Control: The Forgotten Phase

Making Lay-ups

March 09, 2009

A recent Wall Street Journal article on efforts to reduce hospital infections (Laura Landro, April 5, 2006) highlights the importance of nailing the Control phase of a DMAIC project — the often‐overlooked and under‐appreciated last step to sustaining improvement.

Many projects resemble running a fast‐break in a basketball game: the ball is rebounded, outlet pass made, ball advanced up the floor, lanes filled by players hustling down the court, and then — the lay‐up is missed. The Control phase is like "finishing" the fast break after all the other pieces are put in place. The shot may look simple, but it can't be taken for granted.

In the case of the Wall Street Journal story, the U.S. Centers for Disease Control (CDC) and the Institute for Healthcare Improvement have been pushing a seemingly simple solution to infection reduction — hand washing.

But like any effort to influence human behavior, merely issuing instructions is not sufficient. Institutionalizing the improvement requires compliance, and real compliance requires more than an updated policy manual. In spite of CDC efforts to share best practices and guidelines designed to stop the spread of infection from contaminated hands, "compliance rates remain mired at 40% to 50% nationwide, studies show" (WSJ).

Not a very reassuring statistic, is it? However, hospitals which employ active monitoring, positive reinforcement, punitive measures for repeat offenders, and collaborative design of the process and facilities have experienced much higher compliance rates in the 85‐95% range.

Here's a framework for thinking about the Control phase that might be useful — 5 attributes of a good control strategy based on 5‐C's:

1)Communicated — The process must be clearly and actively communicated, and should explain WHY the process is important. Communicating the WHY establishes the connection between cause and effect, and broadens organizational process knowledge. The best communication is pushed through multiple channels using different media in a visible way (audio, video, text messages, signage at point of use). Changing written procedures in a binder that nobody ever looks at does not change process behavior.

2)Confirmed — Understanding of the requirements should be actively confirmed by an assessment and check‐off. This eliminates later excuses like: "I didn't understand the requirements."

3)Convenient — The more convenient the process is, the higher the probability that it will be followed. Placing a hand‐washing station down the hall and up a flight of stairs means it won't happen very often. Returning to the WSJ article: "according to the Charles Huskins, an author of the IHI toolkit for hand hygiene and an infectious‐disease expert at the Mayo Clinic in Rochester, MN, compliance rates at Mayo hospitals were sharply improved, in part, because employees were allowed to test different alcohol hand rubs, and chose one with strong moisturizers to avoid irritation that might lead to discontinued use." Involving the operators of a process in the process design seems to always improve the result.

4)Compelling — Positive and negative incentives are necessary to both "pull" and "push" employees toward compliance. A compliance program with no teeth is just wishful thinking, not a compliance program.

5) Checked — Results must be monitored and measured in order to gauge success or failure, and provide feedback on the effectiveness of the first four "C's".

Try these 5‐C's and see if your lay‐up percentage doesn't go up.

You can read more about the CDC's hand‐washing guidelines, and find other related resources at: