27/08/2017 1 NUR5326 Quality, safety and clinical governance in nursing and health care management Lecture 6 – Planning for Improvement 2 2 Learning outcomes  Develop recommendations from causal statements  Apply the principles of change management  Identify the difference between approaches to short-term and long-term improvement project planning and implementation  Apply the principles of effective evaluation  Identify strategies for optimising sustainability 3 Recap – why change? http://www.goalsandachievements.co.uk/blog/the‐upside‐of‐change/ 27/08/2017 2 4 Is a change an improvement?  It can only be an improvement if we know the change has improved something  Improvement is a process – What needs to change and why? – What measures might ensure that we know the change is an improvement? – Will people agree to change? 5 Readiness for change and improvement  Based on early research on the adoption of new ideas:1 – About 20% very open to change and embrace it easily – About 20% completely resistant – Remaining 60% not completely for or against the change  Top five reasons people will resist change:2 1. Not aware of the reason for the change 2. Afraid of potential or real lay-offs as part of the change 3. Unsure if they have the necessary skills required for the proposed change 4. Comfortable with the current state 5. Afraid they will be asked to do more for the same or less pay. 1. Bohlen et al. (1962). Adoption of new farm ideas: Characteristics and communications behavior. East Lansing: Michigan State University. 2. Kotter et al. (1998). Harvard business review on change. Boston: Harvard Business School Press. 6 Rogers – diffusion of innovations  Relative advantage – Perceived as better or more advantageous will tend to decrease uncertainty (1)  Compatibility – Perceived as more compatible with values, past experiences and current needs of will tend to decrease uncertainty  Complexity – Perceived as complex or challenging will tend to increase uncertainty (2)  Trialability – Degree it can be trialled or rolled out in stages will tend to decrease uncertainty  Observability – Degree it can be visualised and explained will tend to decrease uncertainty 27/08/2017 3 7 What is the issue or problem?  Need to collect and analyse sufficient quantitative and qualitative data to establish potential causes and potential solutions – Nature and extent of the issue or problem – Consumer and staff understanding and expectations – Available resources – What others have done to address the issue or problem – Prioritisation of potential solutions 8 Tools and methods for uncovering causal/contributing factors and leverage points  Process flow diagram  Customer grid  Affinity diagram  Nominal group technique  Fishbone diagram  Pareto chart  Run chart  Statistical process control chart  Annotated SPC chart Diagnosing the problem Analysing the problem Evaluating the outcomes 9 Root cause analysis (RCA) of adverse events  A systematic, problem solving approach that aims to – Identify the true cause(s) of an adverse event – Determine actions necessary to ensure there will be no recurrence of the event  Not appropriate for incidents involving criminal acts or requiring disciplinary action  RCA investigation principles – Needs to be undertaken as soon as possible after the incident – Needs to focus on systems and processes, not individuals – Needs to be fair, thorough and efficient – Needs to focus on problem solving 27/08/2017 4 10 Smaller scale changes  Small to medium team or ward-based – Some simple process changes (eg administrative or practice issues) can be implemented readily by directive (I decide), with consultation (We discuss and I decide) or by consensus We discuss and We decide) – For others, a more structured approach such as the Model for Improvement is likely to be more effective – a change that is actually an improvement  Smaller-scale changes can be leveraged up for broader scale change – Spreading from one team, section or ward to other teams, sections or wards – Transferring and trialling in new contexts (eg from acute care to mental health, from community care to hospital care) 11 Model for improvement Plan Study Do Act What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement? 12 Plan-Do-Study-Act cycles Single test Multiple tests 27/08/2017 5 13 Clinical practice improvement project  Clarify the problem  Establish the project team  Clarify the project governance – The senior person or team to whom the project team is answerable  What are we trying to accomplish? – This is our aim statement (SMART)  How will we know the change is an improvement? – What do we need to measure?  What changes can we make that will result in an improvement? – Test a change or a series of changes and implement what works best 14 Clinical practice improvement process http://www.cec.health.nsw.gov.au/programs/clinical‐practice 15 Questions? 27/08/2017 6 16 Evaluating impact, spread and sustainability 17 Evaluating impact  Demonstration of effect – Statistical process control charts (better with annotations) – Statistically significant difference, but using 95% CIs (cf. p-values) is better, effect size is even better (eg Cohen’s d, regression or hierarchical modelling) – Clinical significance is important too – practical value or relevance of a change – Qualitative measures very worthwhile (eg clinician and consumer feedback, opinion) Width of CIs indicates degree of variation in data for each time period mean 18 Spread and sustainability  Spread – the process of actively disseminating improvement across care settings – Also called adoption or diffusion – Can be knowledge translation too Performance Project completion Before Now  Sustainability – ensuring gains are maintained beyond the life of the project – Must always be concerned about improvement evaporation 27/08/2017 7 19 Sustaining the gains  Standardisation of systems and processes – Consistent implementation of changes in day-to-day leadership and practice  Documentation – policies & procedures, protocols & guidelines – Ensuring consistency of direction, performance and accountability  Measurement and review – Provides evidence of change implementation and improvement – Enables review of impact and outcomes – Provides a basis for ongoing improvement (eg ‘tweaking’ processes and procedures)  Education and training – Change usually requires updating of knowledge and skills for key personnel – May include information provision, on-the-job training/coaching, workshops/seminars 20 Sustainability wheel (CEC, 2008) 21 NHS sustainability model Source: http://www.qihub.scot.nhs.uk/media/162236/sustainability_model.pdf 27/08/2017 8 22 Larger scale improvements 23 Larger scale change  Health services – Hospital or service-wide changes  Health systems – Health networks – State-wide services or systems  Broad-scale change with many components or multiple contexts – May need to consider utilising multiple smaller-scale change models 24 Lewin – 3-step model of change  Unfreezing – need for change – Guide people out of their ‘comfort zone’ and preparing for change – identifying current challenges / deficiencies and relative benefits / advantages of new systems / practices  Moving – implementing cha
nge – Developing ways of implementing the change, perhaps through trial and error – Opportunity for collaboration and teamwork  Refreezing – sustaining change – New systems or practices become the standard or norm – Compatible with the values, experiences and needs of stakeholders 27/08/2017 9 25 Kotter – 8-stage change process 1. Create a sense of urgency 2. Build a guiding coalition 3. Form as strategic vision and initiatives 4. Enlist a volunteer army 5. Empower staff by removing barriers 6. Generate short-term wins 7. Sustain acceleration 8. Sustain the gains 26 Other models  RAID – Review – Agree – Implement – Demonstrate  Four As – Antecedents – Analysis of options – Action on change – Aftermath of change 27 Questions? 27/08/2017 10 28 Key ingredients for successful change  Evidence of need for change – A clear rationale (which feeds into the urgency aspect)  Clear goal – SMART formulation especially useful  Leadership and teamwork – Consultation and collaboration  Working with those who are open to change (the 20-60 group) – Bringing everyone else along  Harnessing available resources – Doesn’t have to be costly  Demonstration of and sustaining impact – Clear evidence that the change is an improvement and will stick 29 Conclusion  Change requires a rationale – What is the evidence that change is needed?  The change needs to be worth the effort – What do we need to change? – How will we know that change will be an improvement?  The change needs to stick – How can we ensure the gains will be sustained? – Can we accept and plan for the ‘nuancing’ that may be required? 30 References Clinical Excellence Commission (2008). Enhancing project spread and sustainability: A companion to the ‘easy guide to clinical practice improvement’. Sydney: Clinical Excellence Commission. Retrieved from http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0007/258343/spread-and-sustainability.pdf Kotter international (2015). 8 steps to accelerate change in 2015. Seattle: Kotter International. Retrieved from http://kotterinternational.com/ebook/Kotter-8-steps-ebook.pdf Langley G.L., Moen R., Nolan K.M., Nolan T.W., Norman C.L. & Provost, L.P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd edn.). San Francisco: Jossey-Bass Publishers. NSW Health (2001). The clinician’s toolkit for improving patient care. North Sydney: NSW Health Department. Retrieved from http://www.scdhb.health.nz/uploads/File/Clinical%20Governance%20Training/Clinicians%20Toolkit%20NSW%20Health.pdf NSW Health (2002). Easy guide to clinical practice improvement: A guide for healthcare professionals. North Sydney: NSW Health Department. Retrieved from http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0005/286052/cpi- Easyguide.pdf NSW Health (2005). Checklist flip chart for root cause analysis teams. North Sydney: NSW Department of Health. Retrieved from http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0007/313297/rca-flipchart.pdf Rogers, E.M. (2003) Diffusion of innovations (5th ed). New York: Free Press.