7. Improvement Culture: A Useful Guide “ Every enterprise has four organisations: the one that is written down, the one that most people believe exists, the one that people wished existed and finally, the one that the organisation really needs” NHS Chief Executive
8. The Discomfort Zone Comfort Zone: People stay here, don’t change, don’t learn Discomfort Zone : People uncertain, but most likely to change, most likely to learn Panic Zone: People freeze, will not change, will not learn To encourage people to leave a comfort zone, you need to help them feel safe. You can do this by creating the right environment and culture, ensuring that there is no blame.
9. The Individual: Readiness to Change Prochaska et al 1992 Descriptor Behaviour Action Pre-contemplation The individual is not ready to discuss or consider change Consciousness raising Contemplation The individual is willing to listen and to consider a change Emphasis on benefits Preparation The individual gets ready to do something concrete Provide support Action The individual starts to work with the change Continue support in addition to encouragement and praise Maintenance The individual strives not to slip back to old behaviours Scrutiny of process?
10. The Nature of Change Change can be….. Collective Everyone in a group must decide to adopt or not Authoritative The individual is told to adopt Contingent The individual cannot choose to adopt until the organisation has sanctioned it
11. The Scepticism Continuum behaviour behaviour attitude active passive scepticism neutrality acceptance commitment active resistance resistance involvement Scepticism : The questioning or doubting of accepted opinion Resistance : Through actions and arguments prevent someone from doing something, or prevent something from happening
12. The Value of Resistance “ Commercial practice, for example, often interprets resistance to change as a natural and necessary force for exposing and resolving conflict, and consequently for planning and implementing change effectively. “ Organisations need resistance to change in order to prevent bad and poorly developed ideas from being implemented. Mabin et al 2001 Schön 1963
13. The Involvement Conundrum Impact on personal status, patients and the organisation Political considerations Timing Degree of information or understanding Complexity Impact Skills required Priority Source Focus The individual contemplating change The proposed change Time Context
15. Errors and harm - are they the same thing? Errors Errors that cause no harm to the patient (Near Misses) Errors that harm the patient Harm Harm caused by “normal care”
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20. Why are you measuring? The answer to this question will guide your entire quality measurement journey! Improvement? Judgment? Research?
21. The Three Faces of Performance Measurement Bob Lloyd, IHI Aspect Improvement Accountability Research Aim Improvement of care Comparison, choice, reassurance New knowledge Methods: Test Observability Tests are observable No test; merely evaluate current performance Test blinded or controlled tests Bias Accept consistent bias Measure and adjust to reduce bias Design to eliminate bias Sample Size “ Just enough” data, small sequential samples Obtain 100% of available, relevant data “ Just in case” data Flexibility of Hypothesis Hypothesis flexible, changes with learning No hypothesis Fixed hypothesis Testing Strategy Sequential tests No tests One large test Determining if change is an imrovement Run charts or Shewhart control charts No change focus Hypothesis, statistical tests Confidentiality of the Data Data used only by those involved with improvement Data available for public consumption and review Research subjects’ identities protected
25. Results from NPSF/AIG and Estes Park Survey Definitely Not at all 1 2 3 4 5 How comfortable are you with your level of engagement safety? 9 37 32 14 7 % Mgmt 4 42 46 6 2 % Board C-Suite Does patient safety trump productivity in your work organization? 9 18 41 20 12 % Mgmt 40 34 20 4 2 % Board C-Suite Are you able to engage your staff in patient safety activities? 13 31 41 13 0 % Mgmt 41 45 12 2 0 % Board C-Suite
26. Results from NPSF/AIG and Estes Park Survey Definitely Not at all 1 2 3 4 5 Executive leadership and the board are visibly engaged in patient safety 10 31 36 15 8 % Mgmt 19 65 14 1 1 % Board C-Suite Executive leadership provides the tools and training to be effective 9 30 37 17 7 % Mgmt 14 58 25 2 1 % Board C-Suite Physician leadership is actively engaged in patient safety efforts 5 18 33 31 12 % Mgmt 20 48 26 5 1 % Board C-Suite
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28. Board Stages in Quality Engaged Capable No Yes No Q is just fine, thanks, and besides, it’s not our problem Frustrated and confused about how Yes If we could only light the fire… How do we do this even better?
29. Framework: Leadership for Improvement Will Ideas Execution Establish the Foundation Setting Direction: Mission, Vision and Strategy PULL PUSH Changing the old Making the future attractive
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32. Mission & Strategy Organisation Objectives Local Objectives Improvement Projects Individual PDP Projects not aligned to organisation objectives are doomed to failure as senior staff will have no interest in their outcome
38. Jönköping County Council is responsible for the public health care services 160 new patients staying over night at the hospitals/day 9 newborns/day 3 Hospitals 34 Primary care centers 9,500 employees 350,000 inhabitants 6.100 visits per day 1.500 visit a specialist/day 1.300 visit to GP/day (300 visits to private doctors/day) Jönköping Höglandet Värnamo
39. The Esther Project “ Esther” is not a real patient but her persona as a grey-haired, ailing, but competent elderly Swedish woman with a chronic condition and occasional acute needs has inspired impressive improvement in how patients flow through a complex network of providers and care settings in Höglandet, Sweden “ What is best for Esther?”
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42. The Inspiration of Esther Improvements 1998 2003 Hospital Admissions 9,300 7,300 Hospital Days for CHF 3,500 2,500 (yr 2000) Waiting times to see a neurologist 85d 14d Waiting times to see a gastroenterologist 48d 14d
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44. Patient focused “ Activities and sub processes organised after prioritised patient values” Patient ask for Primary Care Examination primary care treatment Hospital Diagnosis & decision on treatment Prim.C/ Hospital Rehabilitation Primary Care Treatment Hospital Rehabilitation Municipality/ Community Care Esther Six Primary care units Rehab ER Medicine Hospital in the town Eksjö Six municipalities Traditional “ Functional" Lab Pharmacy From a Functional to a Patient Oriented Healthcare Organisation Patient treatment finished Patient with disease
Editor's Notes
Unquestioning compliance with reform is interpreted as being incompatible with the development of grass-roots ownership of change.
The findings also demonstrate that individuals’ acceptance of change is affected by a complex and connected set of social and organisational factors, including the nature of the change itself as well as issues of context and timing. These powerful influences on decision making are summarised in the figure above. They represent a conundrum for those who are considering change but are not convinced of its value. How are those factors perceived and weighted in terms of significance and priority with regard to shaping the individual’s ultimate decision and the timing of that outcome?
