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Ask These Four Questions Before Starting Any Improvement
Hospitalist Ryan Murphy and Value Engineer Luca Boi outline four questions to address at the outset of any improvement.

Case Study

Diane Liu, Pediatrician and Director of the Utah Pediatric Partnership to Improve Quality (UPIQ), works closely with clinical primary care teams to improve team-based asthma care in the community. The UPIQ team (including quality improvement specialists) observed that for some teams, improvement stalls or fails despite implementing evidence-based treatment plans and facilitating improvement of work processes. The reason? Despite every team having a physician champion, the ____ was missing. What's going on here?

Before you begin


onceptual models for improvement like PDSA, Lean, Six-Sigma/DMAIC, or the University of Utah Value Framework are useful tools that help one better understand a specific situation and craft sustainable improvements. But any improvement effort must go beyond the process of structured problem solving and address the behavioral inertia of change. Thinking through a few key questions at the beginning of the work can improve your chances at success (and save time later).

Based on many hard-learned lessons, we strongly encourage you to think through the below questions as early as possible in your improvement effort.

1. Ask yourself: Why do I care about this project? (Hint: You must care)

  • Why is this important to me?
  • Who will this help?

Whether you are assigned a project or identify a novel effort, it is important to identify why you believe this project is important. Any successful improvement effort requires a project leader who is personally invested in its success.

Reflect on your own personal experience. Often, individuals find inspiration in their local work environment—delays, bottlenecks, errors, harm, or just a better way to do something (The Seven Wastes can help). Look at the potential impact of your effort on others, whether it’s other members of your team or the patients you care for.

Bottom line: If you are not personally committed to solving the problem—if it is not a priority to you, why would it be a priority to anyone else? Project success starts with you.

2. Find a sponsor: Who will support this project?

  • Who do I report to? Would an additional sponsor be helpful?
  • How will this project impact my dept./div./unit/organization?

Even with the best intentions and a clear need for improvement, any effort without support can fail. A “sponsor” is a person in a leadership role who understands and supports your efforts. They can help provide necessary time and resources and remove barriers to implementation, including getting buy-in from unengaged stakeholders. Often, they can provide unique perspective on the role of your effort within the larger clinical environment.​​​​​​​

3. Find a shared purpose: Why should others care about this project?

  • Why should we do this?
  • How will this project impact the individual/team/system?
  • From the perspective of those you need to convince: What's in it for them?

Any improvement effort that changes a process affects others. These “stakeholders” can include patients, clinicians, staff, or even entire units or departments. They can be your ally and augment your efforts. Or, if not appropriately engaged, they can create roadblocks that ultimately sink your project.

Finding a “shared purpose”—a common thread—helps you succinctly communicate why your work is important and why others will also benefit from your project. All of your stakeholders have many activities competing for their time and attention. Why should they pay attention to your project? And why should they pay attention now?

Be respectful when approaching stakeholders, as everyone can offer a unique perspective. You will likely encounter a spectrum of responses, from passionate enthusiasm, to interest with some hesitation, to vigorous opposition. The more support you can engender from all of your stakeholders, the more likely you will find success.

4. Be patient-centered: How will this project improve care for patients?

  • Will this create a better experience for patients?
  • Will it lead to better outcomes?
  • Will it create more reliable or more cost effective care?

Ultimately, every improvement effort in healthcare should somehow benefit the patient, by directly or indirectly improving the quality or service of care or reducing waste and the costs of care. This concept is at the heart of Utah’s value equation.

It is sometimes difficult to see how any given improvement may benefit the patient, especially if your environment is not directly related to patient care. This is where your stakeholders and sponsors can provide perspective into the upstream and downstream processes that ultimately relate your efforts to patient care.


No improvement effort has unanimous support and limitless resources. Leading change within this reality is part of the hard work of improvement. The four questions above are alone insufficient, but absolutely critical to the success. Start thinking about these questions early and revisit them when you encounter challenges to the success of your project.

* Note: Measures are a critical component to any project, and we will address this in a future article. For now, if you, your sponsor(s) and enough stakeholders are invested—developing an appropriate measure is your next step.

Want to learn more?

*Originially published Apr. 19, 2019


Ryan Murphy

Hospitalist and Associate Editor, Accelerate, University of Utah Health

Luca Boi

Senior Consultant, Process Improvement, Analytics, Planning, Strategy and Improvement, Brigham and Women's Hospital

Diane Liu

Associate Chief Value Officer, Pediatrics, University of Utah Health

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