Characteristics of the process redesign projects within the collaborative
Table 1 gives an overview of the characteristics of the process redesign projects. Fifteen project teams chose to redesign an elective care process. Eight of those projects involved care for cancer patients. Two project teams chose to redesign an acute care process.
Table 1 Characteristics of enrolled process redesign projects
All project teams intended to make improvements in waiting times and delays, but in different areas (access times, throughput times of diagnostic trajectories, and/or length of stay) and for different types of patient groups. The median value of the volume of the involved patient groups was 150 patients a year (range 17 to 1,000). The number of medical departments involved in the redesigned care process was on average three and varied per project from one to eight departments. In seven instances, not all medical departments involved participated in the project team.
Presence of preconditions for successful use of the QIC method
The project leaders and project staff members of six project teams shared the opinion that preconditions for successful use of the QIC method--i.e., 'team organisation', 'organisational support', and 'external change agent support'--were sufficiently present (project no. 1, 4, 6, 10, 16, and 17). The remaining project teams show a diverse picture of the presence of the preconditions. In general, almost all project teams were positive about the organisation of their project team. One-half of the project teams had the opinion that support from their organisation and/or external change agent support was lacking.
Evaluation of the collaborative process
This section describes the collaborative process according to the step-by-step guide provided to the process redesign collaborative (see figure 3).
Step one
All projects started with a process analysis of the existing care process. Sixteen of the seventeen projects performed a baseline measurement.
Step two
The baseline measurement and ideas about the desired care process formed the input for the project aims and changes that needed to be implemented. Although all project teams formulated project aims, only fourteen formulated at least one specific and measurable aim (range 0 to 7, average 2) (see Table 2).
Table 2 Application of the model for improvement in the enrolled process redesign projects
Step three
After setting aims, the next step was to establish measures that would indicate whether a change led to an improvement. With one exception, all project teams made use of one or more of the outcome measures provided for the effect measurement. The provided intermediate measure was used by eleven project teams (Table 2). For three teams, this measure (number of visits to outpatient clinic) was not applicable because these projects involved only the redesign of in-hospital stay. For two project teams, the provided intermediate measure was not applicable because it was not related to the project aims: namely, the project did not strive to reduce the number of visits.
Eight project teams established additional outcome measures: for example, time between several diagnostic examinations within the diagnostic trajectory. Six project teams appointed intermediate and/or process measures to establish whether a process change was accomplished, for instance: Is the date of surgery planned directly after setting the diagnosis, yes or no? Five projects used no additional intermediate or process measure at all. Reasons for not using project-specific measures were that teams thought the provided measures gave enough insight to know whether a change is an improvement or because their project aims were not considered measurable (e.g., qualitative aims such as a standardised discharge planning, or appointing one contact person for the patient during the whole care process).
Step four
The main change idea, the one-stop-shop, presented in the collaborative meetings was applicable for 11 project teams (Table 2). Two of them did not succeed in combining the visits in one day due to organisational characteristics, the nature of the needed diagnostics, and/or the burden of the diagnostics to the patients. Six project teams thought the evidence was not applicable because they already combined all visits in the diagnostic trajectory into one; they did not redesign a diagnostic trajectory at the outpatients' clinic; or the long throughput time was not a result of many visits but of a long waiting list for one specific diagnostic examination. All project teams applied one or more of the other provided change concepts to redesign their care processes. Application of these change ideas required that project teams first investigated the causes of waiting times and delays in the redesigned process and then tailored the change ideas to their own setting. However, according to the project staff, tailoring change ideas proved more difficult in care processes in which more medical departments were involved, and accordingly more disagreement existed between the involved medical departments about the changes that had to be made.
Steps five and six
During the interviews, project staff members were asked whether they had applied the PDSA cycle for change. Five confirmed that their project team used or was going to use the PDSA cycle. However, these five project teams did not split up every planned change in smaller changes as the change agent suggested. Further, staff members of these five project teams indicated that the PDSA cycle was not or would not be performed in a rapid cyclical mode because both the preparation for the test as well as the test of the change itself was time consuming. Because the patient groups were relatively small, a testing cycle took considerable time even when the number of patients per testing period was scaled down. The use of the PDSA cycle was also hampered by the fact that hospital information systems proved unable to generate data on the appointed measures when more hospital departments were involved. As a consequence, project teams had to gather data by hand, which was time consuming.
The teams that did not use or were not going to use PDSA for implementation (n = 10) chose to change the organisation of the care process radically by implementing their 'newly designed process' at once without first testing the individual changes. According to these project teams, testing change ideas within a short timeframe was not applicable to their situation because of the number of medical departments involved and/or the small number of patients involved in their redesign. Another reason for not testing in rapid cycles was the feeling that a test could fail due to non-optimal conditions when supporting processes were not optimised. For example, the team implementing changes in the care for open chest surgery patients considered it impossible to test a new operating room planning process. Changing the planning system for the operating room would necessitate adjusting all the supporting processes, including the working hours of the teams and how the rooms were prepared. Any testing before the altering of supporting processes would be massively disruptive.
Step seven
Three project teams performed an effect measurement and reached collaborative goals (Table 2). The other project teams, including those that used the PDSA cycle, had not yet measured any interim results by December 2007 (one year after the start of the QIC). Therefore it is unknown whether they reached the collaborative goals.
From this description of the collaborative process we can identify several difficulties experienced by the project teams in applying the QIC method to process redesign. First, the adoption of change ideas and the accompanying measures provided by the external change agent, appeared not (directly) applicable for these collaborative project teams. Project teams had to tailor change ideas to their own context or could not use the provided change ideas at all.
Second, the adoption of the model for improvement by the project teams was hampered. Project teams were not capable of testing change ideas within a short time frame using PDSA cycles due to: the need for tailoring change ideas to their own context, and the complexity of aligning several interests of involved medical departments; the small volumes of the involved patient groups; and hospital information systems that proved unable to generate data on the appointed measures.
Third, project teams did not experience peer stimulus. All collaborative project teams intended to make improvements on an administrative subject, but in different parts of care processes (access times, throughput times of diagnostic trajectories, and/or length of stay) for different types of patient groups. As a consequence, project teams saw few similarities between their projects, rarely shared experiences, and demonstrated no competitive behaviour.
Further, a number of project teams perceived a lack of organisational support and external change agent support. However, the project teams that succeeded in implementing changes (projects 15, 16, and 17) shared the opinion that preconditions for successful use of the QIC method--i.e., 'team organisation', 'organisational support', and 'external change agent support'--were in general sufficiently present. Only organisational support lacked in one of the three project teams (project 15).