Map-enabled experiential review: A novel approach to engaging

healthcare staff in quality improvement

Received (in revised form): 14th May, 2018

Donna R. Cohen

is Principal Consultant at Darcy Associates and Director of MEERQAT Pty Ltd. Following a successful career as a biomedical researcher in the 1980s–1990s, she shifted her focus to the health and higher education sectors, where she has been involved in research, programme design and implementation, policy development and stakeholder engagement. For the last 10 years, she has been a significant contributor to Victorian initiatives aimed at improving and expanding the clinical education and training capacity of Victorian health services. She has a bachelor’s degree in Science, a PhD in Biochemistry and Molecular Biology and a master’s degree in Public Policy and Management. She is a member of the Australasian Evaluation Society.

MEERQAT Pty Ltd., 1/26 Robe Street, St Kilda, VIC 3182, Australia Tel: +61 3 9525 3234 E-mail: donna@meerqat.com.au

Philip J. Cohen

is a Director and Vice President of Business Development at MEERQAT Pty Ltd. He has trained as a social researcher and has worked for 20 years in research and health-related organisations within Victoria. He has been a consultant for the last eight years, specialising in research, evaluation, project management and quality improvement. He has a bachelor’s degree and a master’s degree in Sociology and is a member of the Australasian Evaluation Society.

MEERQAT Pty Ltd., 1/26 Robe Street, St Kilda, VIC 3182, Australia Tel: +61 3 9525 3234 E-mail: phil@meerqat.com.au

Vitas Anderson

is Vice President — Software Development at MEERQAT Pty Ltd. His undergraduate training was in Engineering and the Medical Sciences, and he holds a doctorate in Biophysics. He is currently an Honorary Principal Fellow with the University of Wollongong and is an active contributor to national and international standards bodies dealing with radiation health physics. He also serves as an honorary technical assessor for the Australian National Association of Testing Authorities (NATA).

MEERQAT Pty Ltd., 1/26 Robe Street, St Kilda, VIC 3182, Australia Tel: +61 3 9525 3234 E-mail: vitas@meerqat.com.au

Abstract A common barrier to continuous and sustainable improvement in many organisations is the lack of staff engagement with quality improvement. In the healthcare sector, the failure to engage staff with quality has been associated with preventable patient harm, which persists despite more than two decades of emphasis on safety and quality in this sector. This paper describes a novel approach — map-enabled experiential review (MEER) — that has significant potential to address staff engagement issues and produce meaningful improvement outcomes. The MEER approach uses map-based simulation of organisational processes to enable structured conversations among staff about their daily implementation of those processes as a means of identifying and addressing latent safety threats and other areas for improvement.

KEYWORDS: quality improvement, staff engagement, map-enabled experiential review, preventable patient harm

INTRODUCTION: THE PERSISTENCE OF QUALITY AND SAFETY ISSUES IN HEALTHCARE

The drive to improve the safety and quality of healthcare has gained considerable momentum over the last 20 years. Since the publication of landmark studies highlighting the large number of adverse events in healthcare, quality assurance has become a critical issue for healthcare providers. In Australia, numerous strategies and initiatives have been developed to address inefficiencies/inadequacies of systems within healthcare, including the development of National Safety and Quality Health Service (NSQHS) Standards, which were released by the Australian Commission on Safety and Quality in Health Care (ACSQHC) in 2011, as well as a range of indicators for benchmarking performance.

While improvements in the general safety and quality of healthcare have been noted, the problem of preventable patient harm in hospitals persists. Indeed, recent reviews — such as the 2016 Duckett Review of hospital safety and quality assurance in Victoria — have noted that quality and safety have become very compliance-focused, with issues often not addressed until they become major problems. Of particular concern is a general lack of engagement of clinicians in quality improvement activities. Another factor contributing to preventable harm is the phenomenon of ‘normalized deviance’, whereby small variations to standard protocols are gradually introduced by individuals and normalized. Importantly, when healthcare organisations take steps to reduce protocol variance, this results in dramatic improvements in patient health outcomes and reductions in the costs of delivering care.

Therefore, there is a growing awareness of the need for approaches to quality improvement that both engage front-line clinicians and address the issue of protocol variance. One such approach is in situ simulation, which is a team-based training technique conducted using real facilities, equipment, resources and personnel. The simulation exercise is usually filmed. Review of the video provides structure to the debrief of participants and serves to identify system-based threats — termed latent safety threats (LST) — that might not otherwise be recognised and that can compromise the quality and safety of patient care. Since in situ simulation is both costly and resource intensive, however, it is not a practical option as a routine quality improvement tool for many healthcare organisations. This paper describes an approach that taps into many of the same principles that make in situ simulation a useful tool for quality improvement, using a format that is more adaptable and accessible — and less costly and resource intensive — than simulation. This approach has already been used successfully in a quality improvement initiative in the healthcare sector, and the descriptions and observations presented in the following sections are drawn from that initiative and from trials of the approach in hospitals that are currently under way.

A NEW APPROACH TO QUALITY IMPROVEMENT

Overview

Map-enabled experiential review — or MEER — is an innovative technique that repurposes tools commonly used in process management and evaluation for use in a quality improvement context. The premise on which the MEER approach is based is very simple. The essential question in any quality improvement endeavour is ‘How can we do this better?’, but to answer this question, it is necessary to first ask ‘How do we do this now?’ Front-line staff are best placed to reveal what they actually do in routine practice and, importantly, why they do it that way. Therefore, the central activity of quality improvement should involve staff reflecting on their daily activities. In a team-based workplace such as healthcare, these reflections are most usefully undertaken as a team. Without structure, however, these conversations can become aimless and unproductive. Indeed, a systematic approach to process improvement activities is considered the most effective strategy for reliably identifying the source of problems. MEER is a systematic approach, using graphical models or maps, of process systems to enable structured conversations among groups of staff, drawing on the knowledge and experiences of those staff as the basis for a review of how well those processes are being implemented. The outcomes of these structured conversations serve as an evidence base for a quality improvement action plan.

The structured conversations are engaging and educative for staff, who also develop a sense of ownership of the resulting action plan. The map is a process model, a hybrid between a process map and a logic model, and shows the relationship between the inputs, activities and outputs of a given process — or system of processes — and how these give rise to the expected outcomes of the process(es). The level of detail included in a process model can vary depending on the desired granularity of the process review, although the more detail included, the more prescriptive the map tends to be. Ideally, maps for use in MEER activities include sufficient detail to prompt examination of all important aspects of process pathways, without including so much detail that they drill down into the minutiae of process implementation.

As an example, a segment of a process model that corresponds to NSQHS Standard 5 (Patient Identification and Procedure Matching) addresses health service policies that relate to patient identification, and reveals the ideal level of detail for a map intended for use in the MEER approach. Developing process models for use in MEER is relatively straightforward, and many organisations already routinely develop process maps and/or logic models for their business processes and programmes. Indeed, creating these maps is a very useful exercise in itself for crystallising expectations about the way policies and relevant standards should be implemented and for identifying both the underpinning assumptions and the potential indicators of successful implementation. Process models can be created by quality managers or other senior managers (e.g. for a process or standard used widely across the organisation) or by team leaders (e.g. for an activity specific to that team). If front-line staff are engaged in map development, this can be educative for both staff and managers, since the resulting map will reflect both the aspirational and the practical aspects of process implementation.

Steps in the MEER Approach

Implementing MEER is a four-step process, with Step 2 being the defining step of the approach. Once process model resources have been developed (Step 1), the cycle of Steps 2, 3 and 4 can be repeated as often as required. The outcomes from Step 2 (the ‘completed assessment’ at the bottom of the figure) are used both to inform action plan development and for reporting and comparison purposes.

The resulting graphical image is both useful and informative, representing all the relevant components — termed nodes — of the activity pathways and showing the logical connections between the nodes using arrowed lines. To be used in the context of MEER, however, the final aspect of developing a process model involves creating node-specific content that will be used in the structured conversations. This content always includes a rating question and rating options that will be considered by the group, leading to rich discussions about the quality of each aspect of the process reviewed.

Development of a map for use in the MEER approach involves creation of the graphical map and development of node content. Depending on the complexity of the process system represented by the map, a process model can be drawn in 2 or 3 hours. Developing the node content generally takes longer than creating the graphical map, but the size of this task depends on how much information the map's author wishes to include in the node descriptions.

Thus, development of a map for use in the MEER approach has substantial value for the organisation. The map and its content provide a repository of information about organisational processes, clearly and unambiguously setting out the organisation’s expectations about how those processes will be implemented. If process pathways are changed, relevant nodes within the map can be changed accordingly, without the need to recreate the whole map from scratch. Once developed, the map can be used in MEER assessment sessions as often — and as widely — as required.

A MEER assessment session can be as low-tech or high-tech as desired. For example, a team might choose to work with an A3 (or larger) printed version of the process model they are assessing against, or projection of the electronic version of the map using a computer and data projector.

One member of the team acts as facilitator for the session, although this role can be rotated among team members or other individuals as appropriate. For each node in turn, the facilitator reads out any relevant node content, including the rating question. Team members are asked for their views on the most appropriate rating based on their own experience of that aspect of the process; the number of individuals who nominate each rating option can be tallied and recorded by the facilitator. Discussion drawing on the knowledge and experiences of individuals is encouraged, and relevant comments made by the group are also recorded by the facilitator.

Once discussion for a given node has been completed, the group makes a decision on a consensus rating for the node, and this rating is recorded on the node in the map using an agreed schema. The idea is not simply to get through the map as quickly as possible, however, since the discussion component of the MEER assessment session is central to the usefulness of the approach.

As groups work through each node in the map considering the question they are being asked to rate, participating staff reflect on their routine practice, both as individuals and collectively as a team. Such discussions are naturally very engaging for staff, as they are talking about what they know best — their day-to-day activities and work practices. It is important to allow these discussions to flow while retaining focus on the issues at hand.

The MEER assessment is most usefully undertaken at the team or work unit level, with participation focused primarily on front-line staff and their immediate managers. Front-line staff have first-hand knowledge and experience of implementing business processes, while their managers bring a higher-level perspective relating to integrating the various activities of the team.

Steps 3 and 4: Developing and implementing an action plan

Development of a quality improvement action plan commences during the MEER assessment sessions, when teams identify problematic nodes in the course of their rating discussions and decide whether to include those nodes in the action plan. The direct linking of action plan development to the assessment step helps to ensure that useful discussions in the context of issue diagnosis are translated into actions to address any issues identified. This also assists front-line staff to develop a sense of ownership of the resulting action plan.

Once the assessment has been completed, the team can take a more holistic view of the areas needing improvement, grouping together related nodes and identifying activities that are most likely to impact on underlying issues. If the time and resources available for quality improvement activities are limited, it is important to prioritise tasks, set realistic due dates, and assign responsibility for tasks in a way that shares the workload between team members.

While the quality improvement action plan can be developed in a spreadsheet application, implementation can readily be tracked using a Kanban board. The action plan can be set up on a wall in a team workspace or meeting room, providing a visible, collective record of the progress being made on quality improvement activities.

THE VALUE OF THE MEER APPROACH

MEER has considerable value as a quality improvement strategy. The graphical representation of consensus ratings on the map provides a powerful summary of the assessment outcomes. The MEER approach uses a visual medium to drive structured conversations among staff.

Importantly, staff who spend time articulating and codifying their experiences will realise higher performance improvements. By reflecting as a group, there is a greater likelihood of effectively reflecting on practice.

Interestingly, while it might be assumed that presenting an idealised process model to staff as the basis for a discussion will constrain their forthrightness about what they actually do, this is not what happens in practice.

Thus, MEER discussion sessions are not only educative for staff and their managers but can also be helpful to teams to identify where daily practice is deviating from standard protocols, representing an improvement to practice or reflecting problematic underlying system-based issues.

In this regard, MEER represents a proactive approach to quality and safety. Importantly, the MEER approach helps staff to see the quality improvement part of the process as directly related to their daily practice.

CONCLUSIONS

MEER is an innovative approach to quality improvement that repurposes existing tools to provide a framework for regular, structured conversations among front-line staff about daily practices. Irrespective of whether the MEER approach is implemented using a low- or high-tech solution, it is engaging for staff, promotes the development of collective competence and helps teams to identify and address sources of protocol variance.