Good Things Come in Small Changes

Elissa Faro
Elissa Faro, PhD: Senior project manager, NICHQ

I recently wrapped up teaching our intro quality improvement (QI) course, the ABCs of QI, for one of our partners, Family Voices. In the final webinar the participating teams shared the projects that they had worked on, and they reflected on the most useful strategy they learned—the concept of small tests of change.

Testing ideas is not a new concept—we’ve all employed the process of trial and error at some point. A small test of change, however, transforms trial and error into a disciplined process of trial and learning. It involves starting with a plan, including predictions about the outcomes of the test, testing the change while collecting data, studying the results and using what is learned to plan the next test.

Further, the concept of the cycle is critically important. Once the results have been studied, that information is used to inform the next small test. Whether it’s to modify a component (placing the algorithm reminder in a different location); to test under new circumstances (another clinic or another agency); or try with a larger sample (three doctors as opposed to just one in the first test), each time through the test, more information is gathered to understand the system, how the change affects the system and any unexpected results.

One of the teams in the ABCs of QI class wanted to establish a new referral process for families coming in to their system, and had a goal to get 90 percent of those families connected with the appropriate elements of care. They first tested a referral form in one office of one agency. It took several rounds of small-scale testing to modify the components of the form, to choose when time was allotted for the family to complete the form during their visit, and to incorporate the processing of the form into their workflow before the team felt confident that they had a good process. The team then tested the referral process in other offices, and then other agencies. Each time they learned that with each new test/environment/group parts of the referral process could be tweaked to work more efficiently.

The course ended before the team was able to reach their 90 percent goal, but because they had conducted many small tests in multiple agencies, engaging multiple stakeholders, they left confident that the form was effective, had buy-in from the different agencies because they were involved in the process and with engaged families who were more than happy to provide feedback.

This week at NICHQ, I was in a meeting about developing a new process for moving the work of a department forward. There was a good suggestion to develop work groups, each with a different focus to make sure that each area could continue to move forward, independent of the others. The group debated the staffing issues, the constraints presented by competing priorities, etc. until someone said, “why don’t we start with one and see how that goes?” It was like someone switched on the goofy light bulb over our heads. It would make perfect sense to be able to test the make-up of the group, the competing priorities, how much could be accomplished in a set amount time, and all of the other things that made us hesitant to implement the workgroups. Further, at the end of the test, we could present our results to leadership to get buy-in for staffing allocations, budget, autonomy, etc.

Testing isn’t new; it’s not a revolutionary concept. But change is hard, and the more small testing you do around a change, with a little data collection and analysis, the easier it becomes to make an effective, sustainable change.

Elissa Faro, PhD, is a senior project manager at NICHQ.