September 17, 2018

Does the word “agile” mean anything to you other than a synonym for quick, flexible and nimble? If not, then you probably haven’t heard of Agile, the project management methodology that’s beginning to help hospitals, physicians and caregivers, including anesthesia practitioners, address a range of clinical and operational concerns.

The approach originated in the software industry, and, like Lean and Six Sigma, which came from manufacturing, it is finding a place in healthcare.  This eAlert provides a short introduction to a project management and process improvement approach that anesthesia groups and institutions might find themselves using one day to enhance quality, safety, efficiency, change management and new system or process rollouts.

In our view, Agile might serve anesthesia practices as another potential tool, along with Lean, Six Sigma and others, to demonstrate commitment to continuous quality improvement (CQI) in meeting Joint Commission standards, such as the new pain management standards for ambulatory care, critical access hospitals and office-based surgery organizations that will go into effect in 2019.  Use of Agile methods to improve care might also help solidify facilities’ confidence in your group as an anesthesia services provider that delivers value by knowing how to respond and adapt to the needs of a quickly changing environment.

In simple terms, Agile is an iterative development methodology based on short, quick cycles, called sprints, that incorporate continuous feedback from users and build on lessons learned from previous sprints. Each iteration generates new insights that are used to move toward a desired goal. The results of one cycle serve as the starting point for the next cycle. 

As illustrated in the guiding principles of the Agile Manifesto, developed in 2001 by a group of 17 software developers, the approach is as much a culture and a mindset as a methodology. It emphasizes:

• An environment that lets people move out of their siloes and gives them the support they need to get the job done
• Early and continuous product delivery that produces tangible, working results with each iteration
• Work done by self-managed, multidisciplinary teams who regularly review and fine-tune their behavior
• Frequent face -to-face conversation as the most effective method of communication
• Processes that welcome and embrace change, even late in development

Traditional “waterfall” project management, by contrast, consists of sequential, linear phases in which progress flows downward from conception to initiation, analysis, design, construction, testing, production/implementation and maintenance. A new phase doesn’t begin until the previous phase is finished. But once a phase is finished, it can’t be repeated without repeating subsequent tasks. That can delay implementation if problems aren’t discovered until later in the process.

Agile is spreading across a broad range of industries. A Harvard Business Review article notes that National Public Radio employs Agile methods to create new programming, and John Deere uses them to produce new machines. According to a 2017 survey by the Project Management Institute, 71 percent of surveyed organizations reported using Agile approaches for their projects sometimes, often or always. Because it’s designed to tackle complex problems and respond to rapid change, proponents believe it holds promise for healthcare.

Agile Healthcare and Anesthesia

A 2015 review of 60 articles published in the International Journal of Health Care Quality Assurance suggests Agile’s potential to serve as a guiding principle for healthcare improvement. A 2017 paper from Sweden’s Karolinska Institute argues that Lean and Agile might be used alongside each other as complements, with Lean helping to improve efficiency and control costs, and Agile helping organizations respond flexibly to change and variations in demand. 

In a 2016 article in Becker’s Hospital Review, Chet Stagnaro of consulting firm Freed Associates writes that Agile can be particularly useful as a healthcare process improvement tool when an organization or department wants participation by stakeholders in developing a solution, when assessment and evaluation of the impact of a number of alternatives is needed, or when the organization does not have a hard deadline for a solution and has time to discover the solution through iterative work. He said the approach increases return on project investment by enabling the project team to deliver value to the business early in the project’s lifecycle.

An iterative and participatory process that enabled nurses and physicians to think and talk differently about hospital-acquired infections and hand hygiene resulted in the development of clinically relevant solutions for hand hygiene improvement in the operating room in a 2018 Swedish study.

Similarly, a group of global health specialists has used rapid cycles of iterative program improvement and early involvement of ground-level health workers and program beneficiaries to improve technology-based global health interventions in diabetes management and other areas. In an article in Global Health Action, they observe that many of the ideas that govern Agile software design are not necessarily specific to software development, but “reflect sound principles of rapid, cooperative, and flexible design that are broadly applicable to any unpredictable work environment.”

Anesthesia researchers at Massachusetts General Hospital developed a quality improvement initiative to decrease opioid prescribing after c-sections that incorporated an iterative review of discharge data. The initiative included patient counseling regarding expectations related to pain and the importance of nonopioid analgesics, along with shared decision-making in determining the number of opioids prescribed. The multiphase study, published in 2018 in Obstetrics and Gynecology, reported a 35 percent decrease in opioid prescribing and an increase in acetaminophen prescribing from 33 percent to 92 percent as a result of the initiative.

In a 2017 study in Applied Clinical Informatics, a team of anesthesia researchers at the University of Washington reported success with iterative methods to develop a clinical decision support system for the anesthetic management of pediatric traumatic brain injury patients undergoing urgent neurosurgery. The system automatically detected eligible cases and evidence-based key-performance indicators.  The system displays real-time messages indicating unwanted clinical events on the anesthesia information management system (AIMS) computer screen.

Researchers at a large community teaching hospital employed Agile software development methodology and a variety of user participation methods to develop an electronic clinical communication and collaboration platform in which 36 software releases were delivered over 24 months. According to the 2018 study, published in the International Journal of Medical Informatics, user involvement helped identify software defects, improve user interface design and pinpoint necessary changes to the scope of the project early on.

Agile methods appear to be finding their place in healthcare and are a trend worth noting for their growing use in the sector.  For more information, we recommend the Harvard Business Review article, “Embracing Agile.”

Has your practice used Agile methods?  Please let us know.  We would be very interested in hearing about your experiences.

With best wishes,

Tony Mira
President and CEO