NSAP CQI Webinar Implementing Change: Tips for making change so that there is ongoing and comprehensive assessment and care planning - Standard 3

Transcription

1 NSAP CQI Webinar Implementing Change: Tips for making change so that there is ongoing and comprehensive assessment and care planning - Standard 3 Helen Vaz NSAP Quality Manager

2 Purpose of Session Introduce a change management framework and model for improvement to explore some examples in making change so that there is ongoing and comprehensive assessment and care planning

3 Change management framework John Kotter s 8-step process of successful change References: Kotter, J. (2007). Leading change: why transformation efforts fail. Harvard Business Review, Jan Kotter, J., Rathgeber, H. (2006). Our Iceberg is melting: changing and succeeding under any conditions. Macmillian: London.

4 8-step process Set the stage 1. Create a sense of urgency 2. Pull together the guiding team Decide what to do 3. Develop the change vision and strategy Make it happen 4. Communicate for understanding and buy-in 5. Empower others to act 6. Produce short-term wins 7. Don t let up Make it stick 8. Create a new culture

5 Model for improvement What are we trying to accomplish? What changes will result in improvement? How will we know that a change is an improvement? Act Plan Study Do Reference: Langley GL, Nolan KM, Nolan TW (1992) The foundation of improvement. Silver Spring MD: API Publishing

6 Improvement Questions 1. What are we trying to accomplish? An aim with a clear outcome target is essential to assign resources, garner support, etc 2. What changes can we make that will result in improvement? The hypothesis generation step where we test ideas before implementing changes 3. How will we know that a change is an improvement? Measurement to demonstrate improvement

7 Focus for the change Standard 3: Ongoing and comprehensive assessment and care planning are undertaken to meet the needs and wishes of the patient, their caregiver/s and family

8 Background In Specialist Palliative Care Services participated in the NSAP Collaborative Improvement Project Assessment and Care Planning (CIP: A&CP) Project Aims: All patients have an assessment that is patient centred and holistic All patients have a care plan that is holistic and current, that demonstrates patient involvement

9 Step 1: Create a sense of urgency Help others to see the need for change and the importance of acting immediately Communicate the need broadly and dramatically Examples: Frustration in time involved in writing progress notes and inability to easily identify needs Poor multidisciplinary planning resulting in a lot of duplication Patient and carer surveys results identified lack in patient and carer involvement Baseline data demonstrated the gaps in holistic assessment, in particular emotional, cultural and spiritual assessment

10 Step 1: Create a sense of urgency Challenges Can be difficult to achieve (failure in this step is high) Tendency to shoot the bearer of bad news particularly if change is in response to poor performance Not easy to drive people out of their comfort zone Lack of patience enough with the preliminaries let s get on with it Overwhelmed or paralyzed by the downside possibilities Staff become defensive Morale drops Events may spin out of control

11 Step 1: Create a sense of urgency When is the urgency rate high enough? Rule of thumb: 75% of management/staff are convinced that the status quo is unacceptable Change begins well when a good leader sees the need for change

12 Step 2: Pull together a guiding team Leadership doesn t rest with the Senior Manager, Executive or Head of Unit Successful change needs a powerful group guiding the change one with leadership skills, credibility (expertise, reputation), communications ability, authority, analytical skills, and a sense of urgency powerful guiding coalition Example Working group senior clinicians (nursing and psychosocial team), Department Managers, Quality & Risk Coordinator and Executive Officer (Chair)

13 Step 2: Pull together a guiding team Challenges The guiding team may have no history of working together Important to develop a shared assessment of the problem and opportunities Need to create a minimum level of trust, communication and teamwork Managing changes in the guiding coalition Efforts that don t have a powerful enough guiding coalition can make apparent change for a while but sooner or later opposition gathers itself together and stops the change.

14 Step 3: Develop a change vision and strategy Develop a picture for the future that is easy to communicate with a clear compelling statement of where the change is leading Examples: Project Plan identifies scope ie Inclusions and Exclusions - WILL include inpatient assessment and care planning - WILL NOT include community, family meetings, referral process, death audit, bereavement, care coordinator Project aim Reducing the duplication of information gathered from patients/carers

15 Step 3: Develop a change vision and strategy Challenges Without a clear vision change can easily dissolve into mess of incompatible activities Staff become confused or alienated If you can t communicate the vision to someone in five minutes or less and get a reaction that signifies both understanding and interest you ve not completed this phase in the change process

16 Step 4: Communicate for understanding and buy-in Make sure as many others as possible understand and accept the vision and strategy Credible communication (lots and lots of it) using all existing communication channels to broadcast the vision of the change We often significantly under-communicate the vision for the change Examples: CIP: A&CP Standing item on the monthly quality committee agenda Working group meetings were minuted (simple action style minutes) Storyboard (PDSA cycles) to report progress (displayed in the clinical area) captured the work of the working group.

17 Step 4: Communicate for understanding and buy-in These PDSA cycles include: Starting with the Model for Improvement questions 1. What are we trying to accomplish? To improve access to the assessment and care plan 2. What changes can we make that will result in improvement? Put the documents at the front of the chart 3. How will we know that a change is an improvement? Measure how many documents can be found immediately The answers to these question are used to plan the PDSA cycles

18 Step 4: Communicate for understanding and buy-in PLAN The administration staff will put the documents at the front of the chart for the new inpatient admissions only, from Mon 4 th August DO Comments from staff that they were able to find the documents more easily STUDY Audit identified that all documents in the correct place and found immediately ACT Keep the documents at the front of the chart

19 Step 4: Communicate for understanding and buy-in Examples of PDSA tested interventions: - Standardised the care plan terminology - Reviewed the admission process - Changed the format of the multidisciplinary team - Formalised a uniform format for multidisciplinary documentation with prompts to discuss the 5 areas of holistic care (SPECS) - Utilised the Palliative Care Outcome Collaboration (PCOC) clinical assessment tools - Focused on the spirituality and cultural components of a holistic assessment

20 Step 5: Empower others to act Remove as many barriers as possible so that those who want to make the vision a reality can do so Examples Barrier analysis prior to commencing PDSA cycles can identify - Changeover of staff within team - Clinical load impacting on availability for the project - Staff engagement - Different perspective of each MDT member

21 Step 5: Empower others to act Challenges No organisation has the momentum, power or time to get rid of all the obstacles focus on the big one

22 Step 6: Produce short-term wins Real change takes time at risk of losing momentum Create some visible, unambiguous successes as soon as possible Examples Celebrated minor breakthroughs Acknowledgement of the different worldview that each discipline holds Establishing a common language Identifying a good assessment and care plan Look for small successes that may come in the form of words instead of deeds

23 Step 7: Don t let up Press harder and faster after the first successes until the change has sunk into the organisational culture the new approach is fragile and subject to regression Tackle the broader problems (structures and systems) that are consistent with the new process Introduce the sustainability strategies Examples Update the relevant procedure with the new changes Continue the regular audit to monitor that the improvements gained remain as part of the regular practice Continue with a champion concept with the topic being included in some staff members portfolio

24 Step 8: Create a new culture Hold onto the new ways of behaving, and make sure that they succeed, until they become strong enough to replace old traditions Examples SPECS framework embedded into practice: documentation, multidisciplinary meeting format, handovers, discharges etc Demonstrate that the new approach will improve performance Documentation audits - completion of a comprehensive clientcentred assessment (physical, social, cultural, spiritual and emotional) Increase referrals to the psychosocial team

25 Tips Keep it simple and take small steps Planning is important for the success of the change Continue with regular audits to monitor improvement Investigate validated assessment and care planning tools before reinventing the wheel

26 Acknowledgements 20 participating services in the Assessment and Care Planning Continuous Quality Improvement collaborative project Robyn Wright Quality & Risk Coordinator, Banksia community palliative care service

27 RESOURCES Continuous Improvement a hands on guide for the Victorian Public Service (VPS) The Clinician s Toolkit for Improving Patient Care. Easy Guide to Clinical Practice Improvement. Grol R, Wensing M, & Eccles M. Improving Patient Care: The Implementation of Change in Clinical Practice. Elsevier How to Change Practice. National Institute for Health and Clinical Excellence. Institute of Healthcare Improvement

28 RESOURCES from NSAP Included in the kits sent out and available on NSAP website: CareSearch: Involved in Quality Improvement? NSAP Factsheet: QI action plan NSAP QI action plan electronic template Barrier Analysis tool Project planning document PDSA worksheet Sustainability checklist Sustainability worksheet

29 Summary Change management framework: Kotter 8 step process of successful change Model for improvement PDSA cycle: Langley et al Change so that there is ongoing and comprehensive assessment and care planning to meet national palliative care Standard 3.

30 Questions?