Pathway to changing and improving health care


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Health Care improvement in Developing nations

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Pathway to changing and improving health care

  1. 1. 14/08/2010 AND IMPROVING HEALTH CARE Dr Rajeev Kashyap. Sr. Dental Surgeon Dr Rajeev Kashyap PATHWAY TO CHANGING
  2. 2. OBJECTIVES 14/08/2010 Dr Rajeev Kashyap 1. An effective pathway to changing and improving health care practices in developing countries. 2. Core eight principles for supporting a change in health care practices. 3. Identify success factors that build local capacity and smooth the way for effective change in health care practices. 4. Steps to support a change in practices, from initiation through widespread use. 5. The process for building scale-up into the change process from the beginning. 6.The principles for effectively communicating change to varied audiences and generating long-term commitment throughout the process.
  3. 3. FOCUS 14/08/2010 Dr Rajeev Kashyap Focuses on changes in Clinical practices, Behavioral practices of providers, and Management practices at service delivery sites. Changes in management systems and organizational structures and strategies are equally important in supporting and reinforcing the service delivery changes
  4. 4. THE CHALLENGE – INCREASE THE IMPACT OF EACH CHANGE 14/08/2010 Dr Rajeev Kashyap Ministries of Health,  Nongovernmental organizations (NGOs),  Donors  Cooperating agencies All want to improve the health of populations. As a representative of one of these entities, you share responsibility for making or supporting sustainable changes in health services that will impact the lives of impoverished families throughout the countries in which you work. 
  5. 5. IMPROVEMENTS YOU SEEK FACE FORMIDABLE ODDS 14/08/2010 Dr Rajeev Kashyap A high percentage of change efforts fail.  A high percentage of scale-up efforts fall short.  A small percentage of these health improvements meet expectations. Can help you understand what is missing from many change efforts and how to supply these elements so your efforts can achieve sustainable results. 
  6. 6. RESEARCH STUDIES 14/08/2010 Dr Rajeev Kashyap Studies have shown that despite extensive funding, many changes in health care practices are not sufficiently scaled up. They don’t reach the point where they influence national health indicators.
  7. 7. THE MISSING PATHWAY FOR CHANGE 14/08/2010 Dr Rajeev Kashyap
  8. 8. MISSING PATHWAY FOR CHANGE 14/08/2010 Dr Rajeev Kashyap In improving service delivery practices, people often involve stakeholders. Together, they develop and strive to implement plans for improvement. Yet these plans and their implementation often leave out a critical process for change and longterm commitment.
  9. 9. CHANGE PROCESS 14/08/2010 Dr Rajeev Kashyap An effective change process is a recipe for Selecting, Adapting, Implementing, and Scaling up effective practices in a way that will achieve health results and sustain those results over the years.  When we understand the change process, we are less likely to underestimate the time and effort it takes to make change stick.  To ensure that people carry out the change process, you need to generate their long-term commitment. 
  10. 10. COMMITMENT 14/08/2010 Dr Rajeev Kashyap Commitment to change is the determination to carry the process to the end.  The change is complete when all program levels, working together, continually produce desired results as they implement, or support, the changed practices.  When stakeholders are committed to change, they don’t give up when they encounter barriers – nor do they stop when donors turn their resources toward other needs. 
  11. 11. ROLES IN CHANGING HEALTH SERVICES 14/08/2010 Dr Rajeev Kashyap
  12. 12. WHAT DO WE MEAN BY HEALTH DELIVERY PRACTICES? 14/08/2010 Dr Rajeev Kashyap Health delivery practices In health programs, changes can be made in:  Clinical practices  Providers' behaviours and attitudes  Management practices  Management systems  Organizational structures and strategies Changes in the first three elements often have the most direct influence on services. But broader changes in systems, structures, and strategies are important factors in bolstering, maintaining, and expanding the more direct changes.
  13. 13. LOCAL CHANGE AGENTS  WHAT ? With local change teams initiatives and carry out change in the service delivery practice. WHERE ? Service delivery sites. Dr Rajeev Kashyap  WHO? Clinicians, Local managers and Health Services 14/08/2010 
  14. 14. MID-LEVEL CHANGE AGENTS AND CHAMPIONS OF CHANGE  WHAT ? Can either act as change agents themselves or as champions to support local support agents. WHERE ? District or Provincial headquarters or with the central or national NGO`s organization. Dr Rajeev Kashyap  14/08/2010 WHO?  Mid level managers of public or private sector organizations. 
  15. 15. SUPPORTERS OF CHANGE: INDIVIDUALS AND CHANGE COORDINATION TEAM 14/08/2010 Dr Rajeev Kashyap WHO? National, regional or international leaders decision matter or donors.  WHAT ? Foster change and support change agents and change teams at all levels  WHERE ? National or Regional ministries of health , NGO`s or USAID mission or other international agencies. 
  16. 16. ROLES IN THE CHANGE PROCESS (CONTINUED) 14/08/2010 Dr Rajeev Kashyap Clinicians apply effective practices in their delivery sites to save lives and reduce illness. They can make substantial improvements in maternal health, child health, reproductive health, family planning, and infectious diseases.
  17. 17. ROLES IN THE CHANGE PROCESS (CONTINUED 14/08/2010 Dr Rajeev Kashyap Mid-level managers can lead and champion changes in health delivery practices.  Senior management needs to visibly support the changes and those who are leading the change process. 
  18. 18. ROLES IN THE CHANGE PROCESS (CONTINUED) 14/08/2010 Dr Rajeev Kashyap National, regional, and international decision makers support these changes in health delivery practices. They act as matchmakers, creating a marriage between:  Effective practices for clinical and programmatic work and  Successful practices for change and scale-up  As a member of the last group, you can learn how to support the change process and gain the ongoing commitment of the implementers and managers.  Your contribution can significantly increase the chances of producing long-term improvements in health 
  19. 19. DIFFUSION OF INNOVATIONS 14/08/2010 Dr Rajeev Kashyap The change process you will learn in this session includes elements from an approach known as the diffusion of innovations.  The approach was developed to speed up a "natural" progression where new, often more effective practices replace older practices over time. But it can take decades or even centuries for the old practices to die out. Agents can help this progression by working with others to "diffuse" the new practices.  The diffusion is the process by which an innovation is simplified and communicated through certain channels over time among members of a social system.  Originating through the work of agricultural extension agents, this approach has been applied in a broad range of areas, from business and education to public health. In public health, it has been used to bring about small-scale behavior change in communities, and more recently, to change management practices in health care programs.  The diffusion approach is especially useful for helping ministries of health and NGOs adopt and sp new practices in health care. Source: Rogers 2003
  20. 20. RESULTS OF DIFFUSION 14/08/2010 Dr Rajeev Kashyap Diffusion of innovations is central to everything we do to improve health.  Diffusion often begins by simplifying and adapting an innovation that has succeeded on a small scale.  Improvements spread faster when you strategically communicate while supporting a change in practices. 
  21. 21. EVIDENCE & HISTORY Dr Rajeev Kashyap In 1601, a simple experiment yielded convincing evidence that a small amount of lemon juice each day could prevent scurvy. The results were reported but generally ignored. It wasn't until 193 years later, when a young naval physician documented convincing evidence about the effects of lemon juice and made it known to political decision makers, that life-saving lemon juice was provided to the crews of all sailing ships 14/08/2010 
  22. 22. SUPPORTING AND LEADING CHANGE roles in the Local change agents,  Mid-level change agents and champions, and  Supporters of change  Dr Rajeev Kashyap who play all three change process: 14/08/2010 There are some widely accepted principles for change that offer a grounding for those
  23. 23. PRINCIPLES FOR CHANGE 14/08/2010 Dr Rajeev Kashyap
  24. 24. PRINCIPLE 1: CHANGE MUST MATTER TO THOSE MAKING THE CHANGE. 14/08/2010 Dr Rajeev Kashyap Align staff responsibilities, environment, and resources, and set the stage for sustained commitment to implementation.  Change must offer clear benefits to those who must implement the new practice at the hospital, clinic, community, or family level, and to their clients.  The change will offer great advantages to these groups, but the potential implementers may have a very different perception. They may see a different set of benefits, no benefit, or actual disadvantages that will result from the change. 
  25. 25. EXPECTED RESULTS OF THE CHANGE   Work environment Job satisfaction Dr Rajeev Kashyap discussions or focus groups are a good way to learn what they think the benefits can be.  Taking views into account will help you think through all the implications of the change.  The clear benefits for clients  The clear benefits for service providers in: 14/08/2010  Informal
  26. 26. CHANGE AGENTS 14/08/2010 Dr Rajeev Kashyap Principle 2: A credible, committed change agent is critical for change in health care practices.  Change agents are people who lead groups in developing, applying, and advocating for new practices. They transmit their commitment and enthusiasm to those who do the dayto-day implementation that ultimately translates new practices into norms. Examples of change agents  A hospital director who improves linkages and referrals among facilities  A district health officer who secures matching grants and uses them to improve local health services  An experienced, effective clinic nurse who teaches mothers to use local ingredients for effective oral rehydration therapy  An engineer who finds a locally appropriate way to improve water filtration 
  27. 27. EARLY ADOPTERS 14/08/2010 Dr Rajeev Kashyap People known as "early adopters" have the characteristics and credibility to influence others.  These people can be the most effective internal change agents. Scaling up change often requires recruiting change agents from among early adopters at various levels in large programs 
  28. 28. CHANGE AGENTS AND EARLY ADOPTERS 14/08/2010 Dr Rajeev Kashyap Early adopters are opinion leaders in their work or social settings.  Often well respected and connected, they tend to be chosen as leaders or representatives in their work or social groups.  They are more willing to take risks and try new things than later adopters. 
  29. 29. PRINCIPLE 3: SUPPORTING THE CHANGE AGENT GIVES THE AGENT THE CREDIBILITY AND CONFIDENCE TO LEAD. 14/08/2010 Dr Rajeev Kashyap Motivation and support for change agents and their teams throughout implementation and scale-up significantly increases the chances of institutionalizing the change.  Provide ongoing positive reinforcement, appreciation, encouragement, recognition, and legitimacy to change agents.  Share knowledge about pathways to successful change and assist change agents to develop leadership skills, so that they can engage the commitment of their staff and sustain it over the long term, assessments of anticipated benefit. 
  30. 30. COMMIT TO A CHANGE 14/08/2010 Dr Rajeev Kashyap Of particular importance are skills  to plan for implementation,  scale-up, and  sustainability right from the beginning of the change process.  This can help to develop these skills in change agents and their supervisors by giving feedback and support as they plan and address their ongoing challenges.
  31. 31. PRINCIPLE 4: CHANGE IS MORE LIKELY TO SUCCEED WHEN LEADERSHIP AT EACH ORGANIZATIONAL LEVEL SUPPORTS IT AND WHEN IT IS INTRODUCED INTO AN ENVIRONMENT WHERE CHANGE IS AN ONGOING PRACTICE.  Dr Rajeev Kashyap  Supportive leadership: Because change agents are usually working at organizational levels closest to the delivery of services, they often need an influential senior manager as their sponsor or champion in the change process. This person uses his or her influence to open doors for the change agent, to be the agent's intermediary with senior management, and to help improve the environment for change. In some instances, the champion selects the change agent. In other situations the change agent is in place before the champion is recruited. In either case, the champion may be your most direct contact with a change agent at the service delivery or district level. Source: Management Sciences for Health 2004 14/08/2010 
  32. 32. PRINCIPLE 4 (CONTINUED)     Dr Rajeev Kashyap  Supportive Environment: Studies and experience show that successful adaptation and adoption of new practices occurs most often in programs or work groups where the environment is marked by the following characteristics: Knowledge sharing happens at all levels. Top leaders and leaders at all levels readily share information and knowledge, and encourage their staff to do the same. They send a clear message: This change is important and I stand behind it. Making changes is routine. Leading change is part of ongoing organizational practice. Staff are encouraged to make small, practical improvements routinely, not just to undertake big changes in a crisis. Work teams are cross-functional. Work teams are designed to bring together people with varied perspectives who can build on one another's ideas. Prudent risk taking is rewarded. Staff are rewarded or acknowledged for asking questions, taking risks, and challenging the status quo to fulfill their program's mission more effectively. Sources of change are trustworthy. Staff members trust the honesty and credibility of the people who are promoting change. 14/08/2010 
  33. 33. PRINCIPLE 5: CLARITY IS NEEDED ON THE PURPOSE, BENEFITS, AND ANTICIPATED RESULTS OF THE CHANGE Dr Rajeev Kashyap You can help the change agent to communicate clearly to all staff the reasons for the change, what results are likely to ensue, and the ways in which each staff member will benefit from the change. 14/08/2010 
  34. 34. PRINCIPLE 6: PROVIDING ONGOING SUPPORT TO THOSE WHO WILL IMPLEMENT THE CHANGE HELPS MAINTAIN THEIR DEDICATION AND CREATES A SUPPORTIVE NETWORK FOR  Dr Rajeev Kashyap The change agent can encourage continuous staff involvement and generate the enthusiasm needed to carry the change through to results and incorporation into standard procedures. 14/08/2010 THE CHANGE AGENT.
  35. 35. PRINCIPLE 7: CLEARLY ASSIGNED AND ACCEPTED RESPONSIBILITY FOR IMPLEMENTING THE CHANGE INCREASES THE CHANCES OF SUSTAINING THE CHANGE AS A Dr Rajeev Kashyap Unless every staff member understands and agrees to her/his specific responsibilities, critical elements can fall through the cracks, reducing the likelihood of achieving the desired results If staff are held accountable for making the change happen, the change agent needs to:  Encourage staff to recognize the necessity and priority of the proposed change  Provide them with the information, resources, and skills they need to take on new responsibilities  Integrate new responsibilities into their performance plan and hold them accountable 14/08/2010 PART OF ONGOING WORK
  36. 36. PRINCIPLE 8: START WHERE YOU CAN AND START NOW. 14/08/2010 Dr Rajeev Kashyap In some ways, this is the most important principle. If you wait for ideal conditions and a perfect environment in which all the principles are manifested, no changes will ever be initiated. The perfect is the enemy of the good.  As a supporter of change, you can help to create the best possible environment for change, and then move the process forward. With your support, a capable, motivated change agent and champion can work with the principles to make the best of imperfect conditions. Together, you can make impressive improvements in health delivery practices and bring the benefits of change to providers and clients alike. 
  37. 37. SELECT A SITE FOR TESTING 14/08/2010 Dr Rajeev Kashyap Criteria for Choosing the Site  Size and client load: The demonstration site should be small enough to try the practice rapidly and inexpensively, but typical of the settings that will be using the new practice. The change coordination team could analyze caseloads to choose a facility with enough clients to show the impact of the new practice.  Staff cooperation: The best demonstration sites will have some key staff who are early adopters, who are likely to want to cooperate in testing a new, promising practice. In some instances, it may be appropriate to test the practice at the change agent's own site first, building on his or her rapport with staff.  While selecting the initial testing site(s), the change coordination team can identify other sites where the practice will likely be implemented if the first tests are successful.
  38. 38. WHY TEST? 14/08/2010 Dr Rajeev Kashyap A small-scale demonstration lessens the risk of costly mistakes.  It facilitates future adoption and support, especially if the change agent is an opinion leader.  Early success reinforces stakeholders' motivation for continued energy and investment.  If accurately measured and clearly communicated, evidence of improvement will persuade staff of the value of the new practice and encourage its incorporation into day-to-day practices. 
  39. 39. DEVELOP THE TEST PLAN 14/08/2010 Dr Rajeev Kashyap To complete this plan, the change agent and your change coordination team can:  Develop indicators to monitor progress, and ultimately, evaluate whether the change has succeeded in meeting the challenge  Clarify roles and responsibilities for the change coordination team, the champion, the change agent, and his/her local change team  Identify tools that have proven useful in carrying out comparable changes  Plan for linkages to other sectors, systems, and programs.
  40. 40. ESTABLISH GUIDELINES 14/08/2010 Dr Rajeev Kashyap Planning together gives the change agent guidelines to lead the demonstration process. These guidelines allow every player to know what s/he should do, and to be held accountable throughout the process.  Guidelines establish a framework for scheduling and help to set priorities and mobilize resources needed for the test. 
  41. 41. REVIEW PAST CHANGE EFFORTS 14/08/2010 Dr Rajeev Kashyap Before embarking on the demonstration, your change coordination team can suggest that the program assess past change efforts – those that succeeded as well as those clouded by failure.  An honest appraisal will reveal which approaches and activities to repeat and which to do differently in this new demonstration 
  42. 42. COMMITMENT TO SUPPORT 14/08/2010 Dr Rajeev Kashyap One of the most valuable things your change coordination team can do is to publicly commit to provide support for testing the new practice. The plan should incorporate offers from members for a variety of services, including:  Technical support in adapting, testing, and evaluating  Financial resources  Support in setting up a system and defining criteria for acknowledging individual staff efforts
  43. 43. TRANSITION TO MORE SITES 14/08/2010 Dr Rajeev Kashyap From one test site, your change coordination team can help move to new sites to test the new practice under different conditions (rural versus urban, hospital versus health center, application by less professional staff, etc.).  Often the change agent becomes a facilitator for managers who implement the change at other sites under his or her direction. 
  44. 44. THINKING ABOUT SCALE-UP FROM THE START 14/08/2010 Dr Rajeev Kashyap Preliminary planning is essential to anticipate and lay the groundwork for the complexities of scaling up. Start with the action plan you developed when defining a challenge and flesh out the details concerning:  Roles  Sites  Resources  Partners  Communication  Review of past change efforts
  45. 45. PLANNING FOR SCALE-UP 14/08/2010 Dr Rajeev Kashyap This step should always be included in planning for demonstration projects.  Purposeful change can create faster transformation than normal program expansion that has predictable periods of stagnation.  Given the rapid effect of many planned changes, it is wise to be prepared for success and scale-up. 
  46. 46. SUBJECT OF SCALING UP     A question of strategy: What strategies most effectively produce the desired leap? A question of impact: How should the desired impact be measured? A question of sustainability: How do we maintain the gains of an expanded and comprehensive program? A question of access: What kind of coverage is enough to qualify as “scaled up”?  A question of supply and demand: What is being scaled up?  A question of cost: How much will it cost to scale up?   A question of resources: What resources are needed and how can they be mobilized? A question of timing: When is the right time to scale up? Dr Rajeev Kashyap  A question of capacity: What management, technological, and human competencies are necessary to bring programs to scale? 14/08/2010 A question of change: How do w e know when we have achieved scale?
  47. 47. PLANNING FOR SCALE-UP     Dr Rajeev Kashyap  Roles: Clearly divide roles and responsibilities along technical and, if appropriate, geographical lines. This will foster efficient use of support and resources. Research: Set a research agenda to supply the data needed to guide the change, including such methods as focus group discussions, document review, and operations research. The goal is to use the simplest, least expensive, least burdensome research method that will yield the information you need. Sites: Identify the types of sites where successful new practices should be introduced, and the units that will need to support these sites in carrying out the practices. Resources: Estimate the costs of introducing the new practices at each potential site. Consider staff, supplies, information, and funding needed to roll out the practices regionally or countrywide. Identify likely sources that can meet these needs. Partners: Identify potential partners to help attain the needed resources and broaden the reach of the new practices. Identify other stakeholders who will need to be on board. Communication: Analyze potential obstacles that may hinder the successful implementation of the practices and determine where advocacy and dissemination of results may help to reduce these obstacles. 14/08/2010 
  48. 48. PHASE 2: PLAN FOR DEMONSTRATION AND SCALE-UP 14/08/2010 Dr Rajeev Kashyap
  49. 49. COMMUNICATION IS SO CRITICAL        Dr Rajeev Kashyap  To communicate change, begin by knowing your audience. For both internal and external audiences, you will want to convey the answers to these questions: Why are we making this change? How will it affect this audience? How will our program and our clients benefit from the change? At internal organizational meetings, you might also encourage discussion of two additional questions: What may make the change hard to achieve? What can we all do to help? For external audiences, public discussions, notices, interviews, and news reports are all ways to raise awareness and acceptance of coming changes. 14/08/2010 
  50. 50. ENCOURAGE TRUST AND COOPERATION 14/08/2010 Dr Rajeev Kashyap Manage expectations. A critical role of the change coordination team and senior management is to manage the expectations of those who will be affected by the coming change. You can anticipate that most people will have one of four reactions:  Be satisfied just to know what is going on or  Greet the new practice with enthusiasm or  Recommend modifications to the approach or  Be skeptical that meaningful change will happen
  51. 51. PRACTICES THAT MAINTAIN TRUST 14/08/2010 Dr Rajeev Kashyap Consistent and honest messages  Effective performance of the change agent and local change team  Solicitation of and response to feedback  Free flow of information on progress throughout the demonstration  Availability to staff and community leaders  Open discussion of important issues that arise during the demonstration 
  52. 52. AGREE ON ADAPTATIONS 14/08/2010 Dr Rajeev Kashyap Adapting: To fit the set of effective practices to the program and test setting, the change agent and local change team analyze similarities and differences between their setting and the ones where the practice has been used before. They can then make needed adaptations, drawing on elements in the organizational culture that will support the change.  Adapting a practice for testing in a new setting may involve simplifying it.  Fewer and less complex components will speed implementers' understanding of the content and purpose of a change, and make them more willing to try it. 
  53. 53. MONITOR FOR TEST RESULTS 14/08/2010 Dr Rajeev Kashyap One valuable contribution could be to collaborate in developing indicators to monitor changes in such areas as:  Health problems among the population being served  Quality and use of services  Performance of service providers  Capacity to deal with constraints  Implementation of the change process Monitoring also supports a dynamic change environment by:  Encouraging honest feedback  Making objective determinants of success visible to all players  Enabling the change agent and local change team to identify and address barriers to change Honesty is critical. It will seriously undermine the change effort if those doing the test feel compelled to come up with positive results no matter what they actually find.
  54. 54. MARK THE CONCLUSION OF THE TEST A public event is a good way to celebrate the end of a demonstration and reward the efforts of the many people involved.    This is a good way to share findings from the demonstration, describe successes, and acknowledge the contributions of each person who implemented the demonstration and all who supported them. If the demonstration did not fully succeed, it is still important to publicly acknowledge everyone's efforts, to ask participants for the lessons they learned, and to analyze the reasons for failure that could be counteracted in future efforts. This event will encourage a positive mindset among stakeholders. It will motivate the change agent and local change team to persist into the next phase, even if they encounter roadblocks. Dr Rajeev Kashyap  14/08/2010 
  55. 55. PHASE 4: GO TO SCALE 14/08/2010 Dr Rajeev Kashyap
  56. 56. SUCCESS 14/08/2010 Dr Rajeev Kashyap Success: Your change coordination team can help to evaluate the results at all demonstration sites and decide whether or not to go with scale-up. If the change effort at these sites has been successful, your team can work with the champion and change agent to prepare a dissemination package for scale-up.  A typical package would describe the progression of the innovation, identify barriers and potential solutions, and extract lessons from the demonstrations.  At this point, the change agent often hands off the leadership role to another well-connected person who will manage the expansion to new settings.  The champion and change coordination team can work with the change agent to bring his or her experience to bear on a vision and plan for scaling up.
  57. 57. SCALE-UP STRATEGIES 14/08/2010 Dr Rajeev Kashyap
  58. 58. ENGAGE BROADER COMMITMENT 14/08/2010 Dr Rajeev Kashyap Shared vision: When you and your change coordination team helped to initiate the change, you joined with counterparts and colleagues to envision a better future. Now, you can repeat the activity on a much larger scale with organizational managers at different levels, partners, and donors.  One way to create a shared vision is to encourage participants to imagine a future where they have successfully addressed the challenge, as described in Session 3, Define the Need for Change.  First, they individually frame their answers to three questions.  What can you visualize that represents that accomplishment? What will this success look like?  What obstacles will you have encountered on the way to this success?  How will you have worked together to overcome the obstacles?
  59. 59. MONITORING AND EVALUATION (M&E) Dr Rajeev Kashyap Monitoring and Evaluation (M&E) is an essential component of any intervention, project, or program 14/08/2010 
  60. 60. QUESTIONS 14/08/2010 Dr Rajeev Kashyap ?