quality improvement and the psychology of change...quality improvement and the psychology of change...
TRANSCRIPT
Quality Improvement and the
Psychology of ChangeSCANN MEETING - JANUARY 13, 2020
DR. KATHERINE COUGHLIN
Outline
What is QI?
Why should we care?
Systems
The Psychology of Change
An example: using QI in the
management of apnea of prematurity
What is QI… …AND WHAT IS NOT QI?
What exactly is quality improvement?
QI is not a type of Research
Quality Improvement Isn’t New…
Why do we
care?
We Can Do Better
IOM in March, 2001
As a country, we do not supply consistent, high quality care to all people
Delivery of care is complex
Multiple handoffs
Re-inventing systems, fostering innovation
First, do no harm
1999
Hospital deaths from
medical errors in the US was
at least 98,000 per year
Patient safety movement
Part 4: Building a culture of
safety
The 100,000 Lives Campaign
The IOM estimates that as many as
98,000 people die each year in US
hospitals due to medical injuries.
The Centers for Disease Control and
Prevention estimate that two million
patients suffer hospital- acquired
infections each year.
The US spends the most money on health
care of all (advanced) industrialized
nations, but it performs worse than most
on many measures of health care
quality.
QI to Achieve the Triple Aim
The 30,000 foot view…
Improve the health of the defined population
Enhance the patient care experience (including quality, access and reliability)
Reduce, or at least control, the per capita cost of care
The Power of
Systems…AND HOW THEY ARE INTEGRAL TO IMPROVEMENT
Change the System!
“Every system is perfectly designed to get
the results it gets.”Paul Batalden
“If we want better outcomes, we must change
something in the system. To do this we need to understand our systems.”
Don Berwick
1. Pick a number from 3 to 9
2. Multiply your number by 9
3. Add 12 to the result from step 2
4. Add the 2 digits together
5. Divide result of step 4 by 3
6. Convert the
number to a
letter: 1=‘A’, 2=‘B’, etc.
7. Write down the name of a country that begins with the letter
8. Go to the next letter in the alphabet
9. Write down the name of an animal (but not a bird or insect) that begins with that letter
10. Write down the color of that animal.
*Courtesy of Dr. Michael PosenchegChildren’s Hospital of Philadelphia, University of Pennsylvania
QI - How do we do it?
Bar-be-que?
*Courtesy of Dr. Michael Posencheg (w/creative license by me)Children’s Hospital of Philadelphia, University of Pennsylvania
Okay, but…
WE HAVE THIS PROBLEM,
WE DID ALL THE “STEPS,”
WE’VE MANDATED
CHANGES, AND NOTHING
HAS IMPROVED!
The “Know-Do” Gap
Yesterday Today Tomorrow
What we know
What we do
A good idea? Why not just implement?
*Courtesy of Dr. Michael PosenchegChildren’s Hospital of Philadelphia, University of Pennsylvania
The Psychology of Change!
Part 1:
“What
“How”
Part 2:
“Who”
”Why”
Hilton K, Anderson A. IHI Psychology of Change Framework to Advance and Sustain Improvement. IHI
White Paper. Boston, Massachusetts: Institute for Healthcare Improvement; 2018. IHI.org.
Q x A2 = EQuality X (Accountability x Acceptance) = Effectiveness
Psychology of Change
*62% of quality efforts fail from lack of attention to the cultural and people sides of change – the “A”.
© General Electric Co.
2008
Cannot make Effective Change without People
*Courtesy of Dr. Michael PosenchegChildren’s Hospital of Philadelphia, University of Pennsylvania
Real Life & Real People
What motivates people?
What do they do when they encounter change?
Why do people resist change?
Fear, uncertainty…
Technical vs adaptive challenges (attitudes, beliefs,
behaviors)
Activating People’s Agency
*Courtesy of Dr. Michael PosenchegChildren’s Hospital of Philadelphia, University of Pennsylvania
Three Levels of Agency
Self:An individual’s agency to make
his or her own choices
Interpersonal:The collective agency of
people acting together
System:The structures, processes, and conditions
that support the exercise of agency within
and across institutions and organizations
Source: Hilton K, Anderson A. IHI Psychology of Change Framework to Advance and Sustain Improvement. Boston, MA: Institute for Healthcare Improvement; 2018. ihi.org/psychology
1. Unleashing Intrinsic Motivation
Unleashing: “Orchestrating the loss of control of people moving in
the desired direction.”
Intrinsic motivation: Doing something for the inherent satisfaction
that engaging provides (vs. doing it for reward or avoiding
punishment)
Intrinsic motivation generates creativity, engagement, adaptive learning
Experience of meaningfulness and responsibility
Unleash Intrinsic Motivation
Unleash Intrinsic Motivation
zz
Activate
People’s
Agency
Tapping into sources of intrinsic motivation galvanizes
people’s individual and collective commitment to act.
Recommended Practices
1. Public Narrative
2. Motivational Task Design
3. Play and Celebrate
Source: Hilton K, Anderson A. IHI Psychology of Change Framework to Advance and Sustain Improvement. Boston, MA: Institute for Healthcare Improvement; 2018. ihi.org/psychology
“What’s the
matter” vs.
“What matters
to you?”
• SHARED DECISION
MAKING AND
MOTIVATION
• CREATE THE SPACE TO
ELICIT STORIES
2. Co-Design People-Driven Change
Design with people instead of for them
“Empathy regarding a problem is not the same as experiencing a problem”
Everyone who touches a process has something to contribute
PATIENTS! (Or in our case, families)
Co-Design People-Driven Change
Co-Design People-Driven Change
zz
Activate
People’s
Agency
Those most affected by change have the greatest interest in
designing it in ways that are meaningful and workable to them.
Recommended Practices
1. Become Aware of Bias
2. Map Actors
3. Craft People-Driven Aim
Statements
Source: Hilton K, Anderson A. IHI Psychology of Change Framework to Advance and Sustain Improvement. Boston, MA: Institute for Healthcare Improvement; 2018. ihi.org/psychology
Properties of Successful Change
Responsiveness to need
Compatibility with local context
Simplicity
Trialability
Observability
i.e. The change must be workable for the people involved
The Messengers – Adoption is SOCIAL
• Include influencers/opinion leaders
• To identify opinion leaders:
• Survey (Whom do you go to for advice and information
about ____?)
• Discussion and observation within the social system
• Testing teams should be front and center
• Understand the nature of networks
*Courtesy of Dr. Michael PosenchegChildren’s Hospital of Philadelphia, University of Pennsylvania
For a Message/Idea to “tip”….
You need:
1. A volunteer with a good idea
backed by a good reason
2. A group of potential adopters
“The part of the diffusion curve from
about 10 percent to 20 percent adoption
is the heart of the diffusion process.
After that point, it is often impossible to
stop the further diffusion of a new idea,
even if one wished to do so.” - E. Rogers
*Courtesy of Dr. Michael PosenchegChildren’s Hospital of Philadelphia, University of Pennsylvania
3. Co-produce in Authentic Relationship
Give responsibility and authority to everyone involved
Encourage human skills and experience to solve the
problem (versus ”consulting”)
Example: Building a plan with a patient or family
Anti- “Tokenism”
Co-Produce in Authentic Relationship
Co-Produce in Authentic Relationship
zz
Activate
People’s
Agency
Change is co-produced when people inquire, listen, see, and commit to one another.
Recommended Practices
1. Practice One-to-One Meetings
2. Ask Open and Honest Questions
3. Practice Appreciative Inquiry
4. Listen Deeply
Source: Hilton K, Anderson A. IHI Psychology of Change Framework to Advance and Sustain Improvement. Boston, MA: Institute for Healthcare Improvement; 2018. ihi.org/psychology
The Value of One-on-One Meetings
4. Distribute Power
Is ”power” a part of the problem?
“Power with” instead of “Power over”
Power as a “current”
Distributed Leadership
Multiple things can happen simultaneously
RCPs
RNs
Pharm
Distribute Power
Distribute Power
zz
Activate
People’s
Agency
People can contribute their unique assets to bring
about change when power is shared.
Recommended Practices
1. Create a Shared Purpose
2. Develop Distributed Leadership
3. Establish Working Agreements
4. Cede Power
Source: Hilton K, Anderson A. IHI Psychology of Change Framework to Advance and Sustain Improvement. Boston, MA: Institute for Healthcare Improvement; 2018. ihi.org/psychology
5. Adapt in Action
When it’s time to scale up
Stories of successes and failures
Adopting a “growth mindset” or “fail forward”Adapt in Action
Adapt in Action
zz
Activate
People’s
Agency
Acting can be a motivational experience for people to learn and iterate to be effective.
Recommended Practices
1. Coach and Be Coached
2. Adapt a Growth Mindset
3. Fail Forward
4. Embrace Emergence
Source: Hilton K, Anderson A. IHI Psychology of Change Framework to Advance and Sustain Improvement. Boston, MA: Institute for Healthcare Improvement; 2018. ihi.org/psychology
Standardizing the Management of
Apnea of Prematurity
- An Example Project -
Background & Setting
Apnea is common but there is a paucity of evidence on
how to define and manage a clinically significant event
HUP Intensive Care Nursery (ICN), a 40 bed unit
Providers: attendings, fellows, residents, NPs/PAs
Nurses document events in EMR flowsheet
Big stakeholder group
The Problem at HUP
No definition of what made an event clinically significant
No guidance for nurses when documenting
No specified duration of an “event watch”
Range was 0-6 days
Discharge timing was unpredictable
Communication suffered
Everyone was frustrated, especially families
AAP Consensus Statement
• 5-7 days event free is commonly used, infants <26 weeks may need longer
• Start countdown a period of time after caffeine discontinuation
• Consider trial off caffeine at 33-34 wks PMA or no significant events for 5-7 days/off positive pressure
• Lower heart rate alarm settings may be permissible in convalescing preterms
• Only include spontaneously occurring events– Brief, isolated, spontaneously resolving bradys do not count
– Events during PO feeding typically do not count
Recommends making a unit protocolEichenwald & Committee on Fetus and Newborn. 2016. AAP Clinical Report: Apnea of Prematurity. Pediatrics 137.
Nursing Survey
How satisfied are you with MD decision making regarding A/B/D events?
Mean: 59.5
Median: 58.0
Very satisfied Not satisfied at all
Is there consistency in MD determination of clinically significant events?
Mean: 64.6
Median: 66.5Always Never
How satisfied are you with discharge planning surrounding A/B/D events?
Mean: 59.3
Median: 59
Very satisfied Not satisfied at all
How satisfied are you with the current documentation of A/B/D events?
Mean: 57.3
Median: 62.0Very satisfied Not satisfied at all
EMR Documentation
Driver Diagram
Clinical Consensus – Operational
Definitions
A clinically significant event to be documented: Brady <80,
Sat < 85 more than 5 sec and/or apnea > 20 sec
Discharge 5 days after last documented event
Consider discontinuation of caffeine at 34 weeks CGA
Infant should be off caffeine for at least 10 days prior to
discharge
Events during PO feeding documented in “infant driven
feeding” flowsheet
At 34 weeks CGA, the heart rate lower limit alarm is
decreased to 80 BPM
Aim Statement
By July, 2018, for infants born less than 36 weeks
gestation in the HUP ICN, we aim to decrease
variation by standardizing days to discharge after
the last documented cardiorespiratory event,
where the baseline range is 0-6 days (mean 3.6)
to a goal of 5 days.
Outcome Measure
Balancing Measure
Nursing Survey Post-implementation
Adapt in Action
Spread to other NICUs
Revised EMR flowsheet
Biggest Challenge:
What to do with PO feeding events
