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HiQuiPs: QI Implementation Part 1 – Implementation Methodologies

In this two-part series, we will take a deeper dive into several QI conceptual frameworks, or ways to approach QI projects. In our previous posts, we discussed preparation strategies for QI projects; but when it comes to implementing a change, how would a team go about choosing an approach? We will start with a discussion of the variable effectiveness of different change interventions, then we will delve into an overview of some common frameworks, and finally, we will apply our discussion to a case study in our next post.

Hierarchy of Effectiveness

In our last post, we discussed a QI project which aimed to decrease the time between ordering packed red cells (pRBCs) and administration in the ED by 30% over a 6 month period. Interventions to reach this goal can be categorized along a continuum of effective. The basic tenet of this hierarchy is that the more an intervention is reliant on individuals repeatedly performing a specific task in a consistent way, the less likely it is to achieve a consistent and sustainable change. In other words, it is only by changing the system itself that one can ensure reliable and effective improvements. This hierarchy of effectiveness is illustrated below. (1)

Hierarchy of Effectiveness (source: Cafazzo et al. (1))

Keeping the different types of interventions in mind, the following are examples of each level from least to most effectiveness. These examples target different tasks along the pRBC order-to-administration pathway, however, different interventions could also be applied to the same part of the pathway.

Hierarchy Levels (source: Cafazzo et al. (1))

Emergency department clinicians have many competing priorities in a complex environment with multiple stakeholders. Therefore, the approach most likely to achieve consistent and sustainable change is to introduce a forcing function as part of the workflow. When implementing system-level changes such as this, It would be important, however, to observe clinicians in the practice environment post-intervention to ensure they are not performing ‘workarounds’, or other self-initiated adaptations to avoid the forcing function.

Now let’s discuss a few of the many conceptual frameworks that are commonly used for QI projects. We will begin with an overview of Lean, Six Sigma, and the Model for Improvement.

Lean Methodology – ‘Eliminating waste’

Lean was adopted from a Japanese manufacturing philosophy that aims to diminish any form of waste, which is any action that does not add value to the product.(2) A thorough evaluation of each step of the process is undertaken to identify inefficiencies. Two main considerations for decreasing inefficiencies are the standardization of the processes at hand and involvement of employees in the process development.(3) An integral part of the process requires including the front-line staff to identify problems as they arise, and immediately addressing them. The overall approach includes: identifying value from specific stakeholder perspectives, understanding the value stream (what is value-added to the customer and what is a waste), eliminating that waste, as well as establishing flow.(4)

The first step is the ‘walk around’ – an observation of the actual process in detail (i.e. ‘going to the gemba’) – and working with a team to come up with solutions to reduce waste.(5) You may notice that several of these steps are reminiscent of the general QI methodology that we discussed in previous posts such as process mapping, and stakeholder engagement. An example of Lean application in the ED is illustrated by Dickson and colleagues.(2) Moreover, waste in healthcare can be categorized across seven domains that are illustrated below. A full description is provided by Bush.(6)

Waste categories (source: Bush (6))

Six Sigma (DMAIC) Methodology – ‘Eliminate variation’

Six Sigma was invented by Motorola in 1980.(7) In healthcare, it is a data-driven methodology to improve processes and reduce costs, improve quality, efficiency, and satisfaction.(8) The benefits of Six Sigma are achieved through the utilization of a systematic approach such as the Define-Measure-Analyse-Improve-Control (DMAIC) approach:(4)

DMAIC Process – 6 Sigma. Adapted from Scoville et al.(4)

This approach aims to identify and remove the causes of errors or defects while minimizing variability in processes. It uses a set of statistical methods and trained individuals with different levels of experience (e.g., green belt, black belt) to lead the projects.(4) Examples of projects include cycle time reduction, process flow improvement and medical-error reduction.(7)

Model for Improvement: [Plan-Do-Study-Act (PDSA) Methodology]

PDSA Cycles are the crux of the Model for Improvement’s iterative improvement cycles, which include the four following phases:

Plan: An appropriate intervention is selected and planned for, along with a hypothesis of what is likely to happen

Do: The intervention is carried out and measured

Study: The intervention measurements are studied and its implications for the intervention analyzed

Act: The intervention is modified based on the lessons learned and feedback collected, in order to start the next PDSA cycle.

A visual representation of it is seen below:(9)

PDSA Cycle. Adapted from Riley W. (9)

PDSA cycles include ongoing modifications or enhancements to the intervention(s) with each cycle by building on collected information.(10) An important advantage of this method is its focus on small-scale projects, which start with low-resource requirements to test an intervention prior to a large-scale implementation if successful. It can also increase buy-in as staff notice that interventions are modified as needed. This approach can be incorporated as a type of continuous improvement methodology, or as a dynamic learning process that sustains a culture of improvement. As an example, Chartier et al. previously demonstrated how sequential PDSA cycles were used to iteratively learn, design and improve a new method of seeing patients in their ED.


Each clinical problem may be best solved by the application of one, or a combination, of these frameworks or tools. How does a change team go about choosing the change framework that will best apply to your ED? Stay tuned for our next post where we work through these approaches with more illustration and see how they may be applied to different problems.(11)

This post was copyedited by Paula Sneath


1.Cafazzo J, St-Cyr O. From discovery to design: the evolution of human factors in healthcare. Healthc Q. 2012;15 Spec No:24-29. [PubMed] 2.Dickson E, Singh S, Cheung D, Wyatt C, Nugent A. Application of lean manufacturing techniques in the Emergency Department. J Emerg Med. 2009;37(2):177-182. [PubMed] 3. Ohno T. Toyota Production System: Beyond Large-Scale Production. 1st ed. Portland, OR: Productivity Press; 1988. 4. Scoville R, Zak H, Norouzzadeh S. An Integrated Approach to Lean, Six Sigma and the Model for Improvement. Institute for Healthcare Improvement; 2013:42. 5. Casey J, Brinton T, Gonzalez C. Utilization of lean management principles in the ambulatory clinic setting. Nat Clin Pract Urol. 2009;6(3):146-153. [PubMed] 6. Bush R. Reducing waste in US health care systems. JAMA. 2007;297(8):871-874. [PubMed] 7. Breyfogle FW. Implementing Six Sigma: Smarter Solutions Using Statistical Methods. 2nd ed. New York, NY: Wiley; 2003. 8. Feng Q, Manuel C. Under the knife: a national survey of six sigma programs in US healthcare organizations. Int J Health Care Qual Assur. 2008;21(6):535-547. [PubMed] 9. Riley W. Process engineering for primary care: Quality improvement and population health. f. 2016;4(2):29-35. doi:10.15212/fmch.2015.0151 10. McHugh M, Van Dyke K, McClelland M, Moss D. Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals. Agency for Healthcare Research and Quality; 2011:48. 11. Chartier L, Josephson T, Bates K, Kuipers M. Improving emergency department flow through Rapid Medical Evaluation unit. BMJ Qual Improv Rep. 2015;4(1). [PubMed]

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