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This chapter is from the book

No Emphasis On Control

Probably the most common questions and discussions in healthcare performance improvement currently are those centered on sustaining the gains from changes implemented. It appears that the vast majority of organizations are failing in this goal and much focus is placed here, from the numerous presentations at conferences to whole conferences targeting the subject.

The primary reasons for this failure are embedded in the failings of the traditional change methods described to this point, plus the lack of emphasis in traditional change models placed on control of the new process.

With multiple disparate change groups making change in the business, it is inevitable that a good process gets further tweaked by a subsequent change team. Individuals in the process are positively encouraged to tweak their processes (sometimes known as “simple tests of change”) without context or data to validate their actions, contributing to the 1-sigma churn described previously.

Even the commonly implemented PDCA change model itself is inherently designed to fail in controlling the process. The approach is one of cycles of PDCA with the clear intent to make change and then later return to the process to make further change. The process never settles, and the tendency (call it human nature if you will) is to assume that rigor in control isn’t really necessary because “we’ll be back around again here shortly.”

The people-versus-process factor is also a key element in failing to sustain. By relying completely on the individuals involved in the process to maintain new performance levels, rather than changing the fundamental physics of the process, staff either burn out trying to maintain the new process given their unreduced workload, or their focus simply gets diverted elsewhere. With no link of process metrics to personal accountability, it is inevitable that a process slides back to its original state.

With the divide between the quality group and operations groups, the sheer stress of pulling the team through the process to the point of implementation takes its toll, and the team, not given the task of placing robust controls, get dragged on to the “next thing” before control is even considered.

With all of these inherent flaws in the change model, it is absolutely no surprise that change is not sustained; in fact, it would be remarkable if it were.

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