From the start, quality leaders and the healthcare quality workforce have played a vital role in Lifespan’s strategic initiative to deliver operational excellence. The drive for operational excellence has produced major process and performance improvements and saved $12 million in four years for Rhode Island’s largest health system, with current projects expected to save another $7.5 million.

In identifying key improvement opportunities, Lifespan’s quality leaders and professionals turned their attention to their own function in the organization. That scrutiny initiated “the journey, working closely with the National Association of Healthcare Quality, in totally transforming our quality structures and processes across our organization as well as elevating the competencies of our healthcare quality workforce,” said Cathy Duquette, PhD RN NEA-BC CPHQ FNAHQ, Lifespan’s executive vice president of nursing affairs who co-leads, with the executive vice president of physician affairs, systemwide operational excellence efforts.

Building blocks of structure and process

To emphasize the need for quality to underpin operational excellence, Lifespan’s CEO created two new system-level executive vice president positions and appointed a nurse (Duquette) and a physician to set system quality, safety and patient experience strategy. Charged with achieving operational excellence, Lifespan’s new quality leaders first set out to understand the current state of quality efforts.

They used an eight-step process, with the initial phase focused on gathering information to determine the best quality structure and processes:
  1. Identify core quality functions within the system
  2. Evaluate the current quality structure for efficiency and effectiveness
  3. Identify and address gaps and needs

The assessment exposed shortcomings, such as  no quality professionals focused on ambulatory care even though it represented 60% of Lifespan’s services. The findings led Lifespan to reorganize quality reporting structures and processes. The health system:

  • Created a quality leadership dynamic similar to system leadership, with chief nursing officers and chief medical officers co-leading quality, safety and patient experience at their hospital, ambulatory center or other location
  • Moved from a completely decentralized system to a centralized quality organization, staff and core functions. In reengineering the quality structure, Lifespan took advantage of NAHQ resources, especially a 2013 white paper NAHQ co-authored with IHI called, “Quality Structures and Functions at Half the Expense”
  • Made Lean, Kaizen and Six Sigma practices and principles the foundation of all the quality work throughout the system
  • Required business cases to justify and set operational excellence priority projects. Quality professionals began working with Lifespan’s finance experts to develop data-driven, quantifiable estimated savings for operational excellence efforts

“Moving to a centralized quality structure has accelerated the improvement agenda and supported our aims toward better integration as a system,” said Nidia Williams, PhD MBB CPHQ FNAHQ, Lifespan’s vice president of operational excellence and NAHQ Competencies Commission Chair.

Investment to develop quality workforce competencies

Restructuring the quality organization to better align with operational excellence programs was only half the battle. Ensuring the quality workforce was up to growing challenges and responsibilities was equally critical.

For the second phase, Lifespan:
  1. Evaluated its quality workforce
  2. Defined competencies based on available resources
  3. Evaluated quality professionals against needed competencies
  4. Provided training, support and coaching to develop needed competencies
  5. Instituted periodic formal competency assessments

One major change was creating position descriptions that expanded the job scope from primarily task-driven to assigned accountability for achieving specific outcomes, Williams explained. Once exclusively generalists, all professionals are now required to become subject matter experts in one or more core quality functions and understand the other functions as well. Today, high costs – measured in the cost of healthcare delivery and lost or harmed human lives – are driving health systems toward quality as a solution. For quality professionals this means less generalists focused on retrospective measures and reviews, but more specialization to solve the problems of today and tomorrow.

Lifespan relied on NAHQ’s HQ Essentials guide to specify the advanced quality competencies essential to becoming a subject matter expert. “What we saw as a jewel,” Williams said. “It was an opportunity to use these industry-elevating competencies to really help inform the workforce that we had just started developing. We had our position descriptions, but now we had something we could use to help better define the skills and competencies that our workforce had to acquire or possess.”

To support the transition, Lifespan provided extensive education and training to help its quality workforce master necessary competencies and meet heightened requirements, including training in Six Sigma, TapRoot root-cause analysis and Failure Modes and Effects Analysis (FMEA), plus certifying as a Lean Green Belt.

Investing in its quality workforce to raise performance and build competencies was a necessity rather than a nice-to-have, noted Duquette: “Our healthcare quality professionals are critical in driving much of the work we need to accomplish on more than half of our (10) areas of strategic focus. So as a business imperative, having a highly qualified and competent healthcare quality workforce is critical.”

To learn more about competency-based training and workforce development, please contact NAHQ at

– Cathy Duquette, PhD RN NEA-BC CPHQ FNAHQ

Executive Vice President, Nursing Affairs

– Nidia Williams, PhD MBB CPHQ FNAHQ

Vice President, Operational Excellence

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