How do you manage and mitigate the risks and uncertainties associated with Quality Improvement?

It is crucial to get frontline staff involved early so they can be a part of the solution instead of just the ones to implement a solution that leadership has come up with. By getting early buy-in, success is more likely. Additionally, improvement can be incremental and organizations can choose the highest priorities to focus on first.

It's all about Cowboys and Indians, and where each role-player understands their role. When there is an imbalance in roles or where someone jumps in to become a Cowboy - processes lose their impetus. I've experienced that quality control is more easily managed across all operational areas when the entire business knows "how" and "where" they are playing. So removing any uncertainty with regard to roles is essential in the process picture. Then communication is absolutely critical followed by constant monitoring and measurement.

Ill add to this, the ROI needs to be considered. In my space (healthcare) often companies are looking to improve efficiencies and improve outcomes. But sometimes the “juice isnt worth the squeeze” as pushing for improvements can backlash with the staff that have to execute the plan. With turnover rates on the rise, part of the risk assessment must be what is the moral of the workforce and if we push for improvement, will it cause for an increase in turnover. Consult managers and survey workers for their feedback to determine if we should move forward or not.

Another good way to ensure plans move forward and to mitigate risk of a project floundering or being poorly received is to ensure you have solid executive sponsorship. Although this may be considered a fundamental criterion for a QI project, it bears repeating as it can be an easy part of the setup to overlook or underestimate.

Even prior to determining the risks associated with a particular intervention, it's worth taking a step back to examine whether or not some of the very basics are in place i.e. does the team / department / organisation have the necessary infrastructure, resourcing and culture to ensure that change is embedded and sustained. There are a raft of tools available for the purposes of undertaking a self-assessment, including: ICIPS, Institute for Healthcare Improvement, Virginia Mason, AQUA, NHS Sustainability Toolkit, MUSIQ, NACCHO... some, certainly more robust than others.

Although I agree with the above, it's important to distinguish between "risks" i.e. it may (or may not) manifest. And "issues" i.e. it's happening now and is compromising delivery. A lot of time can be wasted trying to mitigate risks that never materialise, then losing sight of the actual issues and the actions that need to be delivered as part of a QI initiative. While not everyone is a fan, I still maintain that Risk and Issues logs as well as Gantt charts, remain invaluable tools. From a data perspective, a great way of keeping an eye on potential emerging risks is to adopt "balancing measures", perhaps best described as something that someone is concerned about. In other words resolving one issue at the expense of creating another.

Following risk assessment, it's crucial to devise and execute mitigation strategies to alleviate or eradicate potential negative impacts. Mitigation actions encompass preventive, corrective, or contingency measures tailored to each risk's nature and severity. For instance, preventive measures may involve training or testing to avert technical or operational errors, while corrective actions may entail reallocating resources or time to rectify deviations. Additionally, contingency plans and alternatives should be prepared to address unforeseen events. Assign clear roles and responsibilities for each mitigation action, and closely monitor their implementation and effectiveness.

I remain ever surprised at the extent to which people and organisations are either oblivious to PDSA as a concept, or misapply / overcomplicate a beautifully straight forward process. It's not rocket science - small scale tests of change, with rapid evolution based upon learning. Give something a shot (what's the worst that could happen?), reflect upon what went well and could be improved upon, then take that learning forward. I've witnessed organisations simultaneously introduce dozens of large scale changes simultaneously (referring to it as PDSA) yet failing to actually test anything. Then wondering why it didn't stick or, worse still, has done damage.

I couldn't agree more! Recognizing that whatever you implement is not going to be perfect from the onset, and will take studying and adjusting including frontline staff feedback, is so important. This mindset helps to set appropriate expectations.

Acknowledging and navigating uncertainty is vital in QI projects, as complete risk elimination is unattainable. Recognize that uncertainty is inherent in complex systems, presenting both challenges and opportunities for growth. Embrace a mindset of flexibility and adaptability, utilizing data and evidence to guide decision-making. Implement QI frameworks like Plan-Do-Study-Act (PDSA) cycles or Lean Six Sigma methodologies to iteratively test and enhance changes. Foster open communication and collaboration among stakeholders and team members to gather feedback and insights, effectively managing uncertainty throughout the project lifecycle.

Not the most exciting part of QI, but invaluable. And unfortunately not done often or comprehensively enough. Time and capacity to undertake reflection is often a luxury we don't have and we accept a rudimentary assessment of "that worked well" or "that went badly" rather than actually quantifying the impact of an intervention. When it's a good news story, this can be such a powerful motivator. But it's often swept the side as we move to the next crisis. Of less successful, we fail to capture learning and invariably make the same mistakes again at a later date, breeding cynicism and disengagement.

Evaluating and reflecting on the outcomes of your QI project is crucial for continuous improvement. Measure and analyze the impact of your changes using relevant indicators and metrics. Document lessons learned, including successes, challenges, and solutions. Share findings with stakeholders and celebrate achievements. This process facilitates ongoing learning and informs future QI endeavors, contributing to sustained progress and success.