RESEARCH ARTICLE

Developing the Capacity for Rapid-CycleImprovement at a Large Freestanding Children’sHospitalEvan S. Fieldston, MD, MBA, MSHP,a,b Jennifer A. Jonas, BSE, BA,a Virginia A. Lederman, MBA,c Ashley J. Zahm, MHA,d Rui Xiao, PhD,e Christina M. DiMichele, MSN,f

Ellen Tracy, MSN,f Katherine Kurbjun, MSN,f Rebecca Tenney-Soeiro, MD, MSEd,a,b Debra L. Geiger, MHS,c Annique Hogan, MD,a,b Michael Apkon, MD, MBA, PhDg

A B S T R A C T BACKGROUND: To develop the capacity for rapid-cycle improvement at the unit level, a largefreestanding children’s hospital designated 2 inpatient units with normal patient loads andworkforce as pilot “Innovation Units” where frontline staff was trained to lead rigorousimprovement portfolios.

METHODS: Frontline staff received improvement training, and interdisciplinary teamsbrainstormed ideas for tests of change. Ideas were prioritized using an impact-effort evaluation andan assessment of how they aligned with high-level goals. A template for each test summarized thefollowing: the opportunity for improvement, the test being conducted, dates for the tests, driverdiagrams, metrics to measure effects, baseline data, results, findings, and next steps. Successfulinterventions were implemented and disseminated to other units.

RESULTS: Multidisciplinary staff generated 150 improvement ideas and Innovation Unitscollectively ran .40 plan-do-study-act cycles. Of the 10 distinct improvement projects, elements of all10 were deemed “successful” and fully implemented on the unit, and elements from 8 were spreadto other units. More than 3 years later, elements of all of the successful improvements are still inpractice in some form on the units, and each unit has tested .20 additional improvement ideas,using multiple plan-do-study-act cycles to refine them.

CONCLUSIONS: The Innovation Unit model successfully engaged frontline staff in improvementwork and established a sustainable system and framework for managing rigorous improvementportfolios at the unit level. Other hospitals and health care delivery settings may find our qualityimprovement approach helpful, especially because it is rooted in the microsystem of care delivery.

aDivision of GeneralPediatrics, cOffice ofSafety and Medical

Operations, andDepartments of

dAnesthesiology andCritical Care Medicine,and fNursing, Children’sHospital of Philadelphia,

Philadelphia,Pennsylvania;

bDepartments ofPediatrics and

eBiostatistics andEpidemiology, Perelman

School of Medicine,University ofPennsylvania,Philadelphia,

Pennsylvania; andgHospital for Sick

Children, Toronto, Canada

www.hospitalpediatrics.orgDOI:10.1542/hpeds.2015-0239Copyright © 2016 by the American Academy of Pediatrics

Address correspondence to Evan Fieldston, MD, MBA, MSHP, Children’s Hospital of Philadelphia, 34th St and Civic Center Blvd,Philadelphia, PA 19104. E-mail: fieldston@email.chop.edu

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: Internal funds from the Children’s Hospital of Philadelphia

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Dr Fieldston helped conceptualize and designed the study and critically reviewed the manuscript; Ms Jonas drafted and revised themanuscript and contributed to data analysis; Ms Lederman, Ms Zahm, Ms DiMichele, Ms Tracy, Ms Kurbjun, Ms Tenney-Soeiro, Ms Geiger,Dr Hogan, and Dr Apkon helped conceptualize and design the study and critically reviewed the manuscript; Dr Xiao contributed to dataanalysis and critically reviewed the manuscript; and all authors approved the final manuscript as submitted.

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Hospital leaders are responsible for drivingperformance across multiple qualitydomains including safety, clinicaleffectiveness, patient experience, andfinancial stewardship.1,2 However, althoughexecutives can develop strategies, unitmanagers and frontline staff are the oneswho have to effectively change processes todrive performance while simultaneouslymanaging a busy clinical operation. Thus,leadership at our large freestandingchildren’s hospital sought to research,design and pilot a quality improvementmodel that would leverage elements ofexisting models but would focus specificallyon embedding rapid-cycle improvementcapabilities in regular inpatient units witha normal workforce and patient load.

In fiscal year 2013, 2 fully functioninginpatient units were selected to serve aspilot “Innovation Units” (Table 1). Managersand frontline staff on these units weretrained to lead local improvement portfoliosto affect outcomes across a series ofstrategic domains. Leading an improvementportfolio involved encouraging staff topropose ideas for ways to achieve high-leveloutcomes, planning and running plan-do-study-act (PDSA) cycles to test ideas,establishing appropriate metrics andsystematically tracking progress over time,and spreading successful improvementsthroughout the unit and to other units.

One of the premises of the initiative wasthat “innovative” ideas did not have to becompletely revolutionary but could simplybe a modification of an existing process or

object.3 Another premise was that multiplePDSA cycles could occur simultaneously.Because unit-based improvement activitieshad previously focused on 1 or a limitednumber of initiatives at a time, the idea ofmanaging a portfolio of projects withdiffering degrees of complexity and maturitydates was new. The intent of this staggeredapproach was to allow units to test manymore innovations and to ensure thatimprovement work was happeningcontinuously.

The long-term, high-level goals of theInnovation Unit initiative were to improveoutcomes associated with strategicobjectives around patient safety, qualityimprovement, patient/family satisfaction,and cost reduction. However, the goal of thepilot was to assess whether the modelcould successfully accomplish the following:(1) engage unit-based leadership andmultidisciplinary frontline staff in qualityimprovement work, (2) encourage theproposal of new ideas, (3) educate unit-basedstaff in the clinical setting, (4) incorporatea sustainable system and framework toassist unit-based leadership in managing arigorous portfolio of work, and (5) stimulatea culture of continuous quality improvementat the unit level that would mirror theorganization’s long-standing spirit of innovationin biomedical science and clinical care.

METHODS

Design and implementation of theInnovation Unit initiative included 7 focusareas, including: (1) design of project

governance structure, (2) kickoff andtraining, (3) engagement and ideageneration, (4) idea prioritization and buy-in, (5) implementation and communication,(6) portfolio framework and monitoring,and (7) sustainability and spread.

Project Governance Structure

The hospital’s then Chief Medical Officer(M.A.) and Chief Nursing Officer served asexecutive sponsors and provided high-levelguidance and direction to the project team.A general pediatrics hospitalist, who servedas Medical Director of Care ModelInnovation (E.F.), and a Nursing Director(E.T.) cosponsored the initiative. In additionto providing regular guidance, they oversawall aspects of implementation. ImprovementAdvisors (1.75 full-time equivalents) fromthe Office of Safety and Medical Operationswere also assigned to the project. The coreproject team consisted of nurse managers,medical directors, nursing leaders, and achief resident. A steering committeeconsisting of managers and directors fromthe departments of pediatrics, pharmacy,supply chain, and other key areas was alsoassembled to assist with leveragingtechnology, connecting with subject matterexperts, and aligning the tests of changewith other hospital initiatives.

Kickoff and Training

Kickoff meetings were held over a 6-weekperiod to introduce multidisciplinary staff tothe initiative. After the kickoff, all unit-basedstaff, ranging from skilled nursingassistants to medical directors, wererequired to attend educational sessions runby local improvement advisors thatprovided a general “Introduction toImprovement” as well as a more specificintroduction to the hospital’s improvementframework. Training beyond these basicmodules was tailored to the person’s role inthe project. Members of the core team wererequired to complete modules on “RunningPDSA Cycles,” “Creating Driver Diagrams,”and “Managing Costs of Care.” They werealso asked to complete quality improvementand patient safety modules through theInstitute for Healthcare Improvement (IHI)Open School.4 Staff members involved inspecific tests of change were asked tocomplete concise, modular, just-in-time

TABLE 1 Descriptive Information for the 2 Innovation Units

4 West 5 East

No. of Beds 20 22

Annual discharge volume 1100 2600

Patient population General pediatrics General pediatricsIntegrated care service Hematology

(Medically complex and/ortechnology-dependent patients)

Small numbers from otherservices (including Immunology,

Rheumatology)

Staffing for both units Attending physician (1- to 2-wk rotations)Residents (4-wk rotations)Medical students (3-wk rotations)Nursing staff: registered nurses, skilled nursingassistants, student co-ops, in-patient care nurses

Nursing studentsCase managers, social workers, child life therapists

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training as appropriate. Unit leadersmonitored the completion of all requiredmodules for staff on their unit.

Engagement and Idea Generation

Physicians, nurses, advanced practicenurses, social workers, case managers, andother staff attended brainstorming sessionsto generate lists of improvementopportunities linked to the high-level goals.Unit-specific e-mail addresses were alsoestablished for staff to submit ideas. Usingthe framework of business modelinnovation, project sponsors emphasizedthat small changes could lead to significantimprovements in patient outcomes, andtherefore, ideas did not need to becompletely revolutionary but could simplybe enhancements or tweaks to currentprocesses or common objects. For example,they noted that Netflix did not invent theDVD, but simply changed the wayconsumers obtain them. Similarly,improvements in patient care could resultfrom “Netflix ideas” and did not require“inventing the DVD.”

Idea Prioritization and Buy-in

Once the list of potential projects wasgenerated, ideas were organized intocategories and subcategories based on thequality domain that they addressed. Forexample, a “hospital acquired conditions”category was subdivided into groups forcentral line–associated blood streaminfections, nosocomial viral infections, andperipheral intravenous infiltrates. To selectwhich ideas to test, the core team created aprioritization matrix that included an“impact-effort” evaluation and anassessment of how well the idea alignedwith high-level goals (Fig 1).

Implementation and Communication

Once projects were selected, unit leaderspresented plans for the tests of change tofrontline staff at regularly scheduledmultidisciplinary team huddles, and thechief resident presented plans to residentteams. Each stakeholder group discussedsteps necessary to implement the changes,and volunteers were chosen to championand monitor tests on a daily basis.

Multiple methods of communication wereused throughout the process. The core team

had weekly check-ins with project sponsorsand improvement advisors. To remindfrontline staff members about their role inimplementing the tests, the core team usedmultiple forms of communication, includinge-mail, in-person discussions, paperreminders, and instructional videos.Physicians updated their specialty divisions,and the chief resident communicatedupdates to residents. To keep otherstakeholders informed, the steeringcommittee attended quarterly meetings andreceived updates about the status of theprojects. A series of 5-minute videosprovided updates on the initiative and onspecific interventions. Toward the end of thepilot, an internal Web site was launchedwith links to education modules and videosand details about the tests of change.

Portfolio Framework and Monitoring

To help units manage each project, the coreteam designed a template that outlined theportfolio framework. Each PDSA cycle usedthis template to summarize the following:the opportunity for improvement, the testbeing conducted, the dates and locations ofthe test, a driver diagram linking the test tohigh-level goals, the metrics being used tomeasure the effects of the intervention,baseline data, test results, key findings, andnext steps (Fig 2). The template alsospecified which staff members wereresponsible for specific tasks. In someinstances, students were used to observeand track behavior changes.

Sustainability and Spread

Once a test was completed, unit-basedteams evaluated the intervention usingquantitative data and qualitative feedbackfrom staff. If the intervention was deemedsuccessful, it was fully implemented on thatunit. To spread the idea to other units, unitleaders presented the results of theirsuccessful tests in various forums includingregularly scheduled daily calls with nursemanagers from every unit, nursing councilmeetings, and the steering group meetings.Changes were also incorporated intotraining modules and onboarding materials.

Improvement Example

One of the project areas that both unitsselected was increasing clinician

compliance with medication reconciliationwithin 24 hours of admission. Some of thePDSA cycles involved increasing datatransparency, reeducating residents aboutthe process, increasing soft alerts such asverbal reminders from senior residentsduring rounds, and sending weekly e-mailreminders to physicians. Building onlessons learned from these tests, the finalPDSA cycle iteration involved working withinformatics resources to develop andimplement an inline alert in thecomputerized order-entry system.

RESULTSEngagement and Idea Generation

More than 170 staff members and70 physicians attended the kickoff meetings.Within 2 months, multidisciplinary staffgenerated .150 ideas during thebrainstorming sessions and through e-mailsubmissions. The project team also receivedrequests from staff across the organizationto use the Innovation Units as testingground for their ideas.

Education

In addition to the introductory educationsessions, 48 staff members from the 2 unitscompleted quality improvement trainingmodules through the IHI Open School(Table 2). A core group of 8 staff memberscompleted all 6 quality improvementmodules, which included 23 individuallessons and accounted for .8 hours ofeducational time. Other staff completedselect modules that were relevant to theirrole. Collectively, staff on the unitscompleted 498 quality improvement lessons,which accounted for .160 hours of qualityimprovement training.

Improvement Capacity at the UnitLevel

Each unit selected 6 or 7 improvementprojects for the pilot year. Because therewas some overlap between the projectson the 2 units, altogether there were10 distinct projects. Each project includedmultiple PDSA cycles, so collectively theunits ran .40 tests of change during theyear. A snapshot of 1 portfolio a few monthsinto the pilot showed that the unit wasengaged in designing a rounding checklist,fully implementing a safety and care

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coordination team huddle, and planning thedissemination of a charge nurse safetyreport to other units.

Sustainability and Spread

Of the 10 distinct improvement projectareas from the pilot, some elements of all10 were ultimately deemed successful andfully implemented on the unit. However, notall elements of each project “bundle” weresuccessful. A stethoscope hygiene elementof the project that aimed to reducenosocomial viral infections, for example,was abandoned due to consensus that it didnot provide a net benefit. Of the 10 distinctprojects areas, elements of 8 were spread

to other units. More than 3 years later, all10 of the projects that were fully adopted onthe units during the pilot are still in practicein some form, although many have sincebeen further refined.

In addition to the sustainability of theindividual improvements, the InnovationUnits have sustained their capacity forrapid-cycle improvement. In the 3 yearssince the pilot, the units have each tested.20 improvement ideas using iterativePDSA cycles to refine each one.

Improvement Example

In the 3 months before the pilot, the rate ofmedication reconciliation within 24 hours of

admission on the Innovation Units was52%, 58%, and 45% while hospital-widecompliance was between 58% to 59%.Two months postintervention, rates on theInnovation Units increased to 73% andremained high for the remainder of thepilot, with some months exceeding 90%.Although hospital-wide rates alsoincreased during this time to ∼69%, theInnovation Units consistently outperformedthe hospital-wide average with differencesranging from 4 to 26 percentage points. Inthe months that followed implementationof the inline alert, compliance ratescontinued to increase, and after 6 months,compliance remained steadily .95%. When

FIGURE 1 The project team used this prioritization matrix to select which quality improvement ideas to test on the Innovation Units. The matrixincludes an “impact-effort” evaluation and an assessment of how well the idea aligned with high-level goals.

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these improvements were spreadthroughout the hospital, hospital-widecompliance increased to .90% and hasremained steady between 94% to 97%(Fig 3).

DISCUSSION

Continually fostering new ways ofthinking at the frontline and trainingfrontline staff in a rapid, relevant wayis essential to achieving sustainablechanges that benefit patients.5-9 Thus,we sought to design and pilot aquality improvement model that wouldengage frontline staff and ultimatelylead to measurable improvements inpatient- and hospital-level outcomes.

The approach described in this articlediffers from other approaches in a fewways. First, it trains large numbers offrontline staff in the clinical settingwithout dedicating significant resourcesin the form of time or money. Althoughthere are benefits to sending staff awayfor extensive training, it is not practicalfor many organizations. Our approach isalso highly efficient in that it usestargeted, just-in-time training andreinforcement.

Second, other improvement-via-innovationapproaches have elements that operateoutside of “clinical microsystems,” whichare subcultures of clinical and nonclinicalstaff with their own structures and

processes that provide care to specificpatient cohorts.10 For example, someorganizations use designated “InnovationDesigners” or “Chief Innovation Officers” toidentify improvement opportunities, designand test changes, and disseminate them topatient care areas or to lead teams ofinnovators across the organization, whereasother models use “Centers for Innovation”or “Learning Laboratories” to studyimprovement ideas.11-14 However, becauseclinical microsystems are well suited toengage frontline staff in unit-levelimprovement activities,15 we adaptedelements of existing models to focus onengaging and educating staff within theclinical microsystem and building the

FIGURE 2 Snapshot of a template from the Innovation Units’ quality improvement portfolio. These templates were used to help manage and trackthe status of each test of change.

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capacity for rapid-cycle improvement at theunit level.

During the pilot year, the Innovation Unitinitiative successfully engagedmultidisciplinary frontline staff inimprovement work and established asystem and framework to help unitsmanage a rigorous improvement portfolio.Multidisciplinary staff generated.150 improvement ideas, and in addition toattending educational sessions led by localimprovement advisors, 48 staff memberscompleted modules through the IHI OpenSchool. With this base of engagement andtraining, each unit successfully managed aportfolio of 6 to 7 improvement projects,which included .20 PDSA cycles, andsuccessfully spread almost all of theimprovements to other units. More than3 years later, all improvements that weredeemed successful are still in practice, andin each year since the pilot, the units havecontinued to manage a portfolio of ∼6 newprojects, each with multiple PDSA iterations.

In addition to incorporating improvementskills into the core competencies of

unit-based staff, the initiative raisedawareness among staff members abouttheir responsibility to contribute tocontinuous quality improvement. Earlyindications of positive trends on key metricsalso set an example for other units, andsince the pilot, Innovation Unit teams haveplayed an integral role in advising otherunits about quality improvement.

Factors That Contributed to theInitiative’s Success

One factor that was critical to the successof the initiative was the high level of seniorleadership engagement and support sinceits inception.16 The chief medical officer andchief nursing officer rounded on the units,and the project was publicized andacknowledged in multiple venues thatincluded operational and clinical leadership.

Establishing a strong leadership structureon the units was also critical.16 Each unithad a strong nurse manager and medicaldirector championing the work on a dailybasis. Unit leaders also had dedicated timefor quality improvement, which allowedthem to focus on designing, communicating,

implementing, and tracking tests withouthaving to balance improvement work withpatient care. Another key element was thatthe portfolio templates clearly delineatedwho were responsible for each aspect ofmanaging the tests. In addition to ensuringaccountability, this ensured that everyonewas aware of his or her specific role.

Engaging multidisciplinary staff, includingnurses, attending physicians, and residentsfrom the beginning was also important.16

Because all stakeholders were included inthe kickoff and encouraged to participate tothe brainstorming process, there was ahigh level of awareness and support for theinitiative. Providing relevant, just-in-timetraining, keeping staff informed about theprogress of the projects, and continuallyreminding staff members about what theyneeded to do to implement the changes wasalso key.

Another factor that contributed tomaintaining engagement was providingopportunities to highlight small successes.16

Staff members who were integral to thedesign, implementation, or tracking of

TABLE 2 IHI Open School Educational Modules

Course EstimatedCompletion Time

Lesson Number Lesson Title No. of Innovation Unit StaffMembers Who Completed

the Lesson

QI 101: Fundamentals for Improvement 1 h, 15 min Lesson 1 Errors Can Happen Anywhere—and to Anyone 48Lesson 2 Health Care Today 45Lesson 3 The Institute of Medicine’s Aims for Improvement 43Lesson 4 How to Get From Here to There: Changing Systems 42

QI 102: The Model for Improvement 1 h, 30 min Lesson 1 An Overview of the Model for Improvement 20Lesson 2 Setting an Aim 20Lesson 3 Measuring for Improvement 19Lesson 4 Developing Changes 18Lesson 5 Testing Changes 18

QI 103: Measuring for Improvement 1 h, 15 min Lesson 1 Measurement Fundamentals 16Lesson 2 Displaying Data 16Lesson 3 Learning From Measures 16

QI 104: The Life Cycle of a QualityImprovement Project

1 h Lesson 1 The Life Cycle of a Quality Improvement Project:Innovation, to Pilot, to Implementation, to Spread

14

Lesson 2 Spreading Changes 14Lesson 3 Case Study: Reducing Waiting Times Throughout the

Veterans Health Administration14

QI 105: The Human Side of QualityImprovement

1 h, 30 min Lesson 1 Overcoming Resistance to Change 12Lesson 2 What Motivates People to Change 12Lesson 3 Culture Change Versus Process Change 11

QI 106: Measuring PDSA Cycles andRun Charts

2 h Lesson 1 Using Plan-Do-Study-Act (PDSA) Cycles (Part 1) 28Lesson 2 Using Plan-Do-Study-Act (PDSA) Cycles (Part 2) 23Lesson 3 Using a Measurement Planning Form 17Lesson 4 Run Charts (Part 1) 17Lesson 5 Run Charts (Part 2) 15

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successful tests were asked to present theirproject in venues ranging from local staffmeetings to hospital-wide forums. Thesepresentations helped raise awarenessabout successful improvements whileproviding an opportunity to acknowledgeteams for their efforts.

Challenges and Limitations

Some of the challenges of designingimprovement projects involved obtainingbaseline measures and identifyingappropriate target outcomes. Forinterventions aimed at improving carecoordination, for example, it wasdifficult to quantitatively assess the currentstate and track changes. In these cases,qualitative feedback was used. Trackingcompliance with certain interventions, suchas hand-hygiene protocols, was also difficult.

Another challenge involved demonstratingassociations between unit improvementsand high-level outcomes. Because multiple

tests were running simultaneously andbecause so many factors contribute tometrics around patient safety, quality,satisfaction, and costs, it was difficult toassess the direct effects of theinterventions. This was compounded by thefact that clear data for these outcomemetrics are difficult to obtain. However, forthe pilot, demonstrating causality was lessimportant than building the capacity forrapid-cycle improvement.

Measuring whether we were successful ininitiating a culture change was also difficultbecause we did not have baseline data onstaff’s perceptions of the culture on theunits. However, qualitative feedback waspositive, and since the pilot, the Office ofSafety and Medical Operations startedadministering a survey to gaugeperceptions of culture and capability thatunits are now using to target training andtrack progress.

Ensuring the long-term sustainability of theimprovement model also remains anongoing challenge. Although we have triedto embed improvement work in the dailyfunctioning of the units and to distributeresponsibilities so that continuity does notrely on a few individuals, we still experiencesetbacks when key staff members leave.However, incorporating quality improvementresponsibilities into job descriptions andmaintaining protected time has helped tomitigate this.

CONCLUSIONS

The Innovation Unit model succeeded inengaging frontline staff in qualityimprovement work and in establishinga framework for managing rigorousimprovement portfolios at the unit level.Although the process was initiated usingexternal resources in the form of dedicatedtime from improvement advisors, since thepilot, the units have sustained the model

FIGURE 3 Results from the Innovation Unit project on medication reconciliation.

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independently. Other hospitals and healthcare delivery settings may find ourapproach to improvement helpful,particularly because it is rooted in themicrosystem of care delivery.

Acknowledgments

We thank the physicians and nurses who ledthis work on the units, including JenniferSullivan, Elena Becker, Regina Edge, MaryAnn Gibbons, Sarah Murawski, Kim Smith-Whitley, and Erika Leep.

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DOI: 10.1542/hpeds.2015-0239 originally published online July 14, 2016; 2016;6;441Hospital Pediatrics 

Tenney-Soeiro, Debra L. Geiger, Annique Hogan and Michael ApkonXiao, Christina M. DiMichele, Ellen Tracy, Katherine Kurbjun, Rebecca

Evan S. Fieldston, Jennifer A. Jonas, Virginia A. Lederman, Ashley J. Zahm, RuiChildren's Hospital

Developing the Capacity for Rapid-Cycle Improvement at a Large Freestanding

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