Knowledge Area Module (KAM) I
Implementation of Process Improvement Teams
By
Missy Hampel
A Paper Presented in Partial Fulfillment
Of the Requirements of
LEAD 575 Organizational Structures and Behavior
December, 2013
Abstract
Process improvement teams are being used increasingly in health care. A literature review will be conducted about process improvement and team formation. Safety is a primary focus at Via Christi and the reason why the improvement teams were implemented. Process improvement has demonstrated positive results with the use of Six Sigma. Problem solving will be looked at with the five steps and how this approach is beneficial. Team effectiveness is essential to the success of process improvement. The team processes and formation will be looked at. I will conclude with my thoughts of our current journey and my recommendations for the future teams going forward.
Introduction
Providing health care in today’s rapidly changing market is complex and challenging. There is considerable value with using a team approach and process improvement in hospitals today. Process improvement teams are a proven way to enhance patient safety, improve operational effectiveness and a way to gain a sustainable competitive advantage (Gowen, 2012). The implementation of these teams is being conducted as a way to improve quality and safety. Emphasis will be placed with building effective teams and using lean methodology to improve work flow processes at Via Christi. This is an exciting new approach that has been shown to resolve problems and is a way to achieve outcomes that will improve the care of our patients.
Utilizing teams is recognized as a great way to share information, generate new ideas, and increase communication. Great teams don’t just happen. There needs to be time devoted towards building an effective team model that will be used in the organization. Four main components have been shown to build successful teams. The organizational and team environment needs to be in place where it lends support and structure to the teams. The design of the team elements need to be taken into consideration which include the characteristics, size and composition. Team processes will be developed to form roles and trust among the group. Each member should have an understanding of the normal processes the group experiences as the group forms. The team development process is important and will give teams a structure that will help to improve decision making (McShane & Von Gilnow, 2013).
Teams are an integral part of hospital operations and have been used for many years. Via Christi followed the trend of other health care facilities and decided to implement the use of process improvement teams. These teams use lean methodology with Six Sigma, which offers a different strategy to improve processes. Six Sigma has been in place for many years in manufacturing but is relatively new to health care. The steps in the lean process will be looked at in depth along with the improvement processes that are most effective. Health care is being challenged to improve the quality and safety of their care. Using this team approach will help to improve their processes by decreasing costs, enhancing communication and creating sustained changes that will improve the care of our patients.
A review of the literature will look at team effectiveness and the use of process improvement teams. These will be looked at in depth and will conclude with recommended actions for my organization. The team dynamics and use of process improvement will leverage our resources and help to achieve sustained results.
Review of the Literature
Process improvement and the use of Six Sigma will be looked at with their ideas for success. The team dynamics is very important and needs careful consideration when implementing a new practice. The characteristics of an effective team will be discussed along with the structure that is needed.
Process Improvement
Hospitals have been led to concentrating their efforts on process improvement. There are preventable medical errors that occur leading to rising healthcare costs. One study examined how process initiatives could enhance outcomes and improve organizational effectiveness. Continuous quality improvement, six sigma and lean management initiatives are being utilized by hospitals. This study looked at which of these methods are most effective for improving patient safety results (Gowen, McFadden, & Settaluri, 2012). Techniques and structured efforts have been identified to improve the success from improvement projects. These include ensuring that the improvement efforts are part of an overall strategy and should integrate with organizational scorecards (Breyfogle, 2010). There needs to be a strategy implementation plan when using process improvement. The skill sets, tools needed and training that are needed for the work force should be considered. Eventually the process improvement teams will move to continuous improvement that becomes permanent (Brache, 1992).
There are several differences between process improvement teams and project teams. The goals, membership, roles, measures and results have differences that were looked at. The largest indicators of success with process improvement teams are support from leadership, the skills of team member and having the ability to function as a team (Componation & Farrington, 2000). The philosophy of Six Sigma was introduced to the health care industry by GE. A brief history was provided and the benefits described. This rigorous process was used in a radiology department and showed significant benefits. The errors for the MRI ordered process decreased, wait times went down, while patient volume increased (Lloyd & Holsenback, 2006). Six Sigma has proven to reduce wait times, improve work flow and standardize supplies. Processes were identified at a Michigan hospital that experienced stellar results by using this methodology (Germanine, 2007). Several organizations have shown that improvement teams have consistently improved their results by reducing errors and achieving efficiency. This is accomplished by following an analysis process that provides concrete information. Six Sigma does require initial effort but will show rewards in the future (Woodard, 2005). Cost savings have been demonstrated and best practices among process improvement teams were shared (Jacobsen, 2007). Successful tips were shared along with suggestions to prevent failures from occurring. Sources discussed the importance of having a performance measurement system that takes into consideration the goals of the organization. Having leadership support and back up is vital to the success of teams (Popoff & Brache, 1994).
Team Formation
Teams are impacted by the several factors. There needs to be diversity and attention given to ensuring that the right people are on the team. The functions of the team members need to be considered along with ensuring the objective is the “right thing to do” (Kador, 2001). There are several key factors that were identified to have effective improvement teams. These include having enthusiastic team members, providing clear direction, effective team meetings, problem solving and the use of rewards and recognition (Antrim, 1999).
Team effectiveness was outlined looking at the organizational environment, team design, and processes. There are four team processes that influence team effectiveness. These include team development, norms, cohesion and trust. These all contribute to effective decision-making with the teams (McShane & VonGilnow, 2013). There are many benefits of teams that benefit the organization. The benefits include increased problem solving, higher quality decisions, improved processes and communication. Process improvement teams often receive specialized training that helps them to identify root causes of problems. Step by step, they identify ways to enhance a process (deJanasz, Dowd, & Schneider, 2012).
Self directed teams have been shown to have increased team competence. There are a number of implications that can be used from this study that could be used with team design, training and development (Kauffeld, 2006). There have been many advances with communication and technology. The use of virtual teams was researched looking at the
differences with virtual and face to face interactions. Team empowerment was researched where virtual teams were utilized (Kirkman, Rosen, Tesluk Gibson, 2004).
Main Body
A Call to Action at Via Christi
Safety and quality are very important when providing healthcare. A quality consultant visited Via Christi a little over a year ago and assessed the environment. The news he delivered was difficult to hear. He told us we were ordinary, not particularly bad, but also not particularly good. A call to action was initiated at Via Christi that made safety a priority. The organization previously was concentrated on so many directions; many felt that we had lost focus. The consultant offered several suggestions which included starting at the top with leadership. A strategic plan was put into place where safety and quality became our number one focus. As Dr. Reinertsen suggested, when safety becomes #1, everything else falls into place. The quality department was restructured and two top infection concerns were addressed with process improvement teams. Project teams have been in place for many years that have used a variety of methods such as the PDSA process. To achieve stellar results, a process with our teams began, utilizing new methodology.
Process Improvement
The high incidence of preventable medical errors has led to many hospitals looking for new ways to improve their safety and quality. There are three methodology approaches that can be used with process improvement initiatives. Continuous quality improvement (CQI) , Six Sigma (SSI) and Lean Management (LMI) have been shown to be effective. The application of these techniques is an effective way to standardize and sustain processes. (Gowen, McFadden & Settaluri, 2012). The lean process works to eliminate waste and non value added activities. The Six Sigma process is a sophisticated approach with a business model (Hadfield & Holmes, 2008). This is the approach we have chosen to primarily use at Via Christi
It is important that improvement efforts are focused on areas that will enhance their chance of success. There needs to be an emphasis that improvement efforts are part of an overall plan. They are integrated with the system and the results impact the entire system (Breyfogle, 2010). I helped with one of the first process teams at Via Christi this last year. We were tasked with reducing central line infections by 25%. The process was integrated with the whole system where many areas of the hospital were affected by the team’s decisions (2010).
Demonstrated Results
Process improvement teams have shown excellent results. Clinical care, patient satisfaction and financial performance were improved at the Virtua Healthcare system. This was accomplished by streamlining the care of congestive heart failure patients and decreasing the length of stay for the hospitalization (Woodard, 2005). A hospital showed improved timeliness with operating room scheduling and room turnover with the use of Six Sigma (Germaine, 2007). The two teams that began at Via Christi have had exceptional results. Ventilator associated pneumonia has decreased by 65% this year and the central line team exceeded their goal.
Use of Six Sigma
These examples show how businesses and hospitals can use process improvement teams to achieve success. Six Sigma is a disciplined, data driven approach that uses decision-making methodology. The goal is to reduce the occurrences of error and defects. There is a five step process that is used with problem solving. The problem is defined, a team charter is established and process mapping occurs. The key measures are identified and data plan is decided on. The data is then analyzed with a determination made what improvements need to occur. From this point, a plan is designed to make improvements. The potential solutions are determined and a control plan is established. This process works to develop and implement a plan to ensure sustained improvement (Hadfield and Holmes, 2008). Six Sigma goals are aggressive and the methods used are well defined. This approach has been successful by defining the causes of variation and then working to find solutions (Woodard, 2005).
Manufacturing firms have used process improvement teams for years. Healthcare facilities are experiencing many challenges with government cutbacks and concerns from the public about the safety of healthcare. The use of process improvement teams have been shown to help with the challenges they face (Hadfield & Holmes, 2008). The teams work to identify and implement meaningful improvements. When the workforce comes together to solve common problems, true community develops. There is pride from the accomplishments that are achieved (Antrim, 1999). It is important that the leadership demonstrates their commitment to quality and support for the teams.
Teams bring together a group of employees who must identify and implement improvements. Often the team itself can be the obstacle to achieving their goals. It is important that the team structure is designed and there are objectives that will be shared among the team members (Kador, 2001). Failures can occur from not having the right people on the team (Popoff, 1994). It is important to have an effective team in place to ensure process improvement success.
Team Effectiveness
Several models have been identified over the years that have shown to be effective when forming a team. The team effective model recognizes the importance of the organization and the team environment. There should be a structure where the leaders of the organization provide support and a strategic direction. There should be a purpose why the team exists and a goal to achieve (McShane & VonGilnow, 2013). Determining that the objective is the right thing to do helps to make sense if it is right for the organization (Kador, 2001). An effective team should be carefully designed, taking into consideration the task characteristics, size, composition and roles of the group. The level of interdependence should be looked at and determine the goals that will be worked on (2013). The size of the team needs to be thought about. Team members often feel engaged, have increased influence on the group norms and have increased accountability with smaller teams. The size needs to be large enough to accomplish the goals, but also be small enough to have efficient coordination. The composition of the team is very important (2013). The talents of the team members need to be considered and what skills will benefit the team. Different backgrounds and levels of expertise provide a well rounded representation of the team members. The characteristics or behaviors of potential team members need to be looked at. Team members that lack the five competencies tend to undermine the team process. It is important that there is cooperation along with the ability to coordinate and communicate with others. Effective members are comforting, providing emotional support and have the ability to resolve conflict (2013). The process improvement teams (PIT) followed these guidelines. The teams had 12 to 15 members with a diverse group of people represented on the teams.
Team Processes
The processes of the team are important elements that need to be present. These include developing the team, forming the roles of the members, establishing the norms and building the team cohesiveness (McShane & VonGilnow, 2013). A series of stages are gone through as they get to know each other and evolve into teams (deJanasz, Dowd, & Schneider, 2012). The five stages are forming, storming, norming, performing, and adjourning. As the teams form, this is time where teams get to know each other and set group objectives (2012). Behavior boundaries are tested, there is politeness with deference to the leader and members are trying to figure out how they fit in (2013). The storming stage is difficult and the novelty of the new team has faded away. Conflict and chaos occur in this stage where feelings of resentment and resistance emerge. The group works through the storming by developing new communication channels. If the group is unable to resolve their differences, a facilitator may be needed (2012). The norming stage finds members learning new methods to work together and adhering to the standards of behavior. Teams emerge from the last stage with a renewed sense of hope that team unity will be developed. The performing stage emerges with members working together and there is support provided to each other (2012). Members cooperate with each other and there is trust developed among the team members (2013). The final stage is adjourning. The objective of the team has been accomplished. This is a time to complete follow up and enjoy the team’s achievements (2012). Our group experienced each of these stages. After three, one hour long meetings occurred to figure out how to wash your hands, the health care members became frustrated at one point. In the black belt world, it is a yes or no answer, leaving no room for the color grey. Each discipline learned something from each team member, but there was a storming stage that did occur.
Team Roles and Norms
The team should have a structure in place that establishes expectations and team behaviors. Roles need to be established for the team along with the team leader role identified (McShane & VonGilnow, 2013). There should be a clear direction and accountability for the results defined (Antrim, 1999). As the team develops, the members become committed towards each other and the goals. Team cohesion is formed where the members are motivated and each feels a sense of ownership (2013). The team members will need to make effective decisions. It is important to identify the core issues and determine an approach that will be used. The various options concerning the decision should be generated, researched and evaluated. Once a decision is reached, it will be time to implement and monitor the decision that was made (deJanasz, Dowd, & Schneider, 2012).
Conclusion
There is considerable research that supports the use of process improvement teams. Via Christi made a decision to focus on a culture of safety and to begin using this new methodology last year. There is a strong leadership commitment for Six Sigma and support to make this process part of the organizational strategy. Via Christi got off to a good start by having a strategy in place and by hiring black belt experts to lead the teams.
The two teams that were formed last year exceeded the expectations that were set. When the new teams initially began meeting, they formed a charter and defined the goal to achieve. The black belt followed a structured process to form the teams. Going into year two, many new teams are being formed to work on new processes. Although there were lessons learned from last year, there hasn’t been a meeting to gather these thoughts or share this information.
Initially there was education provided to the team members to learn about the Six Sigma process. Team members were carefully thought out and there was encouragement to have bedside caregivers be a part of the teams. The teams have an imbalance of management and staff presence currently. It is important to involve the right people and ensure that the members have the ability to function as a team. Education needs to be continued with new team members to learn about the Six Sigma process.
Via Christi did start off the process improvement teams with leadership giving their full support. This was evidenced this last year when approval was given for an antimicrobial patch. Ordinarily this process would take considerable time for approval. The ability to demonstrate metrics, show improvement, and have a recommendation from team, expedited this process.
Each of the black belt experts came from an aviation background and did not have any medical experience. Likewise, the medical personnel did not have a quality background and many had not heard about the Six Sigma process previously. The team members came together from very different backgrounds, however there wasn’t any education provided to the members about team processes. This would have prepared team members about the stages of team development and helped them understand the storming phase is a normal process of team formation.
Although the teams achieved success this first year, there have not been any team rewards or recognition that has occurred. The results of the teams need to be shared and celebrated. This was mentioned several times as a vital part of the team. Education to the nursing staff was conducted along with regular communication about the team results. New practices were implemented that have improved the care of our patients. At the current time, there are approximately nine new teams forming. There is a fertile environment for process improvement at Via Christi. These teams are a valuable way to look at our problems and develop an improvement process.
Recommendations
Via Christi is off to a solid start with implementing process improvement teams. As we move forward with new teams, I have some recommendations that I will share.
1. Conduct a meeting with the members of the two original process improvement team members. Ask specific questions and solicit feedback about the team processes and lessons learned from being on the team. This information will be shared with the black belt experts and used with the new teams going forward.
2. Continue the selection of having the right people on the team. In addition nurses from the bedside need to be added to the teams. This had been the intent last year; however it was difficult for them to attend each week. Resources will be provided with the help of leadership support, so the nurses can regularly attend the meetings.
3. Education is provided to all team members on the Six Sigma process. As each team forms, I recommend one meeting is dedicated to lean process education, instead of a brief overview.
4. The lean process meeting should also include education to the members about team effectiveness. Education about the five stages of team process needs to be conducted, with special emphasis on the storming phase. Bringing team members from entirely different backgrounds did present a challenge. Providing information would help members understand this is a normal part of team formation. Emphasize team accountability and the importance of regular attendance. Those who cannot commit are replaced.
5. The team successes should be celebrated with recognition given. The intensive care units have worked hard to change their work flow and improve processes. A small celebration should be conducted to reward all the team efforts and hard work.
6. Each month have a report generated from all the teams, communicating the activity of each group.
7. Very few nurses have lean management training. There needs to be an increase of yellow and green belt trained nurses. I myself plan to achieve the green belt level.
8. Consider the use of virtual teams. Although actual attendance is preferred, this would help to include the statewide Via Christi ministries. Currently we utlize the phone, but I would propose we look into a virtual option where team members can see each other as they interact.
This was a very interesting and meaningful assignment. I will personally be involved with five teams this next year and found the information I have learned very relevant. I plan to take the recommendations I have suggested to the director of quality and will work to implement these with our teams.
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