So, let's talk about some key implementation concepts so that we really have a sense of how to bring about change in a real world setting. You probably have already seen this implementation framework in some of the other parts of this MOOC. And I am revisiting it here because this is how you implement your quality improvement or your patient safety intervention. And as I mentioned before, we separate these into Es in order to try to make them easy to remember. So, we start out with engagement, we move to education, we then move to execution and finally to evaluation. And let me say that that's not necessarily a smooth transition, and once you get to the fourth E it does not mean you never have to go back to the first E or the second E or the third. It should be considered as more of a categorization of activities that could be all unfolding at the same time as well as you a little bit of an order. You certainly wouldn't want to be executing before you ever engaged. If you do that, then people will not know why it is that they have been asked to change something about their process, and they won't be very motivated to do so. So, here's your implementation framework that gives you a little bit of a roadmap to use figuring out how to implement a new change to process or procedures in order to improve quality or patient safety. Some of the key concepts that I think are important for people to remember as they're trying to implement something new within a clinical setting are, to begin with, have a plan. Many times in the real world what we see happening is somebody's got a great idea and they sort of launch in or they start doing something a little differently and they do not actually even take notes about what exactly they're doing differently. And as they notice that there's a benefit or that there is a good result from this pattern, then they start to write things down, they start to mention it to other people and they actually develop a plan. Well, it makes sense to try to get a group together and talk about a plan when you know you are going to have a purposive or required change coming through. You want to go ahead and have a plan. And this means using a model or a conceptual framework. The programs that have a plan and have laid it out with a conceptual framework tend to have better results and results that they can report because somebody is keeping track of what exactly has happened at each stage of the program development. And in addition to that the conceptual framework helps you evaluate later on where things may have gotten stuck or not quite work out and you want that to be a theoretically informed framework. So, go to the literature and see what other people have done rather than just jumping off with something that's completely untried or untested. You may need to do some of that kind of innovation but you also want to have kind of a grounding or an understanding of what has typically worked. And so that's one of our key implementation concepts. Another is that your engagement is a continuous step and is a conscious step in the process. And so what that means is that throughout your efforts to change you need to revisit how people are feeling about it and you need to try to make sure that people feel positively by emphasizing the things that are going well, by offering whatever necessary incentives cookies on a Friday whatever it takes to keep people feeling upbeat and positive. And then planning for sustainability has to be a conscious part of the process as well. So, as you're developing your intervention and as you are pulling it out, rolling it out, you want to make sure that you've thought about what kinds of things do we need to do to make sure that this will last? If we do it in an unconscious way, then when we run out of funding or when the person who started everything leaves, the entire program or effort will disappear. And so you don't want that to happen so make some plans to make sure that it lasts over time. Another key implementation concept from the beginning is to think about gathering from the frontline worker, from whoever it is that you are asking to change, what they think is most important, what they think are the potential barriers. This frontline input is absolutely critical, and intervention that's been developed without reference to what the frontline thinks is not going to be successful in most cases. Sometimes we get top down mandates and we're told that we have to make something happen. But if there's no input, then it will be clunky, it will run into problems, it will be a slow improvement that may eventually fail and certainly won't be sustained later if nobody asked the people who were asked to change what they thought was important about that change and how to make it. Further, I would say that it's really important to support whatever quality improvement or process based improvement you are trying to undertake. And that means you need peer support for it, managerial support for it, and you need to have some methods and skills that you are applying from the world of quality improvement or other specific methods and skills for measurement, for evaluation and for a rapid cycle approach to testing little changes and figuring out whether they were actually effective rather than just marching forward and not really knowing whether you are having any effect or not because you maybe do not know how to actually assess that. And so this is one of those key implementation concepts is to have, some of these methods and skills around quality improvement. There are several levers that you can use to promote change and they come in two basic classes. One is motivating change and the other is enabling change. So, it's not enough to just go out there and engage everybody. If you don't give them the tools that they need to actually effect the change, then it won't be successful. And the converse is also true. So, if you go out there and you give them a bunch of tools but you don't tell them why it's important, you don't raise awareness, you don't have any social pressures or other kinds of motivating forces, then people will implement in a lackluster fashion perhaps given the fact that they have so many other things to work on, so many other things to worry about. If they don't feel a strong level of motivation towards improving in this area, it will end up on the back burner for most people. In addition, I think that it's important to realize that when you are trying to change something fundamental about the way people have done their work over time, it's really important for you to work on the culture, not just the clinical or technical issue. And by that I mean there should be some attention to what are the expectations in the specific area where you're working? Do they have a general openness to new things or do they not have that openness? Do they enjoy having people try new roles and grow and try different things or is that not really how they're set up? Is it a strongly hierarchical place or in fact is it open to anyone's ideas? These kinds of movements in culture towards greater creativity and so on, can exist in the face of some really rigid cultural attributes that we sometimes see especially in more hierarchical organizations such as a hospital or physician practice or other kinds of healthcare settings where roles are defined upfront and the expectations for each role are pretty clear in terms of how they fit into the overall pathway of patient care. So, if you don't think about what the culture is that exists there and then work on that culture, the chances are good that you will bring about some clinical change, but that you could do better if you also addressed and sort of openness in the culture that allows for better and more positive perspectives on changes for improvement. I think you should also consider the idea of a proactive assessment of your issues, not just being reactive. And so that means that you have to have this orientation of saying, "What is going to go wrong or what kinds of problems do we think we will foresee later?" If you only react to problems, then you are constantly running around trying to put out fires and you don't have very much time to think forward about what your overall strategy is, where you're going or how you're getting there. And so a proactive assessment of what issues will be, what current issues are rather than just reacting to things as they happen, will serve you well in your implementation. I also think that another implementation concept that will serve you well is integrating the new work into the old work. And so this starts with showing an appreciation for what already exists and letting it be known that people have been doing good work for a long time and you're bringing in something new to enhance what they have done. Not change everything fundamentally, not to say that what they've done today is not adequate or is horrible. Now of course you can highlight safety problems, but you also want to say that you know there are reasons for the way things are. And so having said that, you then want to reconsider what roles are doing what and really say, "Is this the practical, the most logical way to conduct something?" If you know that there is a role, a clinical role, who's going to touch the patient more frequently, then it makes sense to put some kind of intervention that requires frequent patient touch in that role even if it's not traditionally part of that role. So, consider which roles are doing what. Consider moving some activities from one role to another. And don't let that box constrain, the box of what has happened before, constrain what you do as you move forward. In addition, you want to try to reconfigure your touch points to include the prevention of multiple harms. And so this is difficult because there are so many things that you are supposed to be working on, so many things you are supposed to be preventing in patient care as far as harms that reach the patient. And so it may be important to really look at the entire group of potential harms to a given patient and try to deal with all of those in a concerted fashion rather than doing one at a time, considering one thing at a time, and then adding on top. So, maybe they're a vented patient and you're trying to prevent a bloodstream infection and you are trying to prevent deep vein thrombosis. And so each of these are important for you to think about. But if you plan out your care taking care of one problem at a time, you're going to be returning to that patient multiple times rather than pulling them together in one specific touch point. And so one key piece of implementation is trying to find ways to unify what you're doing and reduce work for people rather than increase work for people. And in addition you want to add some structure to your common processes. So, where you see lots of variation, there maybe 12 people doing things 12 different ways. And if that's true, it may call for some standardization through forms or through some kind of communication across people. You want to set all of your processes up so that they don't rely on memory and you want to make sure that improving your communication is focused on because this is one of those key pieces to making sure that a process is conducted effectively. But when you add a structure to a process, you can actually improve communication because people will all have a shared mental model around what is supposed to happen in that process as opposed to each one of them having their own way of approaching it.
