August Hot Topic provided by: Suneela Nayak MS, RN & Senior Director of Operational Excellence


Improvement methods have long been available to leaders and teams.  This Hot Topic explores ways in which small incremental improvements can be leveraged to achieve big goals

Learning Objectives:

  1. Describe lessons learned from how successful healthcare ’transformers’ have achieved and sustained performance improvement with small incremental improvement.
  2. Discuss ways in which small incremental improvement can yield aggregate change resulting in high value and sustained improvement.

Following traditional thinking, healthcare leaders have believed that transformational change can only come only from big well-resourced projects that can be rapidly implemented. In a recent publication Richard Bohmer, a physician and former Professor in Business Administration at the Harvard Business School, debunks this thinking based on an examination of organizations that have achieved and sustained substantial performance improvements such as Seattle’s Virginia Mason Medical Center1. Bohmer notes that these ”successful transformers constantly make small-scale changes to their structures and processes over long period…everything from communicating with patients to cleaning gastroscopes has been redesigned “2.  Major change then emerges from incremental, sustained wins.

In recent years, Operational Excellence has methodically built a platform for incremental workflow improvement.  Five years later, it is well positioned to complement larger projects by yielding dividends such as engaging the care team, delivering high value-low risk return on investment (ROI), and providing a platform for strategy deployment to achieve larger organizational goals.

So, how can small incremental workflow improvements at the local level deliver all this?

First, small incremental improvements work because teams empowered with easy-to-use improvement tools lend their considerable talent to solving problems they care about. This early engagement opens the door to unleashing the full power of the front line to get behind performance improvement.  Bringing deep contextual knowledge, well coached teams take ownership for finding solutions.  Engagement builds as care teams re-connect to their own call to service, feel valued for their contribution by the daily and repeated signals of trust executives send as they attentively listen to KPI presentations, and witness executive ownership for resolving barriers to care. Intellectually rewarded teams soon develop improvement proficiency and focus their valuable capacity on sequential incremental innovations leading to outcomes that matter such as key performance metrics and benchmarks.

Second, incremental workflow improvements are usually simpler to implement because they don’t dramatically change current process.  Locally ‘owned and operated’ PDSA cycles focusing on small gains don’t usually need approval, funding, or sponsorship to get started, and importantly, do not usually encounter challenges such as resistance to change.  At least in part, this is because of rediscovered ‘joy in work’ experienced when exhausting and frustrating redundancy and rework are alleviated.

This brings me to how incremental improvement can yield high value-low risk ROI, a concept of particular value in this time of economic constraint. It is worth noting that while results of each small incremental change seldom produces dramatic ROI, it also generally has little or no cost, is low-risk, and rapid in cadence. Additionally, because each improvement is coupled with engaged ownership, improvements realized from such investments can be long lasting.  The accumulation of numerous small incremental improvements can soon yield sustained, aggregate change adding up to meaningful ROI.

Lastly, how can incremental improvement be leveraged for strategy deployment?   The Operational Excellence Platform provides a stable daily management system for executives and care teams to connect and discuss barriers to safe, reliable and effective patient care.   Recent Op Ex pivots to support operations during our Covid-19 experience provides testimony for this assertion.  Carefully designed improvement tools, empower teams to systematically align their improvement work with key strategic priorities by focusing on Patients, People, Populations, or Value.  Fluid, bi-directional flow of information is channeled every day during Gemba Walks when teams present their KPIs to rounding executives.  In turn, executives gain rich insights about how high-level decisions made at the policy and budget tables impact the real work of care delivery.  In these ways, each small but successful KPI along with the richly talented, hardworking and empowered team behind it, move us closer to achieving the goals of the quadruple aim.

  1. Bohmer RMJ. The Hard Work of Health Care Transformation. n engl j med 375;8 August 25, 2016
  2. Bohmer RMJ. Designing care: aligning the nature and management of health care. Boston: Harvard Business Press, June 2009.
Download PDF