Behind the Health Care Improvement Map

What if hospital leaders had an easier, more streamlined way to chart an improvement path for their organizations? Imagine a list of key processes that could—if implemented reliably—lower mortality,  reduce harm, lessen delays, create a better patient experience, and lower costs. This possibility is now within reach. 

For the past year, the Institute for Healthcare Improvement (IHI) and several scientific partners have been hard at work developing a tool that will offer an alternative to the current state of affairs in which U.S. hospitals must figure out how to juggle and work on nearly 1,500 quality indicators and long lists of requirements from organizations such as the Joint Commission, the Leapfrog Group, and the Centers for Medicare & Medicaid Services, and other payors. Plus, hospitals must participate in various quality assessment programs. While all worthy in their intent and specificity, this everexpanding list of expectations risks creating more frustration and confusion than improvement. 

It is not surprising that, when asked what they would value most, hospital quality leaders told IHI they needed help making sense of all the demands and requirements, especially with tightening budgets for new projects and initiatives and less and less certainty about which programs can truly help patients, reduce waste, and create greater efficiencies. 

Our solution, available to hospitals as of June 15, 2009, is the IHI Improvement Map—an interactive tool that offers hospitals the best knowledge available on processes that lead to excellent patient care, and a way for them to design a customized path to achieve meaningful results.

Background: Developing the map 

How did we arrive at the Improvement Map? The 100,000 Lives and 5 Million Lives Campaigns supported hospitals by packaging information on 12 interventions that were known to reduce mortality and harm. The engagement in these campaigns by more than two-thirds of U.S. hospitals, coupled with the progress of several other national initiatives, demonstrated the will among leaders and front-line hospital staff to make changes, both easy and difficult, to improve performance on important patient outcomes. 

We asked ourselves, "What if we offered not just 12 or 20 random processes for improving results, but a complete list of the essential processes that hospitals must do well to reach better outcomes?" We explored this possibility with Brent James, MD, vice president of Intermountain Health Care (IHC) in Salt Lake City. Dr. James had considered the core processes for IHC hospitals and discovered through careful analysis that 104 clinical processes accounted for 95 percent of IHC’s business. With that information as background, and a complete list of the regulatory requirements and programs in hand, we set about to describe a generic set of processes, both clinical and managerial, that are the foundation of high performance. After consulting with Dr. James and a host of other hospital leaders, we created the Improvement Map. 

The Improvement Map contains information on key processes in a hospital in three domains: patient care processes, support processes, and leadership and management processes. The key processes on the map are designed to cover about 80 percent of most hospitals’ business. They are the high-volume and high-risk processes that have to be done reliably. See them by going to IHI.org. 

Why do we call it a map? 

Improving patient care is a journey and leaders committed to that journey are often looking for a way to map the strategy; the Improvement Map is a tool that can help. Here are some suggested ways to put the Improvement Map to use: 

Develop a focused quality agenda. Most leaders know which outcomes are crucial for the organization’s success. You will be able to sort and filter the processes on the map by important outcomes, whether they are mortality and harm, or costs and efficiency. Plug in your goals to see your own course traced on the Improvement Map, highlighting the processes most important to your success. You will be able to further sort your map by the degree of difficulty in implementing the processes, or the financial implications. The Improvement Map will help you create a sequential path for reaching important goals—your own portfolio of projects. 

Evaluate your improvement initiatives. If you already have an active improvement program, check your activities against those that are identified by the Improvement Map to confirm you are on the path to the results you want to achieve. You will be able to identify important processes for reaching your aims that you may have missed. For example, most organizations have active programs to improve the patient experience, but many do not know how important dietary and pain management programs are to improving that experience. Using the Improvement Map can give you more focused ideas for reaching your stated goals. 

Find resources and information to boost performance improvement. The Improvement Map contains a wealth of information about each process, including what requirements and aims are connected to the process, the prerequisites for success, measurement tools and links to other information and resources for making the processes reliable. Any staff member can use the Improvement Map to find the resources they need to get started on improvement. And that includes executives, who have their own leadership and management section on the Improvement Map.

 Next steps

 The Improvement Map is a flexible and customizable resource:

• It is a magnet for new knowledge and experience, a place for everyone interested in improvement to share what they are learning. For example, we are beginning to document the return on investment (ROI) for improving specific processes. However, most information about ROI has been calculated by individual hospitals or hospital systems for their own use and rarely makes it into the published literature.
• The Improvement Map is adaptable. We envision that hospital organizations and representatives of special hospital groups will make their own customized version of the Improvement Map (i.e., a map for rural hospitals).
• The pull is strong to expand the Improvement Map beyond hospital care. We know care that seamlessly crosses the health care continuum is critical to improving health, improving the individual experience of care, and reducing costs. As knowledge grows about processes that cross the continuum of care, the Improvement Map can grow to include these processes.

The Improvement Map is just a start. It is important to remember that we are not striving for perfection—we are hoping to provide a useful tool, one that balances precision and rigor with practicality. To keep the Improvement Map as accurate and helpful as possible we will seek input from experts and participation from the front line. We will strive to keep building the Improvement Map, which means it will never be complete or perfect. The Improvement Map, like a road map, shows the terrain that is on the way to better results. Taken alone, however, it only shows pathways. To get results, leaders will need to develop their goals, chart a course, and execute the improvements with skill. IHI and others will be there to help.

About The Author

Andrea Kabcenell

Andrea Kabcenell, RN, MPH, vice president of the Institute for Healthcare Improvement (IHI), is on the research and demonstration team and leads the initiative to improve performance in IHI programs. Since 1995, she has directed Breakthrough Series Collaboratives and other improvement programs, including Pursuing Perfection, a national demonstration funded by The Robert Wood Johnson Foundation designed to show that near perfect, leading-edge performance is possible in health care. Prior to joining IHI, Kabcenell was a senior research associate in Cornell University's Department of Policy, Analysis, and Management focusing on chronic illness care, quality, and diffusion of innovation. She also served for four years as program officer at The Robert Wood Johnson Foundation.