A primary constraint when taking a participatory approach to QI is time. Clinical staff hardly have any time outside of patient care. Through discussion with clinical leaders, the following constraint was applied to my work: each activity can only take up to 15 minutes of each persons time.
To accommodate the time challenge, I developed a participatory approach around minimal disruption to clinical processes. In the coming sections I will describe the approach, then present a case study describing the application of the approach in one project.
Outline of the approach
What: A short, repeated set of facilitated activities that are done in 15 mins or less.
Why: To engage busy, clinical teams in a (somewhat) participatory process.
Where: Near where they do their work.
When: Any time there is a need to engage teams, but not the resources for role coverage or group work sessions.
Who: Clinical / clerical staff of inpatient/outpatient units.
How: The primary research question is broken down into any number of 15-minute activities. For each activity, the facilitator brings any necessary materials with them to the site. They engage staff as they are available, respecting their wishes if they say no.
How much: 2 hours on the unit at a time; 15 minutes (maximum) of activity time;
Applying the approach: quality board case study
Quality boards are displays that healthcare has adapted from manufacturing and Lean operations. Their primary function is to act as a touchpoint for quality improvement activities where one can review data and keep up to date with what QI projects are ongoing. They are one way to fulfill an Accreditation Canada standard, but more of a best practice than a required feature. The current iterations had a number of opportunities for improvement related to the physical board.
Challenges included: Can’t update or change board easily; Information displayed was not useful; Quality board purpose was muddled;
Breaking down the research question
The research question.: How might we make quality boards useful quality improvement touchpoint for clinical teams?
Based on time and human resource constraints, this turned into four design research activities to answer the following questions:
- How do you want to be involved in quality improvement?
- What channels should be used to involve you?
- What should your quality board look like?
- What do you think of your quality board?
Each activity is described below.
Approaching potential participants
During the pre-approved, 2-hour period of time on the unit potential participants are “warned” of my arrival by their leadership. Opening with “Hi, I’m Chris from QI. Do you have a few minutes to chat about quality boards?” puts the potential participant in control from the start.
If they agree to participate, a quick exchange about the topic helps to understand their baseline understanding of quality boards, then we start the activity with any additional explanation as-needed.
1. How do you want to be involved in quality improvement?
Participants are presented with a process diagram made of post-its and asked to comment on the accuracy; does it show the current process for QI on your unit? What changes would need to be made to make. it ideal? These questions were presented with fresh post-its and a pen, and participants were informed they could move or replace steps.
Next, 3 scenarios were presented: project started by a close teammate, project started by someone who works nearby, project started by someone from a different department. These represented the types of changes expected to take place.
For each scenario presented, participants were asked to use 2 colours of dot stickers to indicate their preferred level of involvement. The green dot indicated “keep me involved”; red dot indicated “keep me informed”; no dot meant “do it without me”
Activity Review
Despite presenting the process on sticky notes to indicate the draft nature, they were hardly changed. Use of dot stickers to indicate preferred involvement varied widely.
To see an example of how analysis results would have been shared, see Diagram 5 in Mapping Quality Boards in an Information Space.
2. What channels should be used to involve you?
Using the sticky notes from the above activity, I created an updated and printed diagram of their process for QI. The dots used at each step were tallied, and patterns in the responses were used to mark key moments on the process diagram.
To better understand how staff wanted to be involved in this process, the information displays and meeting spaces were turned into card-sized handouts. One of the cards that staff were given was the quality board, allowing staff to being to answer the initial research question of how to make the quality board “useful.”
To see a large list of the information display and meeting spaces present in clinical areas, see Diagram 4 in Mapping Quality Boards in an Information Space.
Staff were asked to use the cards to indicate which display or space they wanted to be engaged with at those key moments. Multiple cards were allowed at each location.
Activity Review
Participants tended to favor multiple ways of being engaged. Email and quick, in-person meetings were identified as the preferred channel in most key moments.
The frequency with which each information display or meeting space was placed at each key moment allowed me to form a point of view about what would be the best way(s) to engage teams at that moment. The process diagram was updated to include 2 channels at each key moment, then taken back to teams for validation and review.
3. What should your quality board look like?
Research before engaging teams showed that there are a few standard pieces of information to be presented on a quality board. To ensure that teams are seeing information in a way that makes sense to them, A/B testing was used.
A few key pieces of a quality board were chosen, and 2 ways of presenting that specific information were presented to staff with the question: which do you prefer?
The two choices presented to teams were chosen to be probe preferences between something that might be more familiar to their QI practices versus something different.
Activity Review
The final results of the A/B testing varied from unit-to-unit and based on how familiar staff were with their QI process. Simple formats that could be understood at-a-glance were often chosen, with graphic or visual options chosen less frequently.
4. What do you think of your Quality Board?
Draft quality boards were taken to team as drafts on paper to solicit quick first impressions and get team sign off on what will be implemented in their unit. The approved quality boards were made with a whiteboard and removable vinyl, cut using a Cricut machine to create sections and structure.
After installation, teams had a short, 15-minute huddle to ask questions about their new board. A one-page information sheet was pinned to each board for those who could not attend the huddle.
Lessons for next time
Time was a challenge in some executions, mostly due to the nature of hospital operations during a pandemic (this was done over the 2nd, 3rd and 4th waves of the virus). Participants were also occasionally quick to ignore the activity instructions or hesitant to participate, which made a list of backup questions a key piece of prep. For future activities, I would like to explore:
- measuring, tracking and evaluating engagement in this process through more formal methods
- how to make these interactions moments of joy, or introduce moments of play