For Healthcare Quality Week, try turning a few familiar quality practices on their heads.

October 18–24 is Healthcare Quality Week, an opportunity to recognize the professionals who lead quality and safety efforts—and the clinical and operational teams who put improvement into practice every day.

Quality improvement isn’t new. Behavioral health organizations have been reviewing incidents, auditing performance, implementing corrective actions, and monitoring compliance for decades.

So, rather than revisit the usual quality topics this year, we’re offering three different ways to look at familiar problems. Each can be used to freshen up your next quality meeting, challenge an assumption, or help your team see an old issue through a different lens.

1. Your Policy Says One Thing. Your Staff Do Another. Which One Is Your Quality Program Measuring?

We tend to assume that the written policy describes the process occurring in practice.

Sometimes it doesn’t.

Consider a routine process such as a handoff, client observation, treatment plan update, medication process, or discharge. The policy may clearly describe each step. An audit may even show that the required documentation is present.

But spend time with the staff actually doing the work and you may discover something different.

Perhaps staff added an extra step because the formal process wasn’t working. Maybe they found a faster way to communicate important information. Perhaps a required step is routinely delayed because it doesn’t fit the workflow. Or different programs have developed entirely different ways of accomplishing the same task.

Those differences matter.

Sometimes the staff practice is unsafe or noncompliant and needs to change.

But sometimes the policy is the problem. It may be outdated, unnecessarily complicated, disconnected from the technology now being used, or simply inconsistent with how care is actually delivered.

If your quality program audits only against the written policy, you may confirm compliance—or identify noncompliance—without understanding whether the process itself makes sense.

Try This

Choose one process where audit results have been inconsistent or staff compliance has been difficult to sustain.

Instead of beginning with the policy, ask frontline staff to show you exactly how they perform the process from beginning to end.

Then pull out the policy.

Compare the two and ask: Does practice need to change, does the policy need to change, or both?

That is a very different quality conversation.

2. Start Paying Attention to What Almost Happened

Quality programs understandably devote significant attention to adverse events.

But some of your best improvement opportunities may be events in which nothing happened.

A staff member catches the wrong medication before it reaches a client. Someone notices an environmental hazard before it causes harm. A communication breakdown is recognized just before it affects care. Staff intervene before escalating behavior results in an injury.

Those are near misses.

It can be tempting to breathe a sigh of relief and move on. Instead, consider them free lessons.

A near miss gives the organization an opportunity to identify a vulnerability without the consequences of an actual adverse event.

There is another benefit. When staff know that identifying a near miss is valued—not viewed as admitting a mistake—they can become an important source of quality and safety information.

Try This

At your next quality meeting, don’t start with:

“What went wrong this month?”

Start with:

“What almost went wrong—and who caught it?”

Recognize the catch. Then look at the process that allowed the near miss to occur.

You may uncover risks that traditional event reporting hasn’t shown you yet.

3. Before You “Reeducate Staff,” Make Sure Education Is the Fix

Read enough corrective action plans and one phrase begins to look very familiar:

“Staff were reeducated.”

A required assessment is missed. Staff are reeducated.

Documentation is incomplete. Staff are reeducated.

A surveyor identifies a deficiency. Staff are reeducated.

Sometimes education is exactly the right response. Sometimes it isn’t.

If staff didn’t know the requirement, education may address the problem.

But if they knew exactly what they were supposed to do and the process still failed, another in-service is unlikely to address the underlying cause.

The workflow may be unnecessarily complicated. Responsibilities may be unclear. Technology may make the correct process difficult. Two policies may conflict. Staffing or workload may contribute. Or staff may have developed a workaround because the official process doesn’t work well in practice.

• A knowledge problem may need education.
• A skill problem may require training and competency validation.
• A process problem may need redesign.
• An accountability problem may require clearer ownership.
• A system problem may require a system solution.

The corrective action should match the reason the process failed.

Try This

Pull five corrective action plans from the past year. Circle every instance of “education,” “reeducation,” “reminded,” or “counseled.”

Then ask:

Did we establish that lack of knowledge caused the problem?

If not, reconsider the corrective action.

And check whether the same problem occurred again. That may tell you whether your “fix” actually fixed anything.

Three Small Changes—A Different Quality Conversation

These ideas don’t require another committee, dashboard, or quality initiative.

They simply change the conversation:

• Policy vs. practice: Are we measuring what the policy says should happen—or understanding what actually happens?
• Adverse event vs. near miss: Are we learning only after something goes wrong—or also from the times someone catches it first?
• Corrective action vs. root cause: Are we fixing why the problem happened—or simply reeducating everyone?

For Healthcare Quality Week, pick one and try it.

Key Takeaway

Quality improvement doesn’t always require a new methodology or more data.

Sometimes it starts by challenging an assumption: that the policy is right, that no harm means no problem, or that education is the answer.

Those assumptions are worth testing.

The Barrins Perspective

During our consultations, some of the most useful findings come from looking beyond the documentation to understand how care and operational processes actually work.

Policies, audits, incident reports, and corrective action plans are important. But sustainable improvement requires understanding the gap between policy and practice, learning from vulnerabilities before they cause harm, and matching the corrective action to the actual cause of the problem.

Apply These Practices

Bring one of these three challenges to your next quality meeting:

1. Find a policy that doesn’t match practice.
2. Discuss a near miss instead of an adverse event.
3. Challenge a corrective action that relies on reeducation.

Give your team 15 minutes.

You may learn more from that conversation than from another hour reviewing the dashboard.