engaging with clinicians by creating highly adoptable improvement: relevance to medication...

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

February 2015 is MedRec Quality Audit Month

There is still time to register

www.saferhealthcarenow.ca/EN/events/other/MedRecAudit

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

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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ENGAGING CLINICIANS BY CREATING HIGHLY ADOPTABLE IMPROVEMENT Relevance to the sustained implementation of Medication Reconciliation

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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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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?

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

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

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

Cumulative Impact of Change

Time

Workload

Unsustainable

Acceptable

Ideal

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?

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 Same Reduced Increased

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Design For

Here!

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

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?

Highly Adoptable Improvement

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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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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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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.

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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.

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.

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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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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hayesc@smh.ca

@DrChrisHayes

@HighAdoptQI

www.highlyadoptableQI.com

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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

Thank you for attending!

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