Sustaining and Spreading Quality Improvement: A Conversation With Julie Kliger, MPA, BSN, Director, Integrated Nurse Leadership Program, University of California San Francisco

By The Innovations Exchange Team Innovations Exchange: Please describe the Integrated Nurse Leadership Program (INLP) model.

Julie Kliger: The model External Link

gives frontline clinicians the tools, skills, and resources to create sustainable system-wide change. The goal is to foster a universal set of problem-solving skills rather than fix a particular problem through a stand-alone initiative. The model recognizes the value of linkages across staff and departments in sustaining and spreading innovations.

Technical “know-how” related to quality improvement science is insufficient. Attention to “soft” issues such as leadership development and change management are necessary to promote sustainability and spread. To that end, the INLP model is based on supporting each of four pillars—individuals, team, organizational culture, and process. Within each pillar, specific training sessions have been created to support development of the necessary change management skills. For example:

The “individuals” pillar focuses on developing awareness of one’s own preferences and on cultivating emotional intelligence, including an understanding of how one’s actions influence the work and everyone involved in it.
The “team” pillar focuses on how high-performing teams function, complete their work, communicate, and ensure accountability.
The “organizational culture” pillar focuses on developing “political savvy”—that is, an understanding of both formal and informal power sources within an organization, along with skills related to strategic communication, stakeholder identification, and forming allies.
The ”process” pillar tends to be more technical in nature, focusing on evidence-based practices related to the activity to be improved, relevant data and quality improvement indicators, how to use data to predict the next test of change, and other related issues.

Can you elaborate on some of the model’s key components?
Rigorous use of data is critical to the model’s success. Data must be consistently tracked at the unit level. For example, process data, such as whether antibiotics are administered within a certain timeframe to a patient with severe sepsis, provide real-time feedback on whether an intervention is working and hence inform the development of subsequent plan-do-study-act (PDSA) cycles.

Teamwork represents another critical component of the model. Individuals sometimes think that simply working harder will lead to quality improvement when in reality, working as a team is the key to success. High-performing teams should include representatives from across the hospital. Bringing these stakeholders together at an early stage creates an interdisciplinary set of ambassadors who promote the change and take ownership over the change process. In addition, interdisciplinary teamwork ensures that solutions are valid and practical within the context of existing work processes and disciplines affected by the change. This notion of interdisciplinary teamwork fits in with the system orientation of the model.

Finally, training is a third critical component of the model. Individuals learn to approach quality improvement as a team and with a data-driven focus.

Why is it difficult to sustain quality improvement initiatives?
There is no “magic bullet” to ensure that the benefits achieved by quality improvement initiatives endure. Quality improvement work can be a lot like dieting, in that lasting success requires behavior modification. As with weight loss, achieving and maintaining improvements can seem overwhelming at the start, as implementation often proves difficult and the initiative frequently may seem to be on the brink of failure. And, like weight loss, sustaining quality improvement requires adherence to disciplined routines, ongoing measurement, and constant vigilance, even after the goal has been achieved.

Senior leaders often do not appreciate the need for a constant effort. Data must continually be reviewed and processes regularly reevaluated to identify what does and does not work. This type of constant vigilance can be very difficult to operationalize. These leaders typically do not allocate staff time for quality improvement efforts; they want improvement to occur, but do not want to release people from their regular duties to do the work required to generate such improvements. In addition, the fundamental systems and infrastructure that underlie improvement work are not in place in many organizations, including training in process improvement methodologies and the capacity to run PDSA cycles or to track and analyze data on an ongoing basis.

What factors contribute to the sustainability of health care innovations?
Clearly, ongoing processes to monitor performance must be developed and implemented. In addition, organizations must give frontline personnel dedicated time to create, monitor, and improve care processes. These individuals know what needs to be changed, as they work on the front lines every day and understand where the fault lines are. Consequently, they—not senior leaders—are best positioned to identify solutions.

Senior leaders, however, must provide clear, direct communication and support to those on the front lines. They cannot simply pass down a quality improvement directive (e.g., “ do this”) or list quality improvement goals in a memo. Too often, there is a disconnect between what senior leaders want and how they convey that vision to frontline staff. To overcome this problem, organizations need vertical quality improvement teams that include both unit-based workers and senior leaders. In addition, communication about quality improvement efforts should occur regularly, even if for only a few minutes at a monthly meeting. These meetings provide an opportunity for senior leaders to hear about progress and for frontline workers to discuss their needs and expectations related to senior-level support.

How has the INLP model been used to spread and sustain innovations?
To date, the model has been used in the San Francisco Bay area by two cohorts of approximately 12 hospitals each. One cohort focused on reducing medication errors, while the second focused on improving sepsis mortality rates. Both efforts have been successful in spreading quality-enhancing practices throughout the participating institutions.

The INLP model plans for the spread of innovations from the moment a project is initiated. The team understands that changes will be tested and refined on one unit, and then, if they work, will be spread to other units throughout the hospital. As a result, team members lay the groundwork for successful spread as part of the project development process. In addition, hospital employees are surveyed at periodic intervals to proactively identify and address their needs related to adoption and sustainability, thus paving the way for the successful spread of the innovation.

Why has the model succeeded?
First, the model combines core evidence-based requirements with flexibility. For example, use of precisely defined measures and evidence-based practices, such as the timely administration of antibiotics to reduce sepsis mortality, are not open to debate. However, participants may adopt or develop processes to implement these components in a way that fits their own organizational culture and clinical workflows.

Second, the model empowers frontline clinicians to lead change. It provides them with training in advanced leadership and change management, adequate time to do the work, and legitimacy in doing that work. The nurses see themselves not simply as “soldiers fighting the daily work battle,” but rather as innovators who have the power to identify and solve problems and promote quality improvement. Their success changes their self-perception; they recognize their contributions to institution-wide quality improvement and are proud of the positive impact they have on the quality and safety of patient care.

Suggested Readings
AHRQ Innovations Exchange. Nine-Hospital Collaborative Uses Patient Screening Criteria, Fast-Track Diagnosis, and Treatment Protocols to Reduce Sepsis Mortality by 40 Percent. Available at: http://www.innovations.ahrq.gov/content.aspx?id=3424.

Kliger J, Singer S, Hoffman F, et al. Spreading a medication administration intervention organizationwide in six hospitals. Jt Comm J Qual Patient Saf. 2012;38(2):51-60. [PubMed]

Kliger J, Blegen MA, Gootee D, et al. Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy. Jt Comm J Qual Patient Saf. 2009 Dec;35(12):604-12. [PubMed]

Kliger J, Lacey SR, Olney A, et al. Nurse-driven programs to improve patient outcomes: transforming care at the bedside, integrated nurse leadership program, and the clinical scene investigator academy. J Nurs Adm. 2010 Mar;40(3):109-14. [PubMed]

About Julie Kliger
Julie Kliger, MPA, BSN, RN, is Director of the Integrated Nurse Leadership Program at the University of California San Francisco and Founder and Principal of The Altos Group LLC. Over the last 26 years Julie Kliger has established herself as a leading voice for patient safety and improved outcomes. Her work in addressing practice redesign in health care has been nationally recognized for its unprecedented achievements in reducing medication administration error and sepsis mortality.

Disclosure Statement: Ms. Kliger reported that she has received consulting fees from multiple organizations, as well as grants and other support services through the University of California San Francisco. Ms. Kliger also has a pending contract with a health information technology company to help develop sepsis-related technologies.

Last updated: August 01, 2012.