In this course you will learn about the importance of quality in healthcare and how you can contribute by implementing a quality improvement (QI) project to improve processes of care and patient outcomes. You will learn about powerful tools to add to your QI ‘toolbox’ during short lectures and reflective exercises. You will apply these tools to the implementation of a QI project in your own practice setting or an area of personal improvement. At the completion of the course, you will have a storyboard that captures your QI project success to share with others. The QI project will be considered within the context of interprofessional teams and from a systems perspective. The objective of this course is to empower you, the working healthcare professional, to improve your knowledge and skills in the science of quality improvement so that you can take action in your own clinical setting to improve the quality of care for your patients and their families.
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From the course by Case Western Reserve University
Take the Lead on Healthcare Quality Improvement
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Meet the Instructors
Mary A. Dolansky, PhD, RNAssociate Professor, Frances Payne Bolton School of Nursing; Director, QSEN Institute; VA Quality Senior Nurse Fellow, Louis Stokes Cleveland VA
Shirley Moore, PhD, RN, FAANEdward J. and Louise Mellen Professor of Nursing and Associate Dean of Research
Frances Payne Bolton School of Nursing
Mamta K Singh, MD, MSPhysician Director of the Center of Excellence in Primary Care Education, Louis Stokes Cleveland VA; Associate Professor of Medicine, School of Medicine
[SOUND] Welcome to module eight,
The Human Side of Quality Improvement.
Here's where things get very interesting.
Where you identify some change ideas, some things or ways for you to innovate.
Some new things for you to try to change the process.
These are rare improvement gems.
But how do you get these to be implemented into practice?
With the human side of quality improvement,
we then attend to the psychology of change.
How to change contacts, organizations, and also people within those organizations.
Before we get in to the psychology of change,
I'd like to review the components of quality improvement.
I think it's really important that you leave this program knowing what these four
components are, because these are the components that are essential for
improvement success.
The first component was knowledge of a system.
Now, do you remember what tools we have in quality improvement that help us to
understand the system?
Yes, the process flow diagram, and the other is the fish bone diagram.
Very good.
What's then the next component of quality improvement that is essential for success?
Do you remember?
Ah, knowledge of variation, just what we covered last module.
And you may remember, I'm sure you do, the control chart and the run chart,
the tools of quality improvement that help us to understand variation.
Now, the third component of quality improvement.
Well, that's the lecture for today:
psychology of change. What does it take to change an organization, or change a unit?
And that really depends on changing people.
And psychology will help us to get there.
Now, the last component of quality improvement,
that we're going to cover next week, and we call this theory of knowledge.
And remember, this is the model for improvement, where we look at,
what are we trying to change?
And how do we know that an improvement is a change?
And then, what are some things that are important for
us to consider in order to improve our process?
And then running through the plan, do, study, act cycle.
That was a little bit of a review of the four essential components of
quality improvement.
It's basically the things we're covering in this program.
These are the tools that are giving you the confidence, and
the competence in creating improvement in your work.
Now we'll move on to Chapter 8.
Chapter 8 specifically is titled Understanding and
Making Changes in a System.
The specific objectives in Chapter 8 are to really understand system change,
that the system is a very complex entity, and it is not linear at all.
The second objective of Chapter 8 is to really look at
the elements of a complex adaptive system.
It's essential that we look at our systems in this way, so
that we understand that it's not a simple process in making change.
Third component is the Rogers adoption of innovation.
And then lastly, we're going to look at barriers, and
how to address these barriers.
And this chapter does go over the role and utility of the PDSA cycles, but
we're going to hold off on that content till next week.
So complex adaptive systems.
This consists of a collection of individual agents, or humans, or
staff, or patients.
The people in our processes,
who have the freedom to act in ways that are not always predictable.
We know how that goes in health care.
And, whose actions are interconnected,
such that one agent's actions change the context for another agent.
So you can see in this definition that there are a lot of components of
systems thinking.
Where there's a lot of inter-dependencies between the different components, and that
there's also an opportunity for feedback between one component and the other.
This also highlights the fact that most systems, and
healthcare in general, is very unpredictable.
This makes it very hard to study, and very hard to make change.
But when you understand the complex adaptive system,
you are empowered then with the knowledge to make successful change.
So let's look at a little bit more detail at properties of complex adaptive systems.
One of the properties of a complex adaptive system is
that elements are adaptable.
This means that people can change on their own.
That there is really no force, such as in machinery,
that if you trigger one intervention, that then, something will happen in return.
This adaption is an important component to
understand when you are implementing your change.
The second CASP, or
complex adaptive system property, is simple rules: understanding that there's
norms in the system that really have a big impact on the way systems work.
These individual roles really guide the actions of the people in the system.
The third component is that in these adaptive systems that interactions of
the system are non-linear, that one change does not result in improvement.
That you have to really look at other factors, that could be at play.
If you think back to our module number six,
where we looked at the different types of ways to
measure during improvement efforts, you remember we measured balancing measures.
So this is an example of being aware of this non-linear complex system,
and you, then thinking proactively of other outcomes that could be
effective that you will measure to capture this component.
The fourth is novel.
That in a complex adaptive system, creativity is very inherent.
That the players in the system really will work in innovative ways to
try to perform their tasks differently than the time before.
The fifth component is unpredictable.
And I think that you will agree that most of the work that we do in
health care is very unpredictable.
The sixth in this complex, adaptive system is inherently ordered.
That although there is this complexity,
there is some self-organization in the system in which we work.
In the book it gave the example of birds, and knowing where to fly and
where to flock even though weather may change,
and even though there's pieces in their system that may alter their processes.
Inherently in health care, we sort of all do act in ordered fashions.
And the seventh is contextually and embedded, and as the book described,
that this is really to understand the context and
the culture of the systems in which we work.
And that many times, our change efforts don't actually work because there's
an underlying embedded culture in that system that resists the change.
And then the last is co-evolving.
In the co-evolving component of the complex adaptive system,
this means that the tensions that are in a system do eventually achieve a balance,
that homeostasis usually does evolve over time.
As you're thinking about this complex adaptive system,
where did your mind really go to?
And I would like to just suggest that the mind usually goes to
the people that are involved in the change that we're making.
That the people are really integral to our systems, and
truly the people are integral to our improvement efforts.
So that's why the psychology of change is a very important concept to
consider when we are trying to implement our improvement innovations.
The reason why people and this human aspect are so
important, is that, unfortunately, some people naturally resist change.
If we have a greater proportion of people who are resisting our changes,
the likelihood of improvement sticking is really quite low.
Another factor to consider,
is that individuals respond to change in very different ways.
Some are innovators, and they really just jump right in and make the change.
Others are more resistant and take time in order to implement the change.
So we have to understand these variations in order to ensure that
the interventions that we're implementing will be successful.
Another thing to consider is the depth of change,
that we can sometimes create a new policy, or maybe, make a few changes to a process.
But the bottom line is that we really have to think about going deeper.
The depth of culture change is an important component to consider.
And in the literature we read a lot about culture change, and specifically in
the safety literature where we're now even measuring safety culture.
The culture means that there, you're in an institution where there are,
just is a belief that these things are of value and
that we all need to be invested in these types of changes.
So the goal really would be to create this culture of change, where the people at
the front line that you're working with believe that improvement,
that quality improvement, is of value, and a really necessary part of the work.
So why is the understand of human psychology aspect really so important?
Well again, without the knowledge, and patience of understanding psychology and
people, we might fail at our improvement efforts.
Also with profound knowledge of psychology of change, and
human psychology, and again this patience with the process, we can sustain, and
really spread our improvement efforts in patient care quality.
One of the founders and experts that we refer to
quite frequently in improvement is Everett Rogers, and his Diffusion of Innovations.
And what I'd like to go over are a few theory components that he has established.
The first is innovation adoption process, and
the second are characteristics of an organization and of the innovation.
These two components are essential then, in your change process.
Now I know there are a lot of change theories that are available out
in the world, and that you're welcome to look at them.
Cotter has a wonderful model, and there are the freeze, refreeze model.
You're welcome to use and look into these models, and we've
provided you with some references to these additional change models and theories.
But for the process for today, we're going to focus in on Everett Rogers' work.
In Everett Rogers' work, he talks about the innovation adoption process.
He believes that these are the components that are necessary in
order to make change.
The first is knowledge--
that the people who you're impacting need to have the knowledge about the change.
They need to understand the specific components of why the change is needed.
So this is a little movement to the persuasion piece.
They need to be invested.
They need to understand the value of the change.
They need to understand how this change impacts their work,
whether it be in positive or negative ways.
The third component that Everett discusses is the decision.
And here's where the people who you're working with,
that are involved in the need to change, are really at
the point where they're deciding whether this change is worth it or not.
The next component is implementation.
Will the people in the process really implement the changes you
want them to implement?
And then the confirmation component is really the last piece, where you're sure,
that these change components or change initiatives have been
taken up by the people at the front line who are making the improvement.
So let's look at these specific things, in a little bit more detail.
For knowledge then, the participants are getting information on the innovation.
They are sharing what has been learned from the data and
from the process studied.
So in this component of the adoption process,
you are sharing with them the data that you have been collecting.
Show them your run charts, show them your control charts.
Get them to see that there really is in fact a problem that needs to be addressed.
When you specifically are addressing persuasion,
you really want your participants to weigh the pros and cons.
So be up front with them, and
say here's how this process change will improve your work.
You can also share with them that this process change will reduce the time for
you doing the specific tasks of the work.
You can also share with them some of the cons.
Be up front, put them on the table and
say, these might be some negative things that you'll experience.
And then help them to understand that the pros outweigh the cons.
During this process, you also want to discuss and approach the decision.
Is the change to be adopted or not?
You need to talk with the frontline and
ask them, do you think this would be something that you would do?
And if not, what could we improve about this then,
that would help you to now make the decision to engage in the change?
The next is implementation.
Here's where the individuals start to use the innovation.
But here's also where you need to be looking at what exactly they're doing.
So you need to audit the implementation to find out if,
in fact, it is working or not.
If they are implementing the change.
And if they're not, then you need to talk with them to determine what might be
some ways to make it better, so that they will implement the change.
And then lastly to address the confirmation,
that the change then just becomes the way it's done.
And this happens at a personal level and then also at a team level.
Rogers also created this visual of what you've seen, I think,
each module throughout this program.
I think this is a really important visual to have, because it really
demonstrates what you might expect from a typical group related to an innovation, or
an improvement change.
And as you can see, that at the very left side of this graph, is the innovators.
These are the people who are going to really jump in and
say, yeah let's do this.
And as you can see, it's only about 2.5% of the people who you're working with.
[LAUGH] And actually these statistics are, have been studied in Rogers' work.
That's a little disheartening, because the people who are really going to jump on
with you at the beginning of this are going to be not to many, but
don't worry because as time evolves, then the innovation will take effect.
And you'll beginning to accumulate more and
more people who are buying in to this new process change.
You'll get early adopters, and then soon you'll reach the tip,
where you have the early majority of the people who are bought in,
who value the improvement that you are trying to make.
Also look to the right of this graph,
where 16% of the participants are laggards.
And these are people who will not take the innovation and
implement it in your improvement process.
What we really recommend is that you're aware of the number of people who are in
each of these categories, so that you don't get discouraged in your journey for
making your improvement.
Most importantly that you understand that laggards probably will never change, and
that so, that you don't have to reach for
100% of the people in your improvement making this change.
Sometimes we just have to accept that there will be these laggards and
ensure that the process can still be maintained despite them.
Another graphic that Rogers often posts is this tipping point, and
there's also been other literature in this area of which we will include in
the references for this module.
And with the tipping point you can see that incremental change is very slow in
the beginning.
And this is often a difficult time for us in improvement, in that we work hard
in order to get our improvement strategies to be implemented, but it takes time.
And we must be patient, and we must wait for this tipping point to occur.
And once the tipping point occurs,
then we know that our change has been embedded in the processes of our work.
We wanted to also talk about the diffusion of innovations specific to
the characteristics of the organization, and
specific to the characteristics of the innovation.
You must be aware that definitely the organizational characteristics,
have an impact on the change that can be made.
Many times in larger institutions, it's difficult to make a large scale change.
Smaller institutions, sometimes easier to make change.
Also depends on the leadership.
Is your leadership bought in?
Are they supportive of the work that you're doing?
And you may be thinking now that these are similar to the readiness for
change components that you completed in the module two of this program.
And you're right, these are similar.
So we're bringing these concepts back in order for you to realize that that's why
initially you looked at these components before your improvement started.
Now we're reflecting on these characteristics in order for
you to understand maybe why your improvement's working or not working.
The third organizational characteristic is this culture.
You know, are you in a unit where the front line really values change?
Where they really value not just going to work to do their work, but
going to work to improve their work.
And then lastly, our resources.
This is integral to any change.
Having the resources available in order to make the change.
Now let's move to the right side of the slide,
where we're looking at the characteristics of the innovation.
There were the characteristics of innovation that were listed in your book.
And I think they are really important to consider,
now that you are making your change.
You need to consider then, in the change that you identify, specifically, what is
the relative advantage of this change to the front line staff in which you work?
Is this going to save them time?
Is this going to help the patient?
This is an important component that you need to consider when
choosing the change you're going to make.
The next is compatibility.
How compatible is this change with the work that's already being done?
One example of compatibility is the checklist.
And the checklist has actually been seen and has been proven to be
effective in our practice as leading to the reduction in errors in surgeries.
However, there have been some resistance in checklists.
And if we think about these characteristics of this innovation,
we would come back to the compatibility,
that the checklist is actually an extra step that needs to be implemented.
So you really need to have the buy in of the whole surgical team in order to
get this specific checklist, to be implemented into practice.
Another component of an innovation is that it has to be very simple.
It can't be complicated.
You can't be adding like, three different forms for
completion in order to get something implemented.
You have to always think of simplicity.
Trialability is another essential component here.
Trialability means that the front line actually can trial the intervention--
where they can take it and see if it's working for them.
This provides them with the self-efficacy or confidence in order for
them to then implement the innovation into care.
Observability is another component, and
this is essential in that people can see that the change that
they're putting time into implementing is having an observable effect.
And then evidence.
You have to ensure that whatever it is you're implementing has some
evidence behind it to demonstrate that it is an effective intervention.
It's very difficult to get the front-line to implement something if they do
not believe that it is going to work.
You can think about things in your past that you have tried to
implement into practice.
And if you have experienced these things to not be successful,
if you just ponder these little innovation components,
you're probably going to be able to identify why exactly that didn't work.
The whole thing on this module is change.
Change is difficult, and
these are some very quick tips as to how to ensure that change will be
taken on by the front line staff that you're working with.
An essential component for
change is to provide information about the thing you're trying to improve.
So, talk with the front line.
Educate them.
Tell them what this is about and why this is so important.
You also need to anticipate how this change is going to
affect the people who you're asking them to implement it.
Is it going to give them more work,
is it going to provide them with maybe an easier job, so that they will then say,
wow I want to really do this, because it's going to save me time!
Anticipate these things.
And after you anticipate these factors, use them when you implement the change.
The third essential piece here for you when you're taking your change and
trying to implement it into your practice, is you have to provide some resources.
You can't expect the staff to do the change without providing them with
physical resources and then also the training involved for making the change.
And then lastly, an essential component for this is publicizing the change.
You need to let everybody know that this is how we're going to do things now.
So for example, put posters in the backs of the stalls in the bathroom.
Or maybe change the screen on the computers to indicate the change that's
happening on the unit.
This is kind of the fun part of change, the, the marketing of it.
And I think that you can be creative in some of the ways that you'll be
marketing the changes that you decide to make.
So where does this fit in your improvement journey?
Well, this module is covering again, change.
The module and the contents in the book help the team to
really brainstorm ideas as to, what are some potential change interventions that
could be made in order to lead to your improvement?
Remember, that this answers the third question in the model for improvement.
Remember the three questions in the model for improvement?
What are we trying to improve?
How do we know a change is an improvement?
And the last is, what changes can we make that will lead to this improvement?
That completes the module on the psychology of change.
This is a really important module.
And I think it is a place in our improvement journey which we usually skip
over, where we don't take the time to consider all the different potential areas
that we could possibly accept or test for our change efforts.
We've created an application then for you in the next part of this module,
where you will be creating ideas for your change effort.
You're going to brainstorm with your team in filling out this worksheet.
And then you're also going to have the opportunity to understand what might be
some barriers, then, for
implementing the different change strategies that you identify.
It's going to be a lot of fun to work with your team on this component.
And remember, this work is going to be essential for your improvement success.
So, enjoy the application
and we'll see you at Module 9.
Thanks.
[SOUND]
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