The COVID-19 pandemic was a test of the modern healthcare system's readiness to withstand a catastrophic event. Crisis management systems and crisis standards of care have been established for decades,1 but the unprecedented circumstances of 2020 revealed intrinsic barriers within these systems that hindered the delivery of safe, high-quality care in the face of widespread uncertainty.2 Despite many positive gains in the quality of care delivered to patients with COVID-19 as more became known about the virus, the inevitable interruption of routine quality and safety initiatives had unintended consequences, including a significant year-over-year increase in hospital-acquired infections between 2019 and 2020.3,4 The outcomes of the ongoing battle against COVID-19, both positive and negative, have demonstrated the need for a renewed focus on quality and safety in healthcare delivery.
Over the course of the pandemic, healthcare quality professionals were called on to support critical operations such as implementing incident command and triage systems, collecting and reporting data to state and local agencies, developing processes for mass immunization centers, and facilitating rapid cycle improvement of processes where and when needed.5-9 Much of this work relied on common performance and process improvement (PPI) methods and tools. Performance and process improvement is a core domain of healthcare quality work, which involves using project management and change management methods to support operational and clinical quality initiatives. Examples of PPI methods include using Plan–Do–Study–Act (PDSA) frameworks to document and test changes to processes, defining specific, measurable, achievable, relevant, and time-bound (SMART) goals and objectives for processes, and conducting stakeholder analysis to assess potential impacts to process changes based on their effects on the groups of people involved. Performance and process improvement is one of eight domains included in the Healthcare Quality Competency Framework developed for healthcare quality professionals by the National Association for Healthcare Quality (NAHQ)10 and the most commonly reported work domain among healthcare quality professionals.11
This study duplicates previous research conducted in the fall and winter of 2020 by the Q Community, a professional membership organization for healthcare professionals doing improvement work in the United Kingdom and Ireland, sponsored by The Health Foundation.12 Members of the Q Community were asked to identify the various ways in which their teams applied improvement tools, methods, approaches, and mindsets during the response to COVID-19. Findings showed that performance improvement played an important role in healthcare organizations during the pandemic. Improvement methods were used flexibly to achieve short-term goals and were regarded as particularly valuable in organizations that already had an established approach to improvement before the pandemic.5,12
In an effort to better understand the impacts that the COVID-19 pandemic has made on the healthcare quality profession in the United States, the purpose of this study was to describe the ways in which PPI methods were used to combat the crisis and highlight the supportive conditions and enablement factors that empowered healthcare quality professionals to facilitate positive change. The results demonstrate the value that PPI methods provided to crisis management efforts and highlight the need to further embed PPI approaches in day-to-day processes. Building organizational capacity and workforce competency in PPI methods moving forward will better position healthcare organizations to deliver on quality, safety, and value in the post-pandemic era.
The authors of the Q Community study provided the survey questionnaire to the NAHQ and granted permission for NAHQ to use and adapt the questions as needed to suit an audience of healthcare quality professionals based in the United States. This study was evaluated by an institutional review board and determined to meet the requirements for exempt Human Subjects Research (Protocol # IRB-300007601). The researchers distributed the survey through e-mail to all active subscribers of NAHQ e-mail communications based in the United States (∼25K individuals) and collected 234 total analyzable responses between September 2 and September 16, 2021. In addition to the initial distribution e-mail, two e-mail reminders were sent during the 2-week data collection period. Responses were kept anonymous, and no personally identifiable information was collected during the survey.
The survey included 27 questions related to improvement work during the COVID-19 pandemic, including references to specific tools and resources used and questions related to respondents' professional roles and responsibilities, and took approximately 15–20 minutes to complete. The questions were a mixture of multiple-choice and open-ended text entry. Minimal adaptations were made to the original survey used in the Q Community study. These included minor language changes from the British vernacular to American terminology (e.g., “carers” to “caregivers”) and replacement of references to pandemic-related resources in the U.K. to U.S.-specific examples (e.g., National Coronavirus Task Force). The researchers performed basic thematic text analysis on open-ended responses in Excel to extract illustrative examples. Descriptive summaries of the multiple choice data were automatically generated using Qualtrics, an enterprise online survey platform.
Respondents to the survey included NAHQ members and nonmember subscribers based in the United States, whose professional profiles are representative of NAHQ's diverse constituency. The geographic distribution of respondents followed a similar pattern to NAHQ's overall constituency, which largely matches the geographic distribution of the total U.S. population. The most represented states were Florida (7%), Texas (7%), California (7%), Illinois (7%), Maryland (5%), and North Carolina (5%). Nearly half (49.8%) of respondents hold positions at the Manager/Supervisor level or above (including Director/Executive Director, Vice President, or C level). Two-thirds (67%) occupy roles that require a clinical license, and 56% have earned the Certified Professional in Healthcare Quality credential. Eighty-six percent of respondents listed PPI among their current job responsibilities. Fifty-four percent work in an acute hospital, 11% work in a health system/corporate office, 5% are consultants, and the remaining 29% are dispersed across a variety of different healthcare settings including third-party payers (4%), government agencies (3%), and skilled nursing facilities (3%).
During the response to COVID-19, most respondents used improvement methods to a great or moderate extent to measure what was happening (83%), rapidly review and improve processes and practice (81%), and decide where to focus effort (81%). Fewer respondents used PPI methods to engage with patients and families (58% to a great or moderate extent) (Figure 1). Respondents' qualitative comments describe the successful application of specific tools including PDSA and SMART goals and difficulty implementing certain methods including stakeholder analysis, failure modes and effects analysis, and define, measure, analyze, improve, and control (DMAIC) (Table 1).
Table 1. -
Comments From Respondents on Applications of PPI Methods During the Response to COVID-19
|• “The most important method has been measurement of current state and progress. Metrics have been our compass throughout the pandemic, allowing us to have an understanding of our current state as well as where to focus our efforts. We would have been flying blind without it.”
• “SMART goals and PDSA have been the cornerstone of change in our organization. The constantly changing tide of the pandemic and constant evolution of the “Beast” in healthcare required constant PDSA to navigate what works and what didn't. SMART goals set the timelines for the change.”
• “Rapid cycle PI was crucial during this time. With the rapidly changing healthcare landscape, supply availability and regulatory requirements, the ability to quickly pivot was paramount.”
|• “The high demand for the direct care team due to increased capacity only allowed for extremely limited participation in improvement activity. Because things were moving so quickly as also had limited time to develop true consensus and at times hard decisions had to be made quickly by a few individuals.”
• “Especially challenging in a virtual and WFH environment has been the ability to process map, conduct FMEA work and do any type of brainstorming work effectively. In a more Face to Face environment dialogue and interchange with participants is so much better. But we have had to be creative to get to the end result.”
• “DMAIC methodology and other highly structured approaches have been difficult to impractical due to rapid cycle change demands.”
DMAIC = define, measure, analyze, improve, and control; FMEA = failure modes and effects analysis; PDSA = Plan–Do–Study–Act; PPI = performance and process improvement; SMART = specific, measurable, achievable, relevant, and time-bound; WFH = work from home.
When asked about the enabling factors that benefitted their improvement work during the pandemic, respondents cited inclusive and compassionate leadership (76%), clarity of organizational priorities (73%), and well-established improvement skills and approaches in their organizations (68%) (Figure 2). A lower percentage of respondents reported that their improvement work was benefited by protected time and resources (55%), reduced bureaucratic or other practical constraints (50%), and opportunities to involve patients and the public (42%). Comments related to the enabling context for improvement work mentioned support from leadership and established PPI processes pre-pandemic as being beneficial to improvement work, but some also referenced difficulty maintaining progress on routine quality and safety initiatives during the pandemic response (Table 2).
Table 2. -
Comments From Respondents on Enabling Context for Improvement Work During the Response to COVID-19
|• “I work in an American community hospital and my organization started their PI, lean process approach several years ago (Virginia Mason model). This effort has been extremely helpful and easy to apply when the COVID-19 pandemic occurred.”
• “A stronger commitment to quality and improvement in noncrisis times would have helped us respond more robustly.”
• “Senior leadership support has been critical to keep action items owners on point with follow through.”
• “PDSA methods paired with systems thinking (i.e., conducting stakeholder analysis) is a foundational combo tool for performance and process improvement in our healthcare organization. Having senior executive team leading PDSA with the partnership of the Office of Patient Safety, Infection Control and Employee Wellness, Pharmacy, Case Management, etc. continues to propel our organization in providing excellence to our patients, community, our state, and our organization.”
|• “Biggest challenge is the change management—getting the commitment from leadership to incorporate improvement methods and create a standard work model that includes PI efforts regularly embedded in the work week. Finding time/staffing resources to have enterprise wide education—and ongoing mentors/coaches available to continue and nurture that education.”
• “Quality is regarded as an “added extra,” and both it and education are the first things targeted when it comes to budget cuts.”
• “‘Business as usual' mentality that tends to creep in, even after seeing proven results of how well quality tools work during the past 18 months.”
• “Integrating improvement tools and methods early on in healthcare education so all clinicians have some basic understanding. This will better prepare the workforce to be more agile, especially when resources are stretched.”
PDSA = Plan–Do–Study–Act.
Looking to the future, respondents indicated that healthcare quality professionals should prioritize further embedding systematic approaches to improvement within healthcare organizations (59%) and working in a more integrated way across teams (48%) (Figure 3). Prevention and the social determinants of health (46%), improving staff well-being (45%), addressing inequalities in patient access and the experience of care (33%), and introducing digital innovations effectively (31%) were also noted as priorities for the profession to focus on in future.
There are several limitations to this cross-sectional study, the most significant of which was the low response rate and high abandonment rate of the survey. This could be attributed to a variety of factors including the length and complexity of the questions, and the timing of the survey distribution in early September 2021 which coincided with a surge in new COVID-19 infections that severely affected NAHQ constituents in certain parts of the United States. Another limitation is the lack of variety in the type of healthcare organizations represented by the respondent sample, for example, nursing homes, because most of the respondents reported that they work in an acute hospital or health system setting. There was also a higher representation within the respondent sample from upper and middle management roles versus lower-level positions. This population may have experienced different successes and challenges during the pandemic as compared with clinical staff on the front lines. Finally, the researchers acknowledge the timing of this study within the broader context of the pandemic response and recognize that respondents had the opportunity to reflect on lessons learned during the early stages of the pandemic before sharing their experiences.
This study describes the work of healthcare quality professionals during the response to COVID-19, highlighting the successes and challenges they faced when applying their performance improvement expertise to help manage the crisis. Respondents primarily used PPI methodologies for rapid cycle improvement, measurement, and quick decision making while using PPI tools to engage with patients and families was a lower priority. Inclusive and compassionate leadership, clear prioritization, and pre-existing organizational infrastructure for administering improvement initiatives were key enabling factors for improvement work during the pandemic. Respondents found it difficult to engage front-line stakeholders in improvement projects and maintain progress on routine quality and safety efforts. Finally, respondents noted several key areas where healthcare quality professionals can play a leading role moving forward, including further embedding PPI approaches in their organizations, increasing collaboration between teams, developing strategies to address the social determinants of health and inequitable access to care, and improving the well-being of the healthcare workforce.
Although it is impossible to draw any direct comparisons because of the significant differences in context and timing, this study did find some similarities with previous research conducted in the United Kingdom regarding the utilization of improvement methods during the pandemic. Both studies showed that quality professionals found success using flexible and easy-to-use improvement tools such as PSDA and SMART goals, whereas complex methods such as DMAIC and stakeholder analysis were more difficult to apply. Both studies also showed that organizations with existing infrastructure to execute improvement work were better positioned to use PPI methods to support the pandemic response.5,12 These studies provide evidence of the value that performance improvement approaches offer during times of crisis and demonstrate why healthcare organizations should focus on further embedding improvement approaches during non-crisis times.
The conditions of the COVID-19 pandemic provided some healthcare quality professionals with opportunities to apply their expertise in impactful ways, but at the same time, many routine improvement initiatives were neglected because of a lack of capacity, resources, and perceived value among healthcare staff on the front lines. As a consequence of the shift in focus during the pandemic, leaders must now work to make up lost ground in reducing hospital-acquired infection rates.3,4 Using a phased approach, healthcare organizations can build on the successes of PPI work during the pandemic response by reinvigorating improvement projects and advancing improvement capabilities in preparation for new and ongoing challenges.13
There are several key factors that drive the success of PPI initiatives. In addition to establishing robust methodologies and systems to execute the work, these efforts require active involvement from leadership, skilled experts to guide projects, and a heavy focus on teamwork.14 Healthcare quality professionals have the skills and training to lead improvement initiatives because PPI is a central domain of their work.11 However, quality professionals often face barriers because of lack of buy-in from stakeholders who are unfamiliar with PPI methods and their demonstrated ability to improve performance. Continuing to build the improvement infrastructure and capacity will lead to increased system sustainability and resilience overall, and it starts with developing the broader healthcare workforce in PPI competencies.
Organizations that embrace continuous learning are better positioned to address challenges such as the COVID-19 pandemic because they are equipped with culture and processes to rapidly adapt to change. A continuous learning approach, which includes a focus on competency-based training, has been shown to have positive implications for patient outcomes and workforce retention.15 Many studies have also shown that an engaged healthcare workforce and expertise-driven practice are associated with increased performance and patient safety.16,17 As a strategy to help address the current workforce crisis in healthcare, leaders should recognize the value that PPI methods can offer to help facilitate staff engagement, acknowledge the competencies required to leverage these tools effectively, and embed these methods in workforce training and professional development programs.
This study is a replication of research conducted in the United Kingdom in 2020 and describes how performance improvement methods were used during the COVID-19 pandemic, offering descriptive evidence of the impacts the pandemic has had on the work of healthcare quality professionals. The results were gleaned from an anonymous survey of the NAHQ professional community based in the United States, mostly representative of healthcare quality leaders in an acute hospital and health system setting. Respondents reported that during the pandemic response, improvement tools were used to the greatest extent in support of measurement and data collection, rapidly reviewing and improving processes and practice, and deciding where to focus efforts. Healthcare leaders were largely supportive of improvement work to aid crisis management, but as a result, important “business-as-usual” quality initiatives were put on hold, resulting in a backward step on the decades-long journey to improve patient safety. Finally, respondents reported that further embedding systematic approaches to performance improvement in healthcare organizations should be a top priority for the healthcare quality profession in the postpandemic era.
Performance and process improvement methods serve as the foundation of the healthcare quality toolkit and provide exceptional value in crisis situations. The results from this study show that organizations with strong capacity in these methods are better equipped to harness their full potential. The fact that routine quality and safety initiatives were paused during the pandemic highlights a key lesson that can be learned from the experience: PPI is too valuable to be considered optional or expendable moving forward and must become a central component of everyday healthcare operations. Healthcare leaders must empower PPI experts and prioritize building workforce capacity in PPI methods to strengthen staff engagement, build system sustainability, and achieve better outcomes.
The experience of the COVID-19 pandemic demonstrated that everyday initiatives to advance healthcare quality and safety are extremely valuable, and pausing these initiatives can negatively affect patient outcomes. As we enter the postpandemic recovery phase, healthcare organizations have the unique opportunity to reset their approaches to PPI and quality management. Leaders must maximize the lessons learned from this difficult time by reinvigorating quality and safety initiatives to regain lost ground and achieve real progress.
To further activate improvement approaches in healthcare, common workforce standards and training in PPI methods must be established and applied in daily practice. In light of the increased visibility and importance of quality and safety during the pandemic response, the healthcare quality workforce will play a leading role in transforming healthcare moving forward by leveraging their expertise in this area. More research is needed to understand how a fully systematized improvement approach, founded on workforce competencies in improvement methods, can positively affect hospital performance and patient outcomes. Harnessing the power of the workforce will be critical to improving healthcare system sustainability and resilience to future challenges.
Lucie Pesch, MUSA, is the Director of Business Intelligence for the National Association for Healthcare Quality (NAHQ). With expertise in data science and advanced analytics, she leads business intelligence and research efforts for the association and is the chief steward of NAHQ's proprietary database. Her career has focused on providing strategic insights to companies across many different industries, and she is committed to promoting and facilitating a data-driven culture within organizations of all types.
Terry Stafford, PhD, RN, CPHQ, CHCQM, PCC, is a healthcare consultant with Quality Healthcare Partners. Dr. Stafford's work focuses on quality, performance improvement, regulatory and accreditation compliance, facility education, and patient safety. She is also an adjunct faculty member of Thomas Jefferson University School of Population Health, teaching quality, patient safety, tools, and methods to graduate students, physicians, and other healthcare professionals. She also served as the coleader of the National Association for Healthcare Quality Competencies Commission Team.
Jaclyn Hunter, MSHI, RN, CPHQ, is a NAHQ Navigator supporting the National Association for Healthcare Quality's (NAHQ) Workforce Accelerator TM solution. As a Registered Nurse, Jaclyn's clinical experience spans both inpatient and outpatient settings. Jaclyn has spent over 15 years focusing on quality management and performance improvement in community-based hospitals, health systems and consulting. Specializing in organization alignment and technology/workflow optimization, Jaclyn's experience in patient safety, performance and process improvement and clinical informatics brings a high level of Subject Matter Expertise to the NAHQ team.
Glenda Stewart, MSN, RN, CPHQ, CHC, is the Director of Quality Assurance & Compliance for Next Step Care. Glenda has nearly 20 years of experience in healthcare spanning across the continuum to include acute care, medical/surgical nursing, Administration, Quality Management, and Compliance. She holds certifications in both healthcare quality and compliance and leads quality initiatives for her organization which is a home and community-based service provider of case management/care coordination services for over 4,000 elderly and disabled individuals throughout the state of Georgia.
Rebecca Miltner, PhD, RN, CNL, NEA-BC, is the Donna Brown Banton Endowed Professor in Nursing and director of Educationally Focused Partnerships at the University of Alabama at Birmingham (UAB) School of Nursing. She is an associate editor for the Journal for Healthcare Quality. Her current improvement work focuses on interprofessional QI education and creating mechanisms to increase the capacity and capability for improvement work within healthcare organizations.
The authors thank Stephanie Mercado, CAE, CPHQ, whose leadership and strategic guidance helped shape this research. The authors thank Thom Dammrich, DBA, MBA, MSA, CPA, CPHQ, for providing subject matter expertise related to the design of this study. Finally, the authors thank Joanna Scott, Matthew Hill and Penny Pereira of the Q Community for inspiring this work and granting permission for the researchers to replicate their previous study.
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