Staff who resist quality improvement efforts

-by Donald Tex Bryant


Perhaps you are just beginning a quality improvement program or project.  Perhaps you have several project improvement projects successfully completed at your healthcare site.
No matter what your level of experience, you have encountered staff who are roadblocks to your efforts.  What are you to do?  Ignoring them or doing nothing will imperil your quality efforts eventually.  Let me share some ideas on what to do based upon my own experience and on advice from experts.

Before I share some strategies I will share an example based upon my own experiences.  A primary care group with six physicians specializing in family practice and internal medicine has been focusing on process improvement and patient-centered care for six months.  They have retained a Lean healthcare consultant to help them with timely advice and occasional training.  The consultant keeps them focused on standard procedures, value adding processes and waste elimination and on continuous improvement, all of which are focused on the patient outcomes.  They decide to explore whether they should have their patients who come in for physicals have their blood work done a week before their scheduled appointment.  The office manager asks some of the physicians, nurses and office staff to come together for a few one-hour meetings before the practice opens for patients in the morning.  The goal of this team of volunteers is to assess the pros and cons of having the blood work done before the physical and if so, to develop a standard operating procedure (SOP) for having it done.  Some of the pros and cons are:

• Physicians will be able to discuss with the patients indicators such as triglyceride levels outside of normal ranges so lifestyle changes can be suggested
• Patients who are focusing on improving their health can discuss the results with their physician
• Some patients may find going to a lab before the visit an inconvenience, especially if the lab is in the same building or near the group practice site

Overall, the team decides that they will pilot this approach with two of the physicians.  A SOP is developed involving staff who schedule appointments, nurses aides and physicians.  Indicators of the outcomes in terms of patient health and  physician and staff  attitudes are developed and tracked.
The results of this pilot are positive and the office manager decides to implement the changes for the whole office.  She discusses the procedures with the rest of the staff and physicians and sets up a chart for her use and her staffs’ observation of the rate of compliance with the new procedure.  After a couple of months she finds that there is a lack of progress in improved compliance with the procedure.  Upon further investigation she finds that one of the schedulers and a nurse’s aide are consistently not following through with their procedures.  She talks to them about this and after a couple of months they are still not following their procedures.  What should she do?
According to a recent newsletter of Lifewings, a quality improvement group for healthcare, CEO Steve Harden stated that about 8% of staff of groups who are beginning quality improvement projects at their site will not participate or will actively block projects.  In the newsletter he advises that management have a plan in place to deal with these 8%.  Lifewings trainers get a verbal commitment from management that they will actively engage those who are blocking projects by having a conversation with them and trying to get them to commit to join in the improvement efforts.  Some will agree to but will still not change.  Some will not even agree.  Mr. Harden suggests that managers then ask these staff to find another place to work.  Further, he says to celebrate the achievements of those who have helped improve patient health outcomes through process improvement projects.
Jim Zawacki, co-author of It’s Not Magic, the Rebirth of a Small Manufacturing Company, suggests another approach.  In his book which describes the Lean quality improvement efforts at his company, GR Spring and Stamping, he describes how a team of managers and front line employees came to grips with those who would not join others as they started the cultural transformation necessary to ensure the success of a Lean Process Improvement program.  After the Lean program had been well established the team decided that management would have to ask those who were unwilling to change to leave the company.  Mr. Zawacki as CEO made sure that happened.
If you are just beginning quality improvement efforts at your site, you must come to grips with dealing those who will not join it.  Eventually, they will sabotage much of your efforts and will negatively influence those staff members who are involved.  Management should have a plan on how to consistently deal with the recalcitrant staff, including asking them to find other employment.  Do not let a rotten apple spoil the barrel.

Donald Tex Bryant is a consultant who helps healthcare providers meet their challenges. He can be reached at Bryant’s Healthcare Solutions.