwak noted, “We've had projects come up where people wanted to make improvements in the physical space to help with patient privacy. And for that, we required the support of the facilities team. For one of our projects, a nurse noticed that some of the instructions that patients were receiving for their pre-appointment medication information was not clear and patients were expressing that they hadn't done their prep because they really weren't clear about the instructions. So, she decided to take on going through every single patient instruction that had to do with medication and [rewriting them], and that required IT support.
Kwak reinforced perhaps the greatest resource need is leadership support, adding, “Since everyone does have other jobs to do, that's where [we really need to ensure we] provide leadership support to help get traction for some of these projects where it wasn't on somebody's radar to be doing this work in the first place.” This underlines that just because it wasn't a priority [doesn’t mean] it shouldn't be, and also acknowledges that this work tends to move beyond the boundaries of most people’s day-to-day commitments, so it requires a commitment from all levels above all else.
What measures did you establish to determine the success of this effort?
In speaking with Dan Kwak, it was clear the that measures of success of this effort were very powerful and sometimes made a profoundly simple impact as a result of the intentional focus of the program. He noted that while many issues raised could be addressed directly in radiology, there were in fact many that required managing efforts across organizational boundaries.
Kwak shared a specific example from one of the radiology nurses. “We are requested by urology to do this exam called a cystogram. The patients come with a catheter,and there was confusion between the referring physician and our team about who was to discharge this Foley Catheter that the patient has. They thought we did it after the procedure and we were telling the patient that they needed to make an appointment back with Urology to do it. There was no coordination. The poor patient is stuck in the middle, bouncing back and forth. Meanwhile, they have this catheter stuck in them.” This would have never been identified if the nurse didn't address the issue, and with this process she had a platform to voice her concern and create this project, which ultimately brought both services together and created a standard that solved the problem. He added, “Some of the problems that come up through this process are things that we may just never have heard of as leadership, because the staff are the ones who are experiencing it, andthey had no outlet in which to address or improve on what they saw.”
In addition to the broader impact of each project, the team also worked to quantify certain measures of impact, including items such as labor time saved from a project, patient experience scores moving in a certain direction because of a project, and whether a project reduced steps for staff and helped to make their lives easier. A grid of all the metrics was created to track the actual improvements. Labor time, dollars saved, steps saved for employees, and whether or not patient experience scores were impacted. All metrics are tracked and at the end of every project, staff members review what they learned as well as work to quantify which items may be associated and applicable to their project.
In addition, the team conducts a survey for all the people who participate in each project to ask them questions about how it impacted their engagement and whether or not they felt like they were contributing to the organization. The results in most cases are clear and unwavering: staff feel supported, like they are making a difference. It is evident this effort has helped with engagement overall.
Regarding financial impact, Kwak offered, “It's been easy to quantify this. For example, when you take out the barriers, you can get more patients scheduled or provide more access to patients because you have improved the scheduling.” The result in many cases has been significant and positive impact on revenue. For example, Kwak shared, “If you are able to get eight more appointments for CT scans in a week because we've improved how we schedule patients, we impacted revenue potential. I think last year we reported that the positive potential revenue impact was somewhere around $30 million.”
Kwak reinforced that that is why the message to staff about this work and its value is so important and equally as critical to outcomes as it is to buy-in at the start. When staff are aware that this effort and the associated projects are beneficial to the bottom line of the organization, that also helps to ensure their livelihood and the organization’s continued success to be able to care for patients. It also underlines and expands the organization’s mission, as it has the potential to increase access so more patients can get accessibility to the care Stanford wants to provide.
This message also serves as a vivid illustration of the impact every individual can have on the organization through their insights, commitments and action. As Kwak said, “Sometimes, the front line patient care provider is not thinking about [the impact] an improvement in productivity has. And when we start to ask these questions and when we actually report out how this works at the end of a project, they have this "A-ha" moment themselves about how they are contributing, in a way, to the business and to patient experience.” That may be the greatest and most lasting measure of success.
What was the ultimate outcome of your effort?
Kwak noted the outcomes they aspired to and described above were realized and perhaps even exceeded via this effort. He shared, “We wanted our staff to think differently, to be more process improvement minded, to look at things differently and behave differently because they're thinking differently. And then, as they're working through a project and actually reporting it out to their own departments, having their peers see that, ‘Oh, this isn't a manager or a supervisor that's telling us how to do this, this is one of our peers who knows our work flows really well and is taking the opportunity to take this project on their own.’ Our goal was to have them be cheerleaders for each other.” It is evident that people have become more than cheerleaders, but rather they have emerged as improvement leaders committed to the organization, to one another and to the patients and community they serve.
The results have also been realized in the culture at Stanford itself, with highly positive scores on their employee engagement survey. As Kwak shared, “It is evident they want to do this work, and we want to continue to spread it.” The impact it is having is clear.
What lessons would you share with others addressing a similar issue?
In asking Kwak about what lessons he would share here offered perhaps the idea that underlines this entire effort. He said, “As leaders, we think we know how our operations are running, [but] there's no way that we could get to the level of detail of information that our front line workers have. We have to get their feedback and their input on problems in order to really have visibility into the true issues of what our patients are experiencing. We can be looking at patient satisfaction scores, but it really comes from dialogue and giving the people the opportunity to voice the individual problems that they're experiencing as they're providing care. We have to give a platform for people to do that, because we're never going to see the detail of the problems when we look at just our [survey] scores. We need to provide the support to help them solve these problems.” And it is evident in doing so there are great benefits to be realized for the individuals the organization and those they serve.
In wrapping up, this comment from Kwak may best sum up both the impact of and opportunity in an effort such as this. He said, “The really exciting piece is watching people, their attitude from their first time reporting out, where they just thought about this idea and they're really nervous about reporting in front of a group and talking about a problem. And then each week, as they're reporting out, just seeing that change in engagement, seeing them feel more confident about what they're doing, the problem that they're solving, what they learned. That has been the most tremendous. We've just been so in awe about their own personal growth through these projects.” This is truly the essence of caring for those who care for others in a way that reaps great benefits for all. A great lesson for us all from Stanford Health Care.
For more information contact:
Vice President, Patient Experience
Stanford Health Care