Organizational change: challenges to infection prevention ... · Organizational change: challenges to infection prevention and stewardship Dr Mike Cooper Consultant Microbiologist

Organizational change:

challenges to infection

prevention and stewardship Dr Mike Cooper

Consultant Microbiologist and Director of Infection Prevention and Control, Royal Wolverhampton NHS

Trust, UK

Organizational Change

• Change is:

– inevitable

– necessary

• Change management

– (?)essential

Organizational Change

• Challenges for infection prevention and

antimicrobial stewardship:

– how to successfully implement change to

produce improvement?

– how to not become the victim of change?

Organizational Change

Countless theories on change and change

management:

• Examples:

– Kanter’s 10 Commandments for Executing

Change (1992)

– Kotter’s Eight-Stage Process for Successful

Organisational Transformation (1996)

– Luecke’s Seven Steps (2003)

Organizational Change

• Situation in healthcare similar to manufacturing industries in the 1980s: – competitive pressures required improvements in

product quality

– firms initially focused on technology

– quality improvement didn’t follow

– required changes to organizational structures and processes

• Transition from: “managing by imposing control” to “managing by eliciting commitment”

Organizational Framework

Nadler DA, Tushman ML. Organizational frame bending: principles for managing reorientation.

Acad Manage Exec 1989;3(3):194–204

Organizational Change

• Organizational change occurs as a planned response to a defined set of pressures or forces

• Basic choices that an organization confronts in managing this change:

– how is the change defined?

– who participates in the change process and how?

– how is change implemented?

– how is change institutionalized?

How is the change defined?

• Is change required in a few or many components? – “incremental change”

• minor / single factor change

• implemented without altering any organizational components

– “transformational change”

• System-wide improvements require coordinated changes in multiple components: – clinical procedures, attitudes and behaviours of care

providers, incentive systems, coordination structures and processes, patterns of interactions among care providers, organizational culture

• Different responses to the same pressures may be equally effective

Who participates in the change

process and how? • Successful change requires different organizational

groups to play distinct roles in the change management process: – senior leadership (medical and administrative)

• active, visible role in initiating change, and providing a vision of what needs to be achieved

• energize the change process

– CEO - establish a guiding coalition for change: • includes senior administrators, clinicians, and opinion leaders

from across the organization

– CEO and guiding coalition must create dissatisfaction with the status quo

• impart a sense of “urgency” about the proposed change

– other people involved directly in the care delivery process must participate actively in implementing change locally

Who participates in the change

process and how? • Can be challenging:

– “business as usual”

– senior physicians unaware of issue as remote from routine processes

– clinicians may only view serious harm as a significant issue

– clinicians may not completely understand or generally accept the need for change

– medical staff may view some changes, such as increasing interactions with nurses, as inappropriate or unnecessary

• CEO and the guiding coalition must shatter these assumptions – e.g. information on near misses presented regularly to the

medical staff

• CEO and members of the guiding coalition must visibly participate in the change process – helps to “model” desired changes in behaviours

How is change implemented?

• Two basic features are associated with successful change: – dedicated support structures

• implementation group

• pilot test site

• communication channels

• innovative training programmes

• encourage visits to successful organisations

– multiple tactics required • active participation of members of the guiding coalition in the

supporting structures

• frequent review by hospital administrators and senior medical staff

• facilitating reporting systems

• facilitating working across grades / specialties / disciplines

How is change institutionalized?

• Even if implemented successfully, there is a risk of reversion to earlier behaviours – unable to afford the resources allocated to initiating the change

– organization facing new pressures diverting senior leaders’ attention

– turnover among key employees

• The aim of institutionalization is for the change becomes a robust feature of the organizational context (i.e. part of culture) – needs a formal, long-term plan that integrates multiple

interrelated strategies • commitment of the CEO and senior staff to protect the initiative from

competing priorities

• structural changes that reinforce the change

• roles redesigned to match the new organizational realities

• adapt to emerging and unexpected demands

• leaders must continuously monitor the ongoing change process

Organizational Change

Countless theories

on change and

change

management

Organizational Change

Countless theories

on change and

change

management

Don’t be a victim of organizational

change

• How to predict outcome of changes?

– structured / planned

• buildings / facilities, populations, services

(investigations, treatments / therapies, etc),

administration / management, etc

– subtle / unplanned

• population, cultural, external factors, etc

Don’t be a victim of organizational

change

• Ensure involved in all projects that might

have an impact

• Can never be aware of all changes in

advance

• Impossible to predict and compensate for

all potential consequences of change,

even with advanced knowledge of the

change

Don’t be a victim of organizational

change

• Therefore must constantly monitor for

effects of change

• Surveillance:

– collect data

– analyse data

– understand data

– trust data

– act on findings

Don’t be a victim of organizational

change

• Surveillance for infection prevention:

– alert organism

– alert condition

– audits of practices

– environmental audits

– etc.

• Surveillance for stewardship:

– antimicrobial prescribing

– resistance patterns of pathogens

– etc.

0

1

2

3

4

5

6

7

8

9Ja

n-1

0

Mar-

10

May-1

0

Jul-

10

Sep-1

0

Nov-1

0

Ja

n-1

1

Mar-

11

May-1

1

Jul-

11

Sep-1

1

Nov-1

1

Ja

n-1

2

Mar-

12

May-1

2

Jul-

12

Sep-1

2

Nov-1

2

CABG

Valve

Cardiac (other)

Su

rgic

al S

ite

Cardiac Surgical Site Infection

0

2

4

6

8

10

12Ja

n-1

0

Mar-

10

May-1

0

Jul-

10

Sep-1

0

Nov-1

0

Ja

n-1

1

Mar-

11

May-1

1

Jul-

11

Sep-1

1

Nov-1

1

Ja

n-1

2

Mar-

12

May-1

2

Jul-

12

Sep-1

2

Nov-1

2

Total

Su

rgic

al S

ite

Cardiac Surgical Site Infection

0

2

4

6

8

10

12

14

Jan-M

ar

10

Apr-

Jun 1

0

Jul-

Sep 1

0

Oct-

Dec 1

0

Jan-M

ar

11

Apr-

Jun 1

1

Jul-

Sep 1

1

Oct-

Dec 1

1

Jan-M

ar

12

Apr-

Jun 1

2

Jul-

Sep 1

2

Oct-

Dec 1

2

SSI…

Su

rgic

al S

ite

Cardiac Surgical Site Infection Rates -

Is there a problem?

• Not just increase in infection rate:

– increase in early onset (pre-discharge) SSIs

– increase in sternal wound infections

– increase in deep and organ/space SSIs

What had changed?

• No change in:

– theatres

– surgeons

– skin prep

– etc.

What had changed?

• Cardiac anaesthetists unhappy giving local recommended antimicrobial prophylaxis:

flucloxacillin 1 g qds for 4 doses

+

gentamicin 5 mg/kg (LBW) – single dose

• Started giving 3 mg/kg gentamicin – thought it was contributing to post-op AKI

– decision to implement change made amongst themselves

– not discussed with microbiologists (or surgeons)

0

2

4

6

8

10

12

14

Jan-M

ar

10

Apr-

Jun 1

0

Jul-

Sep 1

0

Oct-

Dec 1

0

Jan-M

ar

11

Apr-

Jun 1

1

Jul-

Sep 1

1

Oct-

Dec 1

1

Jan-M

ar

12

Apr-

Jun 1

2

Jul-

Sep 1

2

Oct-

Dec 1

2

SSI…

Su

rgic

al S

ite

Cardiac Surgical Site Infection Rates -

0

2

4

6

8

10

12

14

Jan-M

ar

10

Apr-

Jun 1

0

Jul-

Sep 1

0

Oct-

Dec 1

0

Jan-M

ar

11

Apr-

Jun 1

1

Jul-

Sep 1

1

Oct-

Dec 1

1

Jan-M

ar

12

Apr-

Jun 1

2

Jul-

Sep 1

2

Oct-

Dec 1

2

SSI…

Su

rgic

al S

ite

Cardiac Surgical Site Infection Rates -

Summary

• Embrace change

• Use change

• Be in a position to detect change

• Communicate!