Welcome to this session on Implementing Changes. I'm Melody Malone, a quality improvement consultant with TMF Health Quality Institute. And I'm happy to be presenting this program to you today. One of the hardest steps in quality improvement is making a change actually happen. By now, you may have seen the session on the Model for Improvement and Root Cause Analysis. If so, then you understand the “plan-do-study-act” cycle. And you may have already been through several tests of change. And now, you're at the point in your quality improvement effort that you want to implement your change strategy to the entire facility. And you want it to stick, right? You don't want to see the old problem creeping back in. You don't want to see the staff to work the old way. And you don't really want to hear, "Well, this is the way we used to do it." If that's where you are, or where you want to be, then this session is for you. But before we move on, I want to remind us that regardless of our learning from the data, regardless of how good our change strategy might be, that as we work to our quality improvement process, we must never forget the potential human toll as a result of our clinical errors or errors in our business practices. So we've got to remember, every resident matters, every staff member matters, and every guest and visitor matters. So as you're moving to creating this new world order, and that's really what you're doing, right? You're trying to establish a new order throughout your organization. But this ends up being primarily the responsibility of senior leadership in the organization. The quality improvement teams have an important role to play in this process of creating the new world order. But it is senior leadership that actually decides when it's time to move on and really implement the change throughout the organization. So this program is really going to focus on what quality improvement teams can do to contribute to the process. And the team focuses their work in three areas. Making the improvements as stated in their team goal. And so, when you revisit the team chart, "Well, what was the goal for the team?" And their job is to -- the improvement team is to make those improvements and then to hold those gains that were made during the original improvement process. And then last, the quality improvement team's job is to help spread the improvements to others throughout the organization. Now, your organization can be as broad or as narrow as you choose to define it. Just keep in mind, if I'd even decide to publish your results and spread your improvements to the world. Or maybe, you will share the new process to nursing homes within your corporation, or maybe even to other nursing homes in your town. Regardless, your team has two additional tasks after the project seemed to have met the goal: Hold the gain and spread improvements to others. Now, I know you're familiar with the model for improvement, but let's just do a quick reminder. So we're always asking ourselves the three questions: What are we trying to accomplish? How will we know that a change is an improvement? And what change can we make that will result in an improvement? And once we know that, we go on to develop a rich and robust plan. We implement our plan through the “do” phase. During our implementation of that test of change, we study the results. And based upon those results, we act to decide what will be our next test of change. You can do that same thinking as you go through, looking at how are we going to implement across a wider scale. But when we think about the timeline for improvement, oftentimes, we think of it as looking sort of like this. We make an improvement in our pilot population. We hold those gains. And then we spread that innovation or that improvement. But I think, really, the improvement timeline looks a little bit more like this. I think this is really how it works in true practice. The pilot teams continue with working on improvements. Remember, they're doing small tests of change through the “plan-do-study-act” cycle and growing their small tests to larger and larger tests in the pilot population. And then, they're beginning to spread throughout while they're upholding the original gain. So this is more of an integrative process than a single one-step-at-a-time process. But keep in mind, at some point, the senior leader who's overseen the entire quality improvement process for the organization leads to spread the efforts. Now, back at that point when we say our process is tight enough that we have confidence when we spread it throughout the organization, we're going to make it stick and we're going to continue to hold the gain. So, keep in mind, this is not strictly a sequential process. But what's important is as we go through our quality improvement process, we don't want to see backsliding. Now, the one chart before you now is a great example of that. You can see before they even started to make tests of change. Number one represents their test of change. Two and three, four and five more tests of change. So you can see as they began implementing tests of changes and trying to get their process down path right. Sticky work would really work. They make good progress. And by November, mid-November, they got to their very best performance. But something happened that caused them to start backsliding. They started going back. They started creeping back up, close to the original level, close to the level before they even started making improvements. This is a perfect example of what backsliding or not being able to hold the gain that happened during their quality improvement process. And we don't want to do that. So a way to make our improvement work is to hold the gain. And there's kind of a simple way of doing that. I know this slide seems a bit complicated, so I just want you to look at the top half for the moment. In the new system, the quality improvement team wants to make it very easy to operate in the new system. We want to make it so easy and simple that they don't want to go back to the old system. Now, look at the bottom half. That's the old system. How much effort did it take to actually get done in that old system? What they really had to do? It was quite complicated in following that convoluted [inaudible]. So when you're looking at this new system, this new quality improvement process you're putting in place, you want it to be very effortless for the team to do. Because you want to make it so easy to work in the new way, that they don't even want to think about going back to the old way. And the way that we do that is by hardwiring our changes. Now, in making it easy to function in the new system, the key is empowerment. It's probably the most important word for this entire concept of hardwiring. Think about it. If I am finally empowered to do my job, I know that it is all [inaudible] to make it happen. And if I believe this is important, then how likely am I to do it? Real likely, right? And being successful is really a fundamental joy in life. From the minute we begin to experience our environment, we seek to get affirmation from others that we're headed in the right direction.
^M00:10:01 I'm sure all of you listening to this either have had children or you've seen a child, right? Well, think about back to when you started seeing children start curving around the coffee table. You know, they move away from you a little bit, and then they'd look back at you to cheer them on. Well, our staff needs the same thing. They need that feeling of empowerment that they can move away, that they can be successful, and that they can get cheered on. They want us to encourage them. So when we're looking at new system, and if we've had all the right people on our quality improvement team, then we've got staff that's empowered and have tools to make this new process work and be hardwired into the system. And if we don't empower the staff and hardwire the new system, then they will return to the old way of doing it. So a way for us to this is to build in triggers. And triggers are reminders and it may be things like, say, for example, in a start of meeting, in the beginning of the day, do we do some kind of [inaudible] system, buffing, where we call on the staff to reeducate in the process, to the attendee. And if they get it right, maybe they get a prize or something. So we want to look at how can we empower our staff, how can we make sure that we build in triggers, but I also want to sure that we keep in mind, whatever staff is learning today about the system is great, but what about new people coming in the door? So we've got to make sure part of hardwiring our system is that we address the way that we do things here in orientation. So this allows us to address issues. It allows for discussions with new employees about how we do things here and why we do it our way. And when we hardwire the system changes, we're wanting to make it very hard to function in the old system. And there are some basic things that you can do to make that happen. You can change job descriptions. You want to assign those behaviors that you want to see happen in order for that appraisal to be of value. So what kind of behaviors would you expect to see in the new system? Maybe if you were working on fall, it might be that your employees come up with creative interventions for fall risk reduction. Or if pressure ulcer is a focus for you, it might be early identification of changes of condition. That might increase the staff ability to be empowered to actually increase pressure ulcer prevention interventions. So you can tie all these ideas back to your job description. One that I think should be in every job description is the behavior participating on a team, supporting the changes, mentoring new employees to the facility for the philosophy of being on change, being elder-focused, and not being me-focused. Those are all aspects of being on a team that can easily be in every job description. Part of what you have to do is figure out, how do we not go backward? So some of that is making sure that you remove all those old things about how we did stuff. You might have to strip search the nurse's station to get all the old forms and old files and all of those things out of way that were barriers. Remember, we want to make it very easy to operate in the new system. Another way for you to hardwire the system and make it hard to function in the old system is to make the staff call you personally for approval or notification of a change that they want to make. So for example, maybe if the staff want to apply a new restraint at three in the morning, they have to call the director of nurses to get approval. And you have to say to yourself, "How many of those calls am I really willing to make or take?" Not too many. So we don't want to make it where we can accept those changes very easily. We want to make it hard to function in the old system, easy to function in the new system. And what about if you treat every issue, whatever it might be for you, as an incident? And so, we have to do an incident report on those things that are critical, adverse issues for you, adverse events. You know, it might be that it is a facility-acquired pressure ulcer or any other kind of facility-acquired infection or problem. So the incident report would have to be completed and investigated. And those investigations drain a lot of time, right? But handled well, the investigation gives us that opportunity to, one, celebrate finding this facility-acquired problem. And then to educate everyone that you have to talk with during that investigation process. This raises awareness of risk factors and helps to identify possible breaks in your system. They'd recall it. And once you've done that, then you can go into the quality improvement process. So when you're looking at “How do we hardwire these changes?” these are from ideas that you can make to make it hard to function in the old system and easy to function in the new system.
So some strategies for holding those gains once the initial improvements have been made -- and remember by that, I mean, they've been tested and now we're really looking to implement -- is to really look at how do we establish and document those standardized processes. The permanence of the change should not depend on specific people, but should become institution-wide. One of the ways to do this is to establish and document standard processes. That even if or when there are staff changes, everyone will know what the new process is and be able to follow it. Using storyboards to communicate these changes absolutely is a fun way to do it and it communicates to all, 24, 7, 365 about what your quality improvement efforts are doing. Check out our webinar on storyboards. Data collection continues after implementation, so that the team has information about whether the gains are being maintained. It may be that the data collection schedule can be reduced. But with data collection occurring less frequently or with a smaller sample, we still can measure and ensure that we are holding the gain. Remember, the objective here is to the monitor the new system, rather whether they guide improvements, unless you, as a learning organization, identify new opportunities for improvement that are then tested and implemented. And often during initial improvement, one person is responsible for the team's progress or reporting the team's progress. But this person should not be the only one who is responsible for the permanent implementation of the change. Remember, this is the responsibility of senior leadership. Because everything that we do, we want to make sure that we make it easy to operate in the new system, hard to operate in the old system. So here is my challenge to you with regard to implementing your quality improvement process across your organization. It's you've got to determine what your plan is. So how are you going to embed this change in the fabric of your organization? How we do this new way becoming the culture of your organization? How are you going to continue to monitor to ensure that you hold in the gain? And how are you going to continue to improve? Because we always want to look for those quality improvement efforts. Remember, we're always here to help you. Feel free to reach out to us either through our email or phone and please, please, please, check out our very rich website with many tools and resources for you. Thank you.