Performance Improvement Tip of the Day: A "SMART" PI Project Checklist

In this "list-obsessed" world of ours, its hardly a surprise that one would create a "Checklist for Checklists". In healthcare, the call has gone out from Drs. Peter Pronovost and Atul Gawande to introduce Checklists as "patient safety tools". They are particularly useful when dealing with complex systems, and for reminding personnel of "basic operations" that can't be forgotten. When used properly, Checklists can ensure that necessary aspects of care are delivered, and free up highly trained personnel to think about when to deviate from a Checklist, and focus on higher level decision-making.

As we make our performance improvement teams more results-oriented, the Checklist becomes a useful tool to help keep the projects themselves on track. This helps to remind our project leaders about the steps they need to take in order to ensure that project goals will be met.

The "SMART" PI Project Checklist below - in keeping with our "SMART" theme - helps to provide a relatively simple, easily implementable framework for delivering improvement. In this context, "SMART" reminds us of the following:

• When designing Goals, Feedback, and Profiles, keep them "SMART" in order to ensure efficiency and minimize the likelihood of resistance or conflict. See prior blogs on each of these topics for more details.
• The "SMART" PI Project ensures that we:
• "Specify" ownership of the project.
• "Monitor" results in an ongoing fashion, and ensure that others in the organization help us with the monitoring.
• "Analyze" the current system in order to properly develop Goals, identify Barriers, and identify the Critical Processes that need to be undertaken in order to deliver results.
• "Redesign" the system intelligently building in decision support to ensure reliable outcomes, and enhancing safety mechanisms to catch problems real-time.
• "Train" ourselves, our staff, and our leaders to deliver better results using proven "behavioral management" techniques of Feedback and Profiling.

While this list can be individualized for the needs of particular institutions, the elements included are generally those that I find essential in delivering results. As you work through the list, you are introducing greater reliability into the system and establishing an increasingly mature culture of improvement.

Performance Improvement Tip of the Day: "Outcomes Driven" Meeting Agenda

The meeting agenda is probably one of the most commonly used tools in project management. However, how this tool is used can make a big difference in the effectiveness of meetings, as well as the coordination of the overall performance improvement project.

The "Outcomes Driven Meeting Agenda" template below integrates performance-enhancing features into the staid meeting agenda in order to create a powerful project management tool:

• "Roles" of team members - Leader, Facilitator, Scribe, and Time Keeper - are assigned at the outset in order to keep the agenda flowing. 
• "Time" is allotted for each agenda item in order to guide the discussion, and to keep the team from getting "stuck" on a particular item. 
• "Discussion Type" is a unique element that allows the team to know what the nature of the discussion will be, so that the discussion is more directed. 
• Info = Share Information 
• Proc = Process Information 
• Con = Need Consensus 
• Dec = Make Decision 
• "Desired Discussion Outcomes" is my favorite feature in this tool. It allows the project leaders to envision and lead the team to the desired outcome for each agenda topic. 

Adapted from Mike Hauser and Brian Stancampiano, Quality Solutions Group, Sanofi Aventis.

Performance Improvement Tip of the Day: SMART Goals

Setting up a successful initiative starts with creating a SMART goal.

SMART stands for Specific, Measurable, Attainable, Realistic, and Timely.

I start first with Timely to ensure that the initiative you are picking is going to be of interest to others in the organization at the current time.

• Timeliness results in interest, which in turn leads to support, which ensures that you will have backing to resolve difficult issues when they arise.

Next identify something Specific about the initiative that you would like to achieve.

• Instead of the broad goal of “improve care of heart failure patients” it would bring more clarity to the team to say “improve accurate dissemination of discharge information to 95%”.
• For clinical initiatives, it is helpful to pick a metric that has ample evidence in the literature to support its implementation. This helps to generate the buy-in required to make an initiative successful.

Ensure that your specific goal is measurable.

• Success is unlikely unless you can measure where you start, where you end, and all waypoints in between.
• Even subjective experiences can be measured through the use of surveys.
• Auditing can be used as a technique to generate reasonable sample sizes when the entire population of study is too large.

Attainable and Realistic go hand-in-hand.

• This is a time for a reality check. The goals need to stretch the limits for the team, but still need to be attainable within the scope of the institution’s resources, within a defined amount of time.

This tool is "simple", but it takes repetitive applications before you can really understand how it helps to drive performance. Practice makes perfect!

I want to thank my friends and colleagues Brian Stancampiano and Michael Hauser from the Quality Solutions Team at Sanofi Aventis for recently reminding me about the power of this tool.

Performance Improvement Tip of the Day: Performance Oriented Project Management

Start with a "burning platform" - what is a critical performance issue that needs to be solved at your institution? Is your CEO staying up at night worrying about something? Is the Board requesting frequent reports on a particular topic? What information is being publicly posted (e.g., on www.hospitalcompare.hhs.gov) that represents a vulnerability for the organization?

Build your support - executive leadership and leadership. Talk to some of the key stakeholders in the project of your choice to ensure that they will support the endeavor. In most healthcare organizations, there are so many competing priorities, while the resources and staffing to tackle them are very limited, that you have to ensure that your leadership team will support the project, especially when it comes to the tough issues that will need to be dealt with.

Build your PI team - some of these may be the same executive leaders and leaders that you spoke to in the "building support round". However, many of these individuals will be frontline staff - nurses, physicians, pharmacists, therapists. The team should be multidisciplinary in order to ensure that you are getting wide-ranging input into the project. Most clinical performance improvement projects have ramifications that you may not be able to predict, or may not realize. Having a team of people from different disciplines, and at different levels of the organization, allows the right solutions to emerge, and enables effective problem-solving.

Create the project plan - one of the first things to accomplish when you get the PI team together is create a "formal" project charter, including mission, vision, goals, outcomes, meeting frequency. This can be more structured if you like, including defining team roles - team leader, meeting facilitator, note taker, and time keeper. However, I've generally found that the strict definition of these roles is not critical, particularly in an organization that is not operating otherwise with this level of structure.

• There are some "outcome oriented project management tools" - such as Meeting Agenda, Action Item Log - which can be vital to success. I'll discuss these tools in future blogs.

How often will you meet? - Meeting frequency is one of the project plan parameters that is very important. Contrary to popular opinion which in general disdains meetings, significant progress cannot be made without effective meetings. Meetings allow for multi-directional sharing of information, resolving of concerns, problem-solving, and synchronization. For projects that are high priority or require sustenance of momentum, consider meeting weekly or bi-weekly. For some projects, we've coordinated daily meetings, which proved to be one of the most instrumental factors in attacking difficult problems:

• Patient Flow from ED to Inpatient: Daily huddles led by our CEO, attended by all critical disciplines - particularly frontline staff - helped to identify problems "real-time" with a major change in the way that patients were being admitted to the inpatient units (admission evaluation completed on the inpatient units rather than in the ED). The direct presence of top leadership, transparency of communication, and the speed with which problems were addressed helped the frontline staff accept and adjust to the changes. This project was highly successful, leading to a reduction of time to admission by an average of 90 minutes per patient.

• Communication of Discharge Documentation: Our Hospitalist Program Director and the Director of Quality & Safety moved to daily meetings to address ongoing challenges with getting discharge summaries and other documentation to primary care physicians (PCPs) in a timely and reliable manner. The daily meetings led to rapid identification of ongoing issues, and to resolution of the same in a timely manner. Information from these meetings was communicated to some of our PCPs, who reported greater confidence in our discharge communication.

Identify the PI Specialist - Although there are a number of roles, as mentioned above, that come into play in a complex project, there are none more important than the PI Specialist. This individual is the day-to-day project leader; the person who ensures that the project is moving forward, and following up in between meetings to ensure that action items are being completed.

• This individual often collects data, disseminates data, provides feedback to providers, and identifies irresolute problems for the PI team to troubleshoot. I'll provide more details about these activities in upcoming blogs.