The document discusses creating highly adoptable improvement initiatives to engage clinicians and sustainably implement medication reconciliation. It introduces a model that assesses initiatives based on perceived workload and value. Initiatives with low workload and high value for clinicians are most likely to be adopted. The document provides a guide to apply this model, including evaluating initiatives based on end-user involvement, alignment with goals, estimated workload, complexity, and evidence of effectiveness. Applying this guide can help identify opportunities to simplify initiatives and increase adoption of medication reconciliation and other improvements.

1. ENGAGING CLINICIANS BY CREATING HIGHLY ADOPTABLE
IMPROVEMENT
RELEVANCE TO THE SUSTAINED IMPLEMENTATION
OF MEDICATION RECONCILIATION
February 10th, 2015
Chris Hayes, MD MSc Med
Medical Officer, CPSI
Medical Director, Quality and Performance, St. Michael's Hospital, Toronto

2. February 2015
is MedRec Quality Audit Month
There is still time to register
www.saferhealthcarenow.ca/EN/events/other/MedRecAudit

3. March 31, 2015 Webinar – 12 noon ET
Join us to hear about the national
MedRec Quality Audit Results
Our speakers will
 Review the results of the Canadian MedRec Audit Month 2015
 Discuss lessons learned from the audit month – strengths and areas for
improvement
 Suggest future value of audits and audit tools for your organization
 Gather ideas about how to improve the quality of MedRec at
admission

4. Today’s Speaker
Christopher Hayes, M.D., M.Sc., M.Ed.,
 Chris is a 2013-14 Canadian Harkness/IHI Fellow in Health Care Policy and
Practice, has been at St. Michael’s Hospital in Toronto since 2005, where he is the
critical care response team site director and the medical director of quality and
performance.
 He is an assistant professor at the University of Toronto in the Department of
Medicine and the Institute for Health Policy, Management and Evaluation.
 Since 2008, Hayes has been the medical officer for the Canadian Patient Safety
Institute, where he chaired the Canadian Safe Surgery Saves Lives program.
 He is a recognized leader in patient safety and quality improvement, working
with regional, national, and international organizations, and has received
multiple distinctions and awards.
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5. ENGAGING
CLINICIANS BY
CREATING HIGHLY
ADOPTABLE
IMPROVEMENT
Relevance to the sustained
implementation of Medication
Reconciliation
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6. Medication Reconciliation
• A process of comparing a patient's medication orders to
all of the medications that the patient has been taking
• Comprises five steps:
• Develop Best Possible Medication History
• develop a list of medications to be prescribed
• compare the medications on the two lists
• make clinical decisions based on the comparison
• communicate the new list to appropriate caregivers and to the
patient
• Better information
 Reduces discrepancies
 Reduces harm
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7. Medication Reconciliation
If Med Rec improves medication information which
leads to a reduction in patient harm
Why do we have difficulty in getting clinicians to
buy in, adopt the tools, and sustain the practice?
7

10. In an effort to Improve healthcare
are we making it Harder to provide care

11. Impact of Change on Workload/ Capacity
Ventilator associated
pneumonia bundle
(VAP)
~2hrs/day direct nursing time
- affected other activities
Branch-Elliman. BMJQS 2013
Intensive blood
glucose monitoring in
ICU (GC)
~2hrs/ day direct nursing time Aragon. AJCC 2006
Electronic medical
record / Health IT
(HIT)
Longer workdays, see fewer
patients, disrupted workflows
Miller. Health Affairs 2004
Surgical safety
checklist
(SSC)
~90-120sec/case
- 31% reduction in delays
Nundy. Arch Surg 2008
Central line infection
bundle
(CLB)
Cart was instrumental – everything
available averted delays
Dixon-Woods. Mil Quart 2011

12. Impact of Change on Workload/ Capacity
Workload
Time
Baseline
Zone of change
Post implementation of change
Unchanged
More workload/ less capacity
Less workload/ more
capacity
VAP, GC,
HIT
CLB, SSC
Where do you think Medication
Reconciliation falls
How much workload is it

13. Cumulative Impact of Change
Time
Workload
Unsustainable
Acceptable
Ideal

14. Impact of Change on Perceived Value
• People are not passive recipients of change; they evaluate,
seek meaning and develop feeling towards change
• Perceived Value
the willingness or readiness of individuals to adopt change when they believe
the outcome of the change will be of value to them (or things of importance to
them.)
• Emotional = That will save lives!
• Practical = I can see myself doing that new practice
• Logical = That new process makes sense
What do you think the perceived
value of Med Rec is?

15. Hypothesis
• Change initiatives
that do not add
additional workload
and have high
perceived value are
more likely to be
adopted, cause less
workplace burden
and, achieve the
intended outcomes
More
adoptable
Less
adoptable
Perceived
value
Workload
SameReduced Increased
15
Design
For
Here!

16. Intervention
Design
Burnout, change
fatigue, cynicism,
error, workarounds
Implementation
Strategy
Sustainably adopt
improvement
intervention
-
+
WORKLOAD
VALUE
CAPACITY
Intended
outcomes
NOT
achieved
Intended
outcomes
achieved
Highly Adoptable Improvement
* The person icon represents the collective recipients
of the change; those individuals required to carry out
the tasks associated with the intervention
How we are asking
people to do it
What we are asking
people to do

17. Highly Adoptable Improvement
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Selected Factors Associated Questions
End-user participation Are end-user staff/ physicians involved in the
change?
Alignment and planning Does the change initiative align with the
organization’s and/or team’s goals and has the rollout
been planned effectively?
Resource availability Are the required resources (training, equipment, time,
personnel) for the implementation of the change
initiative known and will they be made available?
Workload How much workload (cognitive, physical, time) is
associated with the intervention?
Complexity How complex is the change intervention?
Efficacy What degree of evidence and belief is there that this
intervention will lead to the intended outcome?

18. Highly Adoptable Improvement
19

19. Highly Adoptable Improvement
Timing the steps and processes involved in the
intervention can give you an estimate of the
additional workload. You can then reflect on the
complexity of the intervention and ask:
1) Does it need all the proposed steps/processes?
2) Could steps/ processes be simplified?
3) Could necessary equipment and technology be
provided to reduce the workload associated with
the steps?
4) Could other staff, providers or patient/families
be involved to distribute the workload? Using
LEAN tools can help identify other workflow steps
that may have associated waste (or non-value
added time), or could be modified to better
incorporate the new work
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20. Feedback
• Workload is a barrier to adoption and change
• Model intuitive, clear and has face validity
• Assessment guide allows for reflection and is useful to:
• Consider current state
• Identify opportunities for improvement
• Use as a communication tool with project team, leadership and
recipients of change
• Suggestions on how to improve clarity and utility
• All will continue to use
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21. Group Exercise
End-user participation
Are end-user staff/ physicians involved in the change?
• Active participation of end-users in the design, testing, revising and implementation of change interventions increases the likelihood of higher
perceived value and is more likely to produce a less workload intensive intervention, thus increases the chance of sustained adoption.
High risk Moderate risk Some risk Highly adoptable
The intervention has not been
designed with or tested with end-
users.
End-user staff/ physicians were
invited to participate in the initial
planning meetings where their
input was sought.
End-user staff/ physicians played
an initial role in the design and
testing of the intervention. Their
feedback will be sought after
implementation.
End-user staff/ physicians play a
continuous role in the change
initiative, including designing,
piloting and revising the
intervention and, during the
implementation phase. Their
feedback is continuously sought
and addressed.
22
Alignment and planning
Does the change initiative align with the organization’s and/or team’s values and goals and has the rollout been planned effectively?
• Change initiatives that are aligned with the goals, values and objectives and planned ahead of time to inform end-users and avoid project/ priority
conflicts are more likely to increase perceived value and sustained adoption.
High risk Moderate risk Some risk Highly adoptable
The change initiative is addressing an
ad-hoc request/ need with little time
to plan and communicate with end-
users. There are competing
priorities or projects.
The change initiative is addressing an
ad-hoc request with some attempt
to communicate the plan with the
end-users and avoid competing
priorities or projects.
The change initiative aligns with our
goals and plan, which have been
communicated effectively with the
end-users. However, there are other
projects being implemented during
the same time period.
The change initiative aligns with our
goals and plan, which have been
communicated effectively with the
end-users (or requested by them.)
The timing of the implementation is
such that there are no competing
priorities or projects.

22. Group Exercise
Workload
How much workload (cognitive, physical, time) is associated with the intervention?
• Interventions that have less workload or make the current workflow easier to perform are more likely to be sustainably adopted and reliably
performed.
High risk Moderate risk Some risk Highly adoptable
We have not estimated how much
workload is associated with the
intervention.
We have attempted to estimate the
additional workload associated
with the intervention and believe
the additional workload should be
adoptable by end-users.
We have piloted the intervention
and worked with end-users to
assess the workload demands and
have determined that the
intervention adds additional
workload. We are looking to see if
the intervention can be further
simplified, other work removed, or
additional resources added.
We have piloted the intervention
and worked with end-users to
assess the workload demands and
have determined that the new
work can be implemented and
reduce workload and make their
current work easier.
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Resource availability
Are the required resources (training, equipment, time, personnel) for the implementation of the change initiative known and will they be made available?
• Providing the necessary supports and resources to aid understanding and implementation of the change initiative increases the ability for end-users to
adapt the changes into their existing workflow.
High risk Moderate risk Some risk Highly adoptable
No assessment of the required
resources has been performed.
The resources have been estimated
without input from end-users and
have not been communicated.
The resources have been estimated
with some input from end-users or
managers and a plan to provide the
resources has been made and
communicated.
The resources required have been
determined through testing the
change initiative and feedback from
end-users. A plan to provide the
resources has been made and
communicated with the end-users.

23. Group Exercise
Complexity
How complex is the change intervention?
• Interventions that are simple in design and application are more likely to be sustainably adopted and reliably performed.
High risk Moderate risk Some risk Highly adoptable
The intervention requires many
steps and processes that require
multiple individuals and multiple
departments to carry out and would
not be testable. Individuals may not
be able to perform the tasks reliably
in multiple circumstances.
The intervention requires many
steps and processes that require
multiple individuals and multiple
departments to be involved for one
cycle of the intervention to be
performed. However we can to test
or simulate the steps and determine
how well it can be performed in
multiple circumstances.
The intervention has relatively few
steps but requires multiple
individuals and/ or departments to
be involved for one cycle of the
intervention to be performed.
However the steps and processes
can be tested and, performed
reliably under most circumstances.
The intervention is comprised of
relatively few steps and processes
that can be tested and, performed
reliably under most circumstances.
One or few people need to be
involved for one cycle to be
performed and realize the intended
benefits.
Efficacy
What degree of evidence and belief is there that this intervention will lead to the intended outcome?
• Perceptions of the quality and validity of the evidence supporting the belief that the intervention will achieve the desired outcome are more likely
to be adopted and produce less change fatigue and cynicism.
High risk Moderate risk Some risk Highly adoptable
The intervention has no published
evidence that it leads to
improvement and we are unaware
if it has been used or been effective
in other organizations.
The intervention has no evidence
demonstrating that it leads to
improvement but has apparently
worked in other organizations
similar to ours
The intervention has demonstrated
evidence that it leads to
improvement but has not been
shown to work in organizations
similar to ours.
The intervention has demonstrated
evidence that is leads to
improvement, and has been shown
to work in many organizations (or
departments) with similar contexts
to ours.
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24. Take Away Messages
• Efforts to improve healthcare, like Med Rec can increase
workload
• The Highly Adoptable Improvement model and guide
supports focusing on the impact of change on care
providers and staff and seems useful and usable
• Ongoing work in this area will continue to provide
guidance on effectively implementing improvement
initiatives and programs
• Change is hard….let’s avoid making it harder!!
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25. hayesc@smh.ca
@DrChrisHayes
@HighAdoptQI
www.highlyadoptableQI.com
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26. March 31, 2015 – 12 noon ET Audit Month Results
Please Note:
• Processes for logging on to national calls may be changing in the future (e.g. use of
passwords to gain access to webinar/ in-advance registration)
• Further information regarding these changes and when they will come into effect will be
communicated via email and website posts.
Upcoming webinars

27. Thank you for attending!
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