Organizational change: challenges to infection prevention and stewardship

Transcription

1 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

2 Organizational Change Change is: inevitable necessary Change management (?)essential

3 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?

4 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)

5

6 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

7 Organizational Framework Nadler DA, Tushman ML. Organizational frame bending: principles for managing reorientation. Acad Manage Exec 1989;3(3):

8 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?

9 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

10 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

11 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

12 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

13 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

14 Organizational Change Countless theories on change and change management

15 Organizational Change Countless theories on change and change management

16 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

17 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

18 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

19 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.

20 Jan-10 Mar-10 May-10 Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May-11 Jul-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Sep-12 Nov-12 Surgical Site Cardiac Surgical Site Infection CABG Valve Cardiac (other) 0

21 Jan-10 Mar-10 May-10 Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May-11 Jul-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Sep-12 Nov-12 Surgical Site 12 Cardiac Surgical Site Infection Total 4 2 0

22 Jan-Mar 10 Apr-Jun 10 Jul-Sep 10 Oct-Dec 10 Jan-Mar 11 Apr-Jun 11 Jul-Sep 11 Oct-Dec 11 Jan-Mar 12 Apr-Jun 12 Jul-Sep 12 Oct-Dec 12 Surgical Site 14 Cardiac Surgical Site Infection Rates SSI 4 2 0

23 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

24 What had changed? No change in: theatres surgeons skin prep etc.

25 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)

26 Jan-Mar 10 Apr-Jun 10 Jul-Sep 10 Oct-Dec 10 Jan-Mar 11 Apr-Jun 11 Jul-Sep 11 Oct-Dec 11 Jan-Mar 12 Apr-Jun 12 Jul-Sep 12 Oct-Dec 12 Surgical Site 14 Cardiac Surgical Site Infection Rates SSI 4 2 0

27 Jan-Mar 10 Apr-Jun 10 Jul-Sep 10 Oct-Dec 10 Jan-Mar 11 Apr-Jun 11 Jul-Sep 11 Oct-Dec 11 Jan-Mar 12 Apr-Jun 12 Jul-Sep 12 Oct-Dec 12 Surgical Site 14 Cardiac Surgical Site Infection Rates SSI 4 2 0

28 Summary Embrace change Use change Be in a position to detect change Communicate!

29