How to Sustain Healthcare Process Improvement in Heterogenous Teams? Evidence from a Systems Dynamic Model

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This research investigates how to sustain process improvement (PI) initiatives in healthcare. Despite the abundant knowledge on PI, we know very little on why and how PI sustains over time. This is particularly true in the context of heterogeneous frontline teams of physicians and nurses with different operational characteristics such as attrition rates, skill sets, training, and goals. Our study builds a model that simulates the mutual, dynamic interaction of these stakeholders with each other and with processes with different characteristics in the presence of endogenous management prioritization. We build confidence in the model by calibrating it to data from PI teams at several family medicine clinics at a large US Midwestern healthcare system. The computational experiments performed using data from these teams yield several important insights for theory and practice. First, we find that process metrics, which are leading metrics related to the day-to-day functioning of the units, and outcome metrics, which are lagging metrics often tied to the unit's bottom line, are both critical for the functioning of the PI teams. Emphasizing one over the other can reduce sustainability while a mixed case in which one group of employees is incentivized to leading and another group to lagging can create a regime that is more effective in many scenarios. Second, we find that management interventions that improve short-term PI gains generally also reduce the likelihood of long-run sustainment. Third, we find that attrition and turnover among the team members affect sustainability of PI initiatives and reducing turnover for one class of employee, which attends lagging metrics, facilitates sustainment while reducing it for the other class, which attends leading metrics, can hinder sustainment. We conclude by discussing these implications to the practice of PI among healthcare teams.