13/08/2017 1 NUR5326 Quality, safety and clinical governance in nursing and health care management Lecture 4 â€“ Planning for Improvement 1 2 Learning outcomes ï‚§ Determine the need for change ï‚§ Describe the difference between change and improvement ï‚§ Assess readiness for change and improvement ï‚§ Describe the Model for Improvement ï‚§ Identify methods for determining underlying causes ï‚§ Identify key steps in undertaking root cause analysis of adverse events 3 Why change? http://www.goalsandachievements.co.uk/blog/theâ€upsideâ€ofâ€change/ 13/08/2017 2 4 Is a change an improvement? ï‚§ It can only be an improvement if we know the change has improved something â€“ Danger of no real change (ie more or less neutral) â€“ Danger of something else being adversely affected â€“ Danger of any improvement lapsing ï‚§ Improvement is a process â€“ What needs to change and why? â€“ What measures might ensure that we know the change is an improvement? â€“ Will people agree to change? 5 Readiness for change and improvement ï‚§ Based on early research on the adoption of new ideas:1 â€“ About 20% of people will be very open to change and embrace it easily â€“ About 20% will be completely resistant â€“ Remaining 60% will not be completely for or against the change ï‚§ 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 â€“ diffusion of innovations ï‚§ Relative advantage â€“ Perceived as better or more advantageous will tend to decrease uncertainty (1) ï‚§ Compatibility â€“ Perceived as more compatible with values, past experiences and current needs of will tend to decrease uncertainty ï‚§ Complexity â€“ Perceived as complex or challenging will tend to increase uncertainty (2) ï‚§ Trialability â€“ Degree it can be trialled or rolled out in stages will tend to decrease uncertainty ï‚§ Observability â€“ Degree it can be visualised and explained will tend to decrease uncertainty 13/08/2017 3 7 Questions? 8 Change models and project development 9 Lewin â€“ 3-step model of change ï‚§ Unfreezing â€“ need for change â€“ Guide people out of their â€˜comfort zoneâ€™ and preparing for change â€“ identifying current challenges / deficiencies and relative benefits / advantages of new systems / practices ï‚§ Moving â€“ implementing change â€“ Developing ways of implementing the change, perhaps through trial and error â€“ Opportunity for collaboration and teamwork ï‚§ Refreezing â€“ sustaining change â€“ New systems or practices become the standard or norm â€“ Compatible with the values, experiences and needs of stakeholders 13/08/2017 4 10 Kotter â€“ 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 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 13/08/2017 5 13 Clinical practice improvement project ï‚§ Clarify the problem â€“ what is it and how do you know it is a problem? ï‚§ Establish the project team â€“ small enough but diverse enough ï‚§ Clarify the project governance â€“ The senior person or team to whom the project team is answerable ï‚§ What are you trying to accomplish? â€“ This is your aim statement (SMART) ï‚§ How will you know that the change is an improvement? â€“ What do you need to measure? ï‚§ What changes can you make that will result in an improvement? â€“ Test a change or a series of changes and implement what works best 14 SMART goal / objectives 1. Specific 2. Measureable 3. Achievable (though not without challenge) 4. Relevant 5. Time-framed Term Scope Measurement Goal Long term benefits (eg health gain) Outcome evaluation Objective Shortâ€medium term impacts (eg behaviour change) Impact evaluation Strategy Short term achievements (eg completed action) Process evaluation 15 Clinical practice improvement process http://www.cec.health.nsw.gov.au/programs/clinicalâ€practice 13/08/2017 6 16 Questions? 17 What is the issue or problem? ï‚§ Many health professionals are adept at â€œsolution jumpingâ€ â€“ Can work well in critical care situations â€“ Not always useful for determining causes of organisational, systems or process issues â€“ Can risk putting efforts into a potential solution insufficiently or not related to the underlying cause(s) and key leverage points ï‚§ Need to collect and analyse sufficient quantitative and qualitative data to establish potential causes and potential solutions â€“ Nature and extent of the issue or problem â€“ Consumer and staff understanding and expectations â€“ Available resources â€“ What others have done to address the issue or problem â€“ Prioritisation of potential solutions 18 Tools and methods for uncovering causal/contributing factors and leverage points ï‚§ Process flow diagram ï‚§ Customer grid ï‚§ Affinity diagram ï‚§ Nominal group technique ï‚§ Fishbone diagram ï‚§ Pareto chart ï‚§ Run chart ï‚§ Statistical process control chart ï‚§ Annotated SPC chart Diagnosing the problem Analysing the problem Evaluating the outcomes 13/08/2017 7 19 Process flow diagram ï‚§ Overall process (macro) and the more detailed stage under investigation (mini) â€“ even micro level analysis may be necessary ï‚§ Aim â€“ to clarify and understand (may be able to simplify or correct) No Yes Arrive at Macro grocery store Mini (detailed) Go to the cereal aisle Choose cereal Go to the cashier Pay for the cereal Review cereal placement Locate muesli Is your preferred choice there? Leave grocery store Review the different brands and ingredients Take a packet Make your choice Example â€“ buying a box of cereal 20 Example â€“ blood donor selection (before) Donor arrives at centre Donor interviewed & completes form Veins checked in waiting room Doctorâ€™s evaluation completed Donor goes to donor room Veins OK? Health OK? Nurse checks donorâ€™s veins Blood drawn from donor Yes Yes No No No Yes Donor rejected Veins OK? From the flow diagram above, it was revealed that donors could be rejected at 3 different steps. This was both complex and time consuming. 21 Example â€“ blood donor selection (after) Simple changes were made. With the doctor evaluating the donorâ€™s health and the condition of their veins, two steps in the process were removed. The process became simpler and less time consuming overall for the donors and the clinical staff. Donor arrives at centre Donor interviewed & completes form Doctor evaluates health & veins Donor goes to donor room Donor rejected Health & veins OK? Blood drawn from donor No Yes 13/08/2017 8 22 Customer grid ï‚§ Clarifying the â€˜customersâ€™ (stakeholders) involved in the process and assessing their needs (eg then conducting individual / group interviews) Direct Indirect Internal External From inside the organisation From outside the organisation Care about your performance Care about the overall outcomes 23 Affinity diagram ï‚§ Example: Why do we have ineffective meetings? 24 Fishbone dia
gram ï‚§ Organising and categorising ideas on primary and secondary causes, generated from brainstorming â€“ may include multi-voting to prioritise 13/08/2017 9 25 Fishbone diagram â€“ Infection NSW Health (2002). Easy guide to clinical practice improvement: A guide for healthcare professionals. North Sydney: NSW Health Department. 26 Fishbone diagram â€“ Pressure ulcers Main causes indicated in bold text Staff Equipment eg mattresses Working Environment Risk Assessment (Norton Scale) Culture (poor staff attitude) Lack of knowledge and skills Not user friendly (hard to understand) No follow up actions attached Lack of equipment Not taking responsibility for completion Eg mattresses, cushions Not relevant to every patient Not enough staff Workload too high Not enough time 27 Nominal group technique (NGT) ï‚§ Structured method of generating, listing and then prioritising ideas â€“ Focusses on every member having a say ï‚§ May use a whiteboard or flip chart 1. Facilitator defines and clarifies the issue/question 2. Team members are asked to individually generate ideas/responses (in larger groups, pairs or trios may form to discuss ideas/responses â€“ could also be asked decide on the three or four most important, for example, with each group feeding back) 3. Facilitator goes around the group and lists each idea/response (clarifying meaning, etc) 4. Facilitator would generally aggregate and number the items â€“ aggregate only with approval of the individual (pairs/trios) and the group as a whole 5. Team members are then asked to rank the items (importance, utility, urgency etc) 6. Facilitator may use any method of multi-voting, but a show of hands for the most important item first, then the second and so on can be very effective 13/08/2017 10 28 Pareto chart ï‚§ Based on the Pareto principle â€“ 80% of wealth owned by 20% of people 29 Run chart ï‚§ A line chart showing variation in performance over time 30 Run chart with control limits (SPC chart) ï‚§ A run chart with control limits (two standard deviations here) Mean + (2 x SD) Mean â€ (2 x SD) 13/08/2017 11 31 Questions? 32 Annotated SPC chart ï‚§ An SPC chart with explanatory annotations (eg showing interventions) 33 Trends ï‚§ We would normally want to look carefully at trends of 5 points or more 13/08/2017 12 34 Special cause variation ï‚§ In monitoring performance, we would want to investigate points ex-CL 35 Questions? 36 Root cause analysis (RCA) of adverse events ï‚§ A systematic, problem solving approach that aims to â€“ Identify the true cause(s) of an adverse event â€“ Determine actions necessary to ensure there will be no recurrence of the event ï‚§ Not appropriate for incidents involving criminal acts or requiring disciplinary action ï‚§ RCA investigation principles â€“ Needs to be undertaken as soon as possible after the incident â€“ Needs to focus on systems and processes, not individuals â€“ Needs to be fair, thorough and efficient â€“ Needs to focus on problem solving 13/08/2017 13 37 Key steps in an RCA 1. Define the event and determine its significance 2. Assemble a team of people with the relevant knowledge 3. Determine the sequence of events â€“ macro flow / affinity 4. Identify causal factors â€“ what, how and why (the â€˜five whysâ€™) 5. Determine the root causes â€“ Root cause statements are generally written as cause and effect statements â€“ Prophetic statements (predictions) can also be important 6. Develop actions and recommendations for service management 7. Implement required changes 8. Evaluate impact and effectiveness of changes RCA team 38 Key areas for identification of causal and contributing factors 1. Communication and flow of information 2. Knowledge, skills and competence 3. Work environment and scheduling 4. Patient factors 5. Equipment 6. Policies, procedures and guidelines 7. Safety and risk minimisation mechanisms 39 Five rules of causation 1. Causal statements must clearly show the â€˜cause and effectâ€™ link (ie between the cause and the unwanted outcome) 2. Use specific and accurate descriptors â€“ avoid vague or negative descriptors in causal statements 3. Each action cause must have a corresponding conditional cause â€“ identify the preceding cause rather than the human error 4. Each procedural deviation must have a preceding cause â€“ identify the preceding cause rather than the procedural violation 5. Failure to act is only causal when there was a pre-existing duty to act 13/08/2017 14 40 This week and next ï‚§ Starting with a review of the outcomes of an RCA â€“ the wrong patient â€“ Chassin & Becher (2002) ï‚§ Commencing an RCA on the administration of vincristine â€“ Part of video today â€“ Organise logistics and review key issues â€“ Workshop on undertaking the RCA all of next week 41 Questions? 42 Conclusion ï‚§ Quality improvement science relates to the application of a range of tools and techniques to: â€“ Identifying the need for change â€“ Measuring the effect of change strategies and interventions â€“ Ensuring that any change is an improvement ï‚§ In conducting improvement activities and investigations of adverse events, the focus needs to be on systems and processes, and causal and contributing factors as a basis for effecting improvement 13/08/2017 15 43 References Bohlen, J.M., Coughenour, C,M,, Lionberger, H.F., Moe, E.O. & Rogers, E.M. (1962). Adoption of new farm ideas: Characteristics and communications behavior. East Lansing: Michigan State University. Department of Health (2011). Root cause analysis (RCA) and risk reduction action plans (RRAP). Melbourne: Victorian Government. Retrieved from https://www2.health.vic.gov.au/Api/downloadmedia/%7B9E236439-7946-40AA-831CE2471052030D% 7D Kotter, J.P. (2007). Leading change: Why transformation efforts fail. Harvard Business Review, January, 1-10. 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 clinicianâ€™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.