Lesson 1 - Hospital Engagement Network

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Dec 14, 2013 (3 years and 7 months ago)

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Wednesday, August 21, 2013




1

Virtual Session #1 Track 2:

The Human Side of Change

By Robert Lloyd, PhD & Dave Williams, PhD

Institute for Healthcare Improvement

Kim
Werkmeister
, RN, Cynosure

Robert Lloyd

Robert Lloyd, PhD

is Executive Director of Performance Improvement for the
Institute for Healthcare Improvement (IHI). Dr. Lloyd provides leadership in
the areas of performance improvement strategies, statistical process control
methods, development of strategic dashboards and building capacity and
capability for quality improvement. He also serves as lead faculty for various
IHI initiatives and demonstration projects in the US, the UK, Sweden,
Denmark, New Zealand and Africa. Before joining the IHI, Dr. Lloyd served as
the Corporate Director of Quality Resource Services for Advocate Health Care
(Oak Brook, IL). He also served as Senior Director of Quality Measurement for
Lutheran General Health System (Park Ridge, IL), directed the American
Hospital Association's Quality Measurement and Management Project
(QMMP) and served in various leadership roles at the Hospital Association of
Pennsylvania. The Pennsylvania State University awarded all three of Dr.
Lloyd’s degrees. His doctorate is in agricultural economics and rural sociology.
Dr. Lloyd has written many articles and chapters in books. He is also the co
-
author of the internationally acclaimed book, Measuring Quality Improvement
in Healthcare: A Guide to Statistical Process Control Applications (American
Society for Quality Press, 2001, 5th printing) and the author of Quality Health
Care: A Guide to Developing and Using Indicators, 2004 by Jones and Bartlett
(Sudbury, MA).

Dave Williams




David M. Williams, PhD,

Improvement Advisor,
truesimple

Consulting, is also on the teaching faculty of The George
Washington University School of Medicine and Health Sciences.
He is also a Six Sigma Black Belt and serves as faculty and an
Improvement Advisor (IA) for the Institute for Healthcare
Improvement, supporting teams through leading system changes
using the Model for Improvement. Dr. Williams started his career
as an urban street paramedic. For the last decade, he has acted as
an internal and external IA to governmental agencies, hospitals,
and for
-
profit and not
-
for
-
profit organizations. He works with
clients to improve their organizations by enabling appreciation of
systems, understanding of data and variation, testing changes,
and recognizing the influence of psychology. He has published
nearly 100 articles, led intensive workshops, presented at major
conferences to thousands of attendees, and writes a popular blog.



Kim
Werkmeister




4

Kim
Werkmeister
, RN, BA, CPHQ
i
s
a National Improvement Advisor
working with the American Hospital Association / Health Research
Educational Trust Hospital Engagement Network (HEN
).
As an
Improvement Advisor, she is responsible for working directly with State
Hospital Associations to drive improvement in hospital acquired
conditions and patient harm in hospitals across the country.

In
addition,
she is
the lead Improvement Advisor for the Hospital Engagement
Network for the Perinatal Harm initiative, the VTE Reduction initiative and
the Psychiatric Affinity Group initiative.


Prior to this, Ms.
Werkmeister

worked with hospitals across California to
improve patient outcomes, implement best practices, set up Quality/Risk
programs, and prepare for and respond to licensing and accreditation
activities. She served as an improvement advisor for both the California
Public Hospital Improvement Collaborative and the California Partnership
for Health/Patient Safety First Collaborative. She also served as the lead
improvement advisor for the ICU Mortality Reduction Collaborative, a
project focusing on reduction of mortality and morbidity in ICU care
across the state of California.


Ms
.
Werkmeister

is a Registered Nurse and graduated with a Bachelor of
Arts degree from California State University Fullerton
.

Where are you today?




5

Discussion Topics


The critical role of Human Behavior in improvement


Everett Roger’s adoption & diffusion journey


Kurt
Lewin’s

unfreezing to refreezing journey


Personality profiles & communication

Note that the material addressed in this session draws heavily upon the
IHI Open
School
pre
-
work assignments. If you have not completed QI 105 Lessons 1 & 2
please take time to do so after this session.

The Sequence of Improvement

Spreading a
change to other
locations

Developing a
change

Implementing
a change
(HTG)

Testing a
change

Act

Plan

Study

Do

Theory and
Prediction

Test under
a variety of
conditions

Make part of
routine
operations

Source: Robert Lloyd, IHI 2013

Spreading a
change to other
locations

Developing a
change

Implementing
a change
(HTG)

Testing a
change

Act

Plan

Study

Do

Theory and
Prediction

Test under
a variety of
conditions

Make part of
routine
operations

Source: Robert Lloyd, IHI 2013

The Sequence of Improvement requires an
understanding of
H
uman
B
ehavior

Deming on the role of Psychology

“Psychology helps us to understand people,
interaction between people and
circumstance, interaction between
customer and supplier, interaction between
teacher and pupil, interaction between a
manager and his people and any system of
management.”

W. Edwards Deming,
The New Economics
, 2000, page 107

Important Concepts from

Psychology and Change Management

Differences in people:


Motivations


Preferences


Aspirations


Learning styles


Beliefs, Values & Culture

Most changes aimed at improvement will have to recognize the
differences in people and account for them.

See Appendix A for details on these differences

Opening Dialogue on

Human Behavior


So how have your interactions gone?


Consider for a moment, the impact of human behavior on your
HEN improvement efforts.

1.
What
has
worked
well
?

2.
What
has
not worked
so well
?

3.
What
will you
do differently

as you move forward
?


Type your reflections into the Chat Box.

Pursuing Perfection for VTE

Jane Northcutt, RN

Chief Quality Officer

Hospital Overview


Located in Birmingham, Alabama


One of 15 General Acute Care Hospital Providers
in the Birmingham MSA (4
-
County)


Licensed Beds
-

534


17

Rehabilitation Beds


64

Psychiatric Beds


Employees
-

1,686


Physicians & Allied Health on Staff:


698


Population for Primary Service Area
-

437,957


Population for Secondary Service Area
-

608,771







VTE
-

HEN

Specific Run Charts

Aim
?
:

By December 2013, 100%
of patients will receive VTE
prophylaxis by defined protocols,
patient assessments or have
documentation of contraindications.

Important
?

VTE is the #1
preventable cause of death in
hospitalized patients.

Aim Statement

Changes Being Tested,
Implemented or Spread

Recommendations and
Next Steps

Lessons Learned

Run Charts


Assessment of patients for VTE
prophylaxis is completed for
Inpatients and ICU patients
.


Protocols are implemented timely.


VTE Discharge Instructions are
completed.


Patients requiring overlap therapy are
identified with measures
implemented.


Surgery patients are assessed for
appropriate prophylaxis.



Build in discharge documentation tools in
electronic system to populate on all patients.


Identify patients from radiological studies for
identification of needed overlap therapy and have
PharmD review for appropriate coverage.


Set required timeline actions before the timeline
actually ends.


Order set with physician to design with physician
driven education to medical staff.


Use PI Referral Form for staff involved to
document why variance occurred and lesson
learned.

Project Title:
Reducing
VTE by Improved compliance with VTE Measures

Date
:
8/10/2013

Hospital Name:
Trinity Medical Center
State:
Alabama


© 2012 Institute for Healthcare Improvement

Team Members

Self Assessment Score =

_5__



Re
-
assess protocols and current actions
with identified variances.


Evaluate effect of new electronic clinical
documentation on compliance
.

CQO

Core Measure Analyst

PharmD

Physician Liaison

Director of Surgical Services

CNO

ICU Nursing Director

Med
-
Surge Nursing Director

Medical VTE Prophylaxis

Lesson 1: Overcoming Resistance to Change Course:

QI 105: The Human Side of Quality Improvement

Many People Don’t Like Change

Have
you ever walked into your house or office and discovered that something is different?
Maybe your roommate rearranged the furniture. Maybe your spouse repainted a wall. How did
you feel? If you are like most people, you were probably a little bit annoyed, a little bit frustrated,
and maybe even anxious to undo the change. Needless to say, you probably didn't jump right in
and embrace it.


Change
in health care is not perceived all that differently from change in any other context. When
organizations make changes to care processes, procedures, and policies


even if those changes
are improvements


the people involved with those processes, procedures, and policies are
often a little bit annoyed, a little bit frustrated, and maybe even anxious to figure out a way to go
back.



When we talk about change and improvement, we often focus on the numbers, the processes,
and the graphs. And we sometimes forget the people. In this lesson, you will learn about barriers
to change as well as different ways that people might respond to change in a social system. You’ll
also be introduced to a basic model of change that includes unfreezing the old way we do things,
moving to the new way, and then refreezing the way we want the future to be.

So what does change look
like?

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Add Text Subtitle


Add Text, Graph, Picture

So what does change look
like?

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Add Text, Graph, Picture

Add Text Subtitle


Add Text, Graph, Picture

Lesson 1: Overcoming Resistance to Change Course:

QI 105: The Human Side of Quality Improvement

Your Turn


Think back to a time when you were confronted with a new process in a familiar
setting. Maybe you were asked to swipe a card, rather than insert cash or tokens,
when boarding the bus or train. Or maybe your entire country switched off analog TV
broadcasting, making it impossible to watch your favorite show without a digital
converter box.


Once
you’ve got a process in mind, write down your answers to the following
questions:

1.
What emotions did you experience when first presented with this change?

2.
Did you resist embracing the change? If so, what were the reasons?

3.
At what point did you accept the change, if ever? What factors helped you accept
it?

Enter your response to each question into the Chat Box.

Source: IHI Open School, QI 105 Lesson 1

Reasons for Resistance to Washing
Your Hands with Hand Sanitizer

Did your list include any of the following reasons?


“Hand washing is incredibly basic. I don’t see why I need a special policy to
tell me how to wash my hands.”


“What’s wrong with regular soap and water?”


“There’s no way I’ll remember to use the sanitizer. Things are just too busy
and this change is not a priority.”


“That alcohol
-
based stuff is going to dry out my hands.”


“With all I have to do, I just don’t have time to use the sanitizer before
every patient visit.”


“I bet the dispensers won’t be located in a convenient place.”


“This sanitizer stuff is just a marketing gimmick.”


“This is just another new policy that’s here today, gone tomorrow.”

Source: IHI Open School, QI 105 Lesson 1

Let’s consider two of these reasons for
resistance

In
his book
The Limits of Organizational Change (Tuscaloosa: University of Alabama Press;
1971
)
,
Herbert Kaufman identified a number of barriers that can affect the implementation of
significant change in health care, including the following:


The expected autonomy or independence of health care workers
: Often, health care
professionals perceive themselves as single providers working independently to provide patient
care. If a health care provider feels a change may reduce or alter that autonomy, he or she may
be reluctant to embrace a change.


Example: “Hand washing is incredibly basic. I don’t see why I need a special policy to tell me
how to wash my hands.”


Stability that comes with routine:

Routines such as standard operating procedures, certain
recurring behaviors, or institutionalized ways of communicating create stability for people. This
is reflected in the common statement, "We've always done it this way, and I’m comfortable
with it, so why change now?"


Example: “What’s wrong with regular soap and water?”

Source: IHI Open School, QI 105 Lesson 1

Anticipating Barriers to Change

As a reminder, the following are some of the barriers we considered for
adopting the new hand hygiene policy and potential responses to these
barriers:


Barriers


“Hand washing is incredibly basic. I don’t see why I need a special policy
to tell me how to wash my hands.”


“What’s wrong with regular soap and water?”


Response

Provide education on the value of using hand sanitizer to reducing the
possibility of infection. Include evidence grounded in good research and
information on the growing numbers of hospitals relying on this new practice.


How Can We Foster the Adoption
of Successful Change Ideas?

The traditional approaches



Adoption is a SOCIAL thing!

A better
idea…

…communicated through a
social network…

…over
time

Diffusion of Innovations

(
1
st

edition1962)

A theory for understanding how people respond to innovation…

… and how to use those
responses to drive needed
change



Diffusion of Innovations
(1962)

An innovation, according to Rogers, is
“an idea, practice, or object that
is perceived as new by an individual or other unit of adoption.”


By this definition, the hand sanitizer example in this Open Scholl
Lesson is an innovation, regardless of how long hand sanitizer has
been on the market.


“If the idea seems new to the individual,”
Rogers wrote,
“it is an
innovation.”

And for many, washing their hands according to defined
practice with sanitizer is innovative, even though it is not a new idea.


Source: IHI Open School, QI 105 Lesson 1



How
Adopters
Adopt

1.
Awareness

2.
Persuasion

3.
Decision

4.
Implementation

5.
Confirmation

E. Roger’s Stages
of Adoption

Adopter Categories
See

(
see page 8 of QI 105 Lesson 1 for descriptions of the categories)

Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.



How Can We Foster Adoption of
Successful Change Ideas?

A somewhat more
sophisticated approach…

An Early Adopter

An Early Adopter



Adopter Exercise 1


Change 1: All primary care physicians should
be required to provide on
-
line consultation to
their patients.




Lets see where each of us would place our self
in the adopter curve:



Innovators, early adopter, early majority, late
majority or laggard




Adopter Exercise 2


Change 2: Each person in our country should
have a: “medical information” chip inserted
into their arm so they literally ‘carry their
medical history with them.”



Lets see where each of us would place our self
in the adopter curve:



Innovator, early adopter, early majority, late
majority or laggard




The “Tipping Point”

“The name given to that one
dramatic moment in an epidemic
when everything can change all
at once
.”





-

M. Gladwell


“The part of the diffusion curve
from about 10 percent to 20
percent adoption is the heart of
the diffusion process. After that
point, it is often impossible to
stop the further diffusion of a
new idea, even if one wished to
do so.”





-

E. Rogers


Tipping
point

Valley Regional Hospital

Michael Lessard
,
RPh
, MBA

Director of Pharmacy

About Us



Critical
Access Hospital



7
Physician practices



General
and Ortho
surgeries



Infusion
Center



Home
Health division



JC
Accredited



Serving
about 24,000
residents


37

Aim?:
Reduce the incidence of
harm due to high
-
alert
medications by 50% by
December 2013.


Why is this project
important?:
Medications
are the most common
intervention in healthcare
but are also most commonly
associated with adverse
events in hospitalized
patients. At least 20% of all
harm is associated with
medication errors.


Aim Statement

Changes Being Tested,
Implemented or Spread

Recommendations and
Next Steps

Lessons Learned

Run Charts


Pharmacy dosing of
warfarin in all
Ortho/surgery patients


Pharmacy dosing of
warfarin as requested of
any other in
-
patients


Pharmacy monitoring of all
warfarin patients


Note in eMar when patient is
receiving no dose of warfarin


Set up order so pharmacy has
daily printouts for warfarin
patients


Note daily INR and wafrarin
doses in vital signs on emar so
MD/nursing have running view
of dosing

Project Title:
Reducing ADEs by Pharmacy Warfarin Dosing

Date:
6/10/2013

Hospital Name:
Valley Regional Hospital

State:
New Hampshire


© 2012 Institute for Healthcare Improvement

Team Members

Self Assessment Score =

_5__




Re
-
assess protocol for
elderly


Look at interaction
evaluation process

Michael Lessard, RPh

Michael Saracino, PharmD

Richard Martin, RPh

Pharmacist INR Clinic in Family
Practice

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
INR Therapeutic (2-3)
Therapeutic INR by Year

2009
2010
2011
2012
2013
Basic Model for Understanding the
Change Process

Kurt Lewin

(1890
-
1947)

So far in this lesson, we have discussed some common barriers to
change, and we have seen that not everyone adopts change at the
same time or in the same way. Being conscious of this behavior can
reduce your frustrations, and help you to work with the people
involved in the change process.


So how can an organization help different types of people adjust to
change?


Let’s take a look at one more model for understanding change in
organizations. This mode, proposed by the psychologist Kurt
Lewin
,
provides a simple way to understand the change process.


Lewin

proposed that organizational change occurs in the following
three stages:


1. Unfreezing

2. Change or transition

3. Freezing (or re
-
freezing)


In other words,
Lewin

suggests that in order to effect long
-
lasting
change, you have to recognize that people have to be loosened from
their old way, transitioned, and then molded into their new way.


It’s a conscious process that involves preparing people for change,
actually managing the change, and then working to ensure that the
change stays in place.



Lewin’s Change Model

(see
page
10
of QI 105 Lesson 1 for descriptions of the
stages)

Source: IHI Open School, QI 105 Lesson 2






I know I am motivated when …


I know I am lacking motivation when …


I know people are motivated when I see…


I know people are not motivated when I see …


I know the organization has de
-
motivated people when I see…




Stephen Brookfield,
Becoming a Critically Reflective Teacher

Lewin’s model requires and
understanding of Motivation!

Type your responses into the Chat Box

Motivation Assumptions Inventory

Lesson 2: What Motivates People to Change

QI 105: The Human Side of Quality Improvement

Using Assessment Tools to Understand Team Dynamics

There are many assessment instruments that can help the members of a
team better understand their individual strengths and preferences. For
instance:


StrengthsFinder

2.0


Myers
-
Briggs Type Indicator (MBTI)


Strength Deployment Inventory (SDI)


DiSC

Profile


Riso
-
Hudson Enneagram Type Indicator (RHETI)


Each tool is different and the decision of which tool to use, if any, often relies
on personal preference. Some tools require qualified professionals to
administer and interpret. Each tool takes a different look at people, but they
all offer a lens into understanding our diversity and openness to change.

Source: IHI Open School, QI 105 Lesson 2




44




45




46



Q
X

A = E

Adapted from General Electric’s approach to Six
Sigma quality improvement

An equation for achieving results…

Q
X

A = E

Quality
of a
Solution

X

Acceptance
of a Solution

=

Effectiveness
of a Solution

Adapted from General Electric’s approach to Six
Sigma quality improvement

An equation for achieving results…

The Primary Drivers of
Improvement

Will

Ideas

Execution

Having the
Will

(desire) to change the current state to one that is better

Developing

Ideas

that will
contribute to
making
processes and
outcome better

Having the
capacity to apply
CQI theories,
tools and
techniques that
enable the
Execution

of the
ideas

QI


Key Components
*


S
elf
-
Assessment




Will (to change)


Ideas


Execution


Low Medium High


Low Medium High


Low Medium High

*
All three components MUST be viewed together. Focusing on one
or even two of the components will guarantee sub optimized
performance. Systems thinking lies at the heart of CQI!

How prepared is your organization?

So, what
forces are
driving you
forward?

And what
forces are
holding you
back?

Driving Forces (+)


Restraining Forces (
-
)


Actions to reduce the Restraining Forces
:











Issue or Project: _______________________________________________

Force Field Analysis Worksheet

Deming on the role of
Psychology

“Psychology helps us to understand
people, interaction between people and
circumstance, interaction between
customer and supplier, interaction
between teacher and pupil, interaction
between a manager and his people and
any system of management.”

W. Edwards Deming,
The New Economics
, 2000, page 107


Appendix
A:

Key Points on
Motivation

1. Differences in People

Fact:
We each have our own preferences, aspirations,
motivations, learning styles.

Fact of Life:
Most changes aimed at improvement will have to
recognize the differences in people and account for them.


2. Behavior is Driven By Motivation

Fact:
Behavior does not often give us a clear window into
what is motivating someone’s behavior.

Fact of Life:
Understanding what is motivating someone rather
than relying on our interpretation of the behavior can help us
take appropriate actions to build commitment to change.


Appendix
A:

Key Points on Motivation
(
continued)

3. Fundamental Attribution Error

Fact:
We make this error when explaining or rationalizing our
behavior in terms of the situation while holding others
accountable for their own behavior.

Fact of Life:
It is often easier to blame people than to take a
hard look at how the system affects behavior
.


4
. Intrinsic and Extrinsic Motivation

Fact:
Commitment to an activity will decline as extrinsic
motivators are reduced or eliminated.

Fact of Life:
When a change is proposed, leaders need to
explain the

why
of the change in terms of the organization’s
values.


Appendix
A:

Key Points on Motivation
(
continued)

5. Attracting People to Change

Fact
:
Building commitment to change requires
leaders to understand that change involves
more than just the tangible and technical
aspects of an activity.

Fact of Life:
People will resist change if they do
not feel included or understand the benefits of
the change to the organization or to themselves.


What’s Next?


The next ILF session is scheduled on
September 11


We want to find out what topics you want to
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