Strategies to support change in your facility Susanne Salem-Schatz, Sc.D. Program Director, MA Coalition for the Prevention of Medical Errors HealthCare.

Strategies to support change in your facility

Susanne Salem-Schatz, Sc.D.

Program Director, MA Coalition for the Prevention of Medical Errors

HealthCare Quality [email protected]

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So far you have heard

Why it is important not to use antibioitics unless absolutely necessary;

How the high prevalence of asymptomatic bacteriuria in the elderly can lead to unnecessary antibiotic use;

Expert recommendations for when to test and when to treat a suspected UTI;

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I’m convinced…

Much of what we heard is not widely understood;

Long standing and habitual practices can actually harm the people we are trying to help.

Changing practices about urine testing and treatment of the elderly is a very reasonable thing to do.

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Time for change

Should be easy We know the right thing to do We intend to make a change We are sure others will follow suit when we share what we

have learned.

Not so fast Change is hard Intention is not enough

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Good news: we can help

1. Tools and strategies to support practice change (after lunch)

2. Proven organizational approaches to practice improvement Engagement strategies: from buy-in to ownership A quality improvement framework.

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Some facts

Knowing is not enough. Evidence of non-clinical influences on clinical

decision-making* It’s not just what you know, it’s who you

know.

*Salem-Schatz SR, Avorn J, Soumerai SB. Influence of knowledge and attitudes on the quality of physicians‘

transfusion practice. Medical Care, 1993;31:868-878.

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Problems & Opportunities Awareness Iceberg

4% known to top leaders

9% known to middle managers

74% known to supervisors

100% known to the front line & customers

Adapted from study conducted by Sidney Yoshida, Source: Keith McCandless

Action unleashed @ the front line

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Including front line staff:

Engages the very people “whose behavior needs to change to solve the problem” to identify existing solutions from within

Front line engagement & ownership can: elicit good ideas that account for day to day

realities suppress the “immune rejection response”

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Over and over we discovered staff who had better

practices. And staff helped develop even better ideas….

Jasper Palmer discovered a

better way to remove gowns and gloves

“…when a group of individuals becomes a ‘we’, a harmonious whole, they have reached as high

as humans can reach.”~ Albert Einstein, 1954

Gown Usage at Billings Clinic, MTJune 2003 through July 2008

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Harrington staff step up the fight against hospital acquired infections

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What you can do

Expand the circle of your conversation Don’t rely solely on train-the-trainer ASK about their experience

What do they know about the problem? What would they like to know? What keeps them doing the right thing 100% of the time? What ideas do they have that might help?

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The Model for Improvement

Study Do

PlanAct

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 improvement?

Setting Aims

Establishing Measures

Selecting Changes

*2001 Associates in Process Improvement

W. Edwards Deming

Study Do

PlanAct

100 percent of CDI patients will be on appropriate precautions (hand hygiene, gloves, gowns, etc)

• % of CDI patient rooms with precaution signage•% of staff donning gowns and gloves before entering•% of staff washing with soap and water

*2001 Associates in Process Improvement

Aim

Measures

•Engage staff in the improvement process•Understand barriers to good practice and come up with ideas for change•Share results with staff on units

Changes

Model for Improvement in Action

Study Do

PlanAct

PDSA: Small Tests of Change

Plan: • 1 small change to test• Predict what will happen• Decide on what data to evaluate test

Do: • Run the test• Document problems and observations• Organize your data

Study• Analyze your data • Compare results t your

predictions• Summarize what you have

learned

Act• Decide what to do next

• More testing? • Try something else?• Finalize the change?

Some tips for testing

Small tests of change Rule of 1

1 patient/resident – 1 staff person – 1 day Test over a short period of time

If they say weeks, think days If they say days, think hours \

PDSA Worksheet to plan your test Call for help!

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Planning your Changes (in your handouts)

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Using the model for improvement to prevent

transmission of CDI: How Franciscan Hospital for Children makes it work.

Improve Communication of Current Precautions Status: Cycle 1

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PLAN:

•Standardize location of signage•Store precautions signage in convenient location near/with PPE

DO:

•Installed sign holder outside room•Store one of each precaution signs in each sign holder

ACT: •Reduce size of signs; magnetize signs to attach to door frame•Reconsider signage storage options

CHECK:

•Sign holders too big for available space to accommodate 4 signs per room•Sign fit well in holders; concern sign holders will break from continual expansion to remove/replace signs

Improve Communication of Current Precautions Status: Cycle 2

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PLAN:

•Reduce sign size; magnetize•Store extra signs in folder attached to precautions cart DO:

•Created 4”X3” print area•Printed on magnetic sheets•Placed on metal door frame•Attached plastic folder to cart; filled with one of each precautions signs

ACT: •Investigate smaller other sign holders•Create signs to fit

CHECK:

•Sign was easily knocked off frame.•Signs were too small.

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Aim: Improve Communication of Current Precautions Status

Delays in precautions

implementation

Improved adherence to

current precautions

APS D

APS

D

A PS DDS

PA

DATADSPA

Cycle 1A: Standardize precautions signage location, test on one room, and get feedback.

Cycle 1B:Reduce size, magnetize for doorframe placement. Test on one room get feedback.

Cycle 1C:Increase size, post in plastic sign holder, test on one room get feedback

Cycle 1D: Educate clinical, ancillary, and support staff on new signage

Cycle 1E: Implement sign holders for all rooms

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Questions?

We are always available for your questions Listserve Email

Next? Lunch Tools and tips for training and practice change Program measurement

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