quality improvement and the psychology of change...quality improvement and the psychology of change...

Quality Improvement and the

Psychology of ChangeSCANN MEETING - JANUARY 13, 2020

DR. KATHERINE COUGHLIN

Outline

What is QI?

Why should we care?

Systems

The Psychology of Change

An example: using QI in the

management of apnea of prematurity

What is QI… …AND WHAT IS NOT QI?

What exactly is quality improvement?

QI is not a type of Research

Quality Improvement Isn’t New…

Why do we

care?

We Can Do Better

IOM in March, 2001

As a country, we do not supply consistent, high quality care to all people

Delivery of care is complex

Multiple handoffs

Re-inventing systems, fostering innovation

First, do no harm

1999

Hospital deaths from

medical errors in the US was

at least 98,000 per year

Patient safety movement

Part 4: Building a culture of

safety

The 100,000 Lives Campaign

The IOM estimates that as many as

98,000 people die each year in US

hospitals due to medical injuries.

The Centers for Disease Control and

Prevention estimate that two million

patients suffer hospital- acquired

infections each year.

The US spends the most money on health

care of all (advanced) industrialized

nations, but it performs worse than most

on many measures of health care

quality.

QI to Achieve the Triple Aim

The 30,000 foot view…

Improve the health of the defined population

Enhance the patient care experience (including quality, access and reliability)

Reduce, or at least control, the per capita cost of care

The Power of

Systems…AND HOW THEY ARE INTEGRAL TO IMPROVEMENT

Change the System!

“Every system is perfectly designed to get

the results it gets.”Paul Batalden

“If we want better outcomes, we must change

something in the system. To do this we need to understand our systems.”

Don Berwick

1. Pick a number from 3 to 9

2. Multiply your number by 9

3. Add 12 to the result from step 2

4. Add the 2 digits together

5. Divide result of step 4 by 3

6. Convert the

number to a

letter: 1=‘A’, 2=‘B’, etc.

7. Write down the name of a country that begins with the letter

8. Go to the next letter in the alphabet

9. Write down the name of an animal (but not a bird or insect) that begins with that letter

10. Write down the color of that animal.

*Courtesy of Dr. Michael PosenchegChildren’s Hospital of Philadelphia, University of Pennsylvania

QI - How do we do it?

Bar-be-que?

*Courtesy of Dr. Michael Posencheg (w/creative license by me)Children’s Hospital of Philadelphia, University of Pennsylvania

Okay, but…

WE HAVE THIS PROBLEM,

WE DID ALL THE “STEPS,”

WE’VE MANDATED

CHANGES, AND NOTHING

HAS IMPROVED!

The “Know-Do” Gap

Yesterday Today Tomorrow

What we know

What we do

A good idea? Why not just implement?

*Courtesy of Dr. Michael PosenchegChildren’s Hospital of Philadelphia, University of Pennsylvania

The Psychology of Change!

Part 1:

“What

“How”

Part 2:

“Who”

”Why”

Hilton K, Anderson A. IHI Psychology of Change Framework to Advance and Sustain Improvement. IHI

White Paper. Boston, Massachusetts: Institute for Healthcare Improvement; 2018. IHI.org.

Q x A2 = EQuality X (Accountability x Acceptance) = Effectiveness

Psychology of Change

*62% of quality efforts fail from lack of attention to the cultural and people sides of change – the “A”.

© General Electric Co.

2008

Cannot make Effective Change without People

*Courtesy of Dr. Michael PosenchegChildren’s Hospital of Philadelphia, University of Pennsylvania

Real Life & Real People

What motivates people?

What do they do when they encounter change?

Why do people resist change?

Fear, uncertainty…

Technical vs adaptive challenges (attitudes, beliefs,

behaviors)

Activating People’s Agency

*Courtesy of Dr. Michael PosenchegChildren’s Hospital of Philadelphia, University of Pennsylvania

Three Levels of Agency

Self:An individual’s agency to make

his or her own choices

Interpersonal:The collective agency of

people acting together

System:The structures, processes, and conditions

that support the exercise of agency within

and across institutions and organizations

Source: Hilton K, Anderson A. IHI Psychology of Change Framework to Advance and Sustain Improvement. Boston, MA: Institute for Healthcare Improvement; 2018. ihi.org/psychology

1. Unleashing Intrinsic Motivation

Unleashing: “Orchestrating the loss of control of people moving in

the desired direction.”

Intrinsic motivation: Doing something for the inherent satisfaction

that engaging provides (vs. doing it for reward or avoiding

punishment)

Intrinsic motivation generates creativity, engagement, adaptive learning

Experience of meaningfulness and responsibility

Unleash Intrinsic Motivation

Unleash Intrinsic Motivation

zz

Activate

People’s

Agency

Tapping into sources of intrinsic motivation galvanizes

people’s individual and collective commitment to act.

Recommended Practices

1. Public Narrative

2. Motivational Task Design

3. Play and Celebrate

Source: Hilton K, Anderson A. IHI Psychology of Change Framework to Advance and Sustain Improvement. Boston, MA: Institute for Healthcare Improvement; 2018. ihi.org/psychology

“What’s the

matter” vs.

“What matters

to you?”

• SHARED DECISION

MAKING AND

MOTIVATION

• CREATE THE SPACE TO

ELICIT STORIES

2. Co-Design People-Driven Change

Design with people instead of for them

“Empathy regarding a problem is not the same as experiencing a problem”

Everyone who touches a process has something to contribute

PATIENTS! (Or in our case, families)

Co-Design People-Driven Change

Co-Design People-Driven Change

zz

Activate

People’s

Agency

Those most affected by change have the greatest interest in

designing it in ways that are meaningful and workable to them.

Recommended Practices

1. Become Aware of Bias

2. Map Actors

3. Craft People-Driven Aim

Statements

Source: Hilton K, Anderson A. IHI Psychology of Change Framework to Advance and Sustain Improvement. Boston, MA: Institute for Healthcare Improvement; 2018. ihi.org/psychology

Properties of Successful Change

Responsiveness to need

Compatibility with local context

Simplicity

Trialability

Observability

i.e. The change must be workable for the people involved

The Messengers – Adoption is SOCIAL

• Include influencers/opinion leaders

• To identify opinion leaders:

• Survey (Whom do you go to for advice and information

about ____?)

• Discussion and observation within the social system

• Testing teams should be front and center

• Understand the nature of networks

*Courtesy of Dr. Michael PosenchegChildren’s Hospital of Philadelphia, University of Pennsylvania

For a Message/Idea to “tip”….

You need:

1. A volunteer with a good idea

backed by a good reason

2. A group of potential adopters

“The part of the diffusion curve from

about 10 percent to 20 percent adoption

is the heart of the diffusion process.

After that point, it is often impossible to

stop the further diffusion of a new idea,

even if one wished to do so.” - E. Rogers

*Courtesy of Dr. Michael PosenchegChildren’s Hospital of Philadelphia, University of Pennsylvania

3. Co-produce in Authentic Relationship

Give responsibility and authority to everyone involved

Encourage human skills and experience to solve the

problem (versus ”consulting”)

Example: Building a plan with a patient or family

Anti- “Tokenism”

Co-Produce in Authentic Relationship

Co-Produce in Authentic Relationship

zz

Activate

People’s

Agency

Change is co-produced when people inquire, listen, see, and commit to one another.

Recommended Practices

1. Practice One-to-One Meetings

2. Ask Open and Honest Questions

3. Practice Appreciative Inquiry

4. Listen Deeply

Source: Hilton K, Anderson A. IHI Psychology of Change Framework to Advance and Sustain Improvement. Boston, MA: Institute for Healthcare Improvement; 2018. ihi.org/psychology

The Value of One-on-One Meetings

4. Distribute Power

Is ”power” a part of the problem?

“Power with” instead of “Power over”

Power as a “current”

Distributed Leadership

Multiple things can happen simultaneously

RCPs

RNs

Pharm

Distribute Power

Distribute Power

zz

Activate

People’s

Agency

People can contribute their unique assets to bring

about change when power is shared.

Recommended Practices

1. Create a Shared Purpose

2. Develop Distributed Leadership

3. Establish Working Agreements

4. Cede Power

Source: Hilton K, Anderson A. IHI Psychology of Change Framework to Advance and Sustain Improvement. Boston, MA: Institute for Healthcare Improvement; 2018. ihi.org/psychology

5. Adapt in Action

When it’s time to scale up

Stories of successes and failures

Adopting a “growth mindset” or “fail forward”Adapt in Action

Adapt in Action

zz

Activate

People’s

Agency

Acting can be a motivational experience for people to learn and iterate to be effective.

Recommended Practices

1. Coach and Be Coached

2. Adapt a Growth Mindset

3. Fail Forward

4. Embrace Emergence

Source: Hilton K, Anderson A. IHI Psychology of Change Framework to Advance and Sustain Improvement. Boston, MA: Institute for Healthcare Improvement; 2018. ihi.org/psychology

Standardizing the Management of

Apnea of Prematurity

- An Example Project -

Background & Setting

Apnea is common but there is a paucity of evidence on

how to define and manage a clinically significant event

HUP Intensive Care Nursery (ICN), a 40 bed unit

Providers: attendings, fellows, residents, NPs/PAs

Nurses document events in EMR flowsheet

Big stakeholder group

The Problem at HUP

No definition of what made an event clinically significant

No guidance for nurses when documenting

No specified duration of an “event watch”

Range was 0-6 days

Discharge timing was unpredictable

Communication suffered

Everyone was frustrated, especially families

AAP Consensus Statement

• 5-7 days event free is commonly used, infants <26 weeks may need longer

• Start countdown a period of time after caffeine discontinuation

• Consider trial off caffeine at 33-34 wks PMA or no significant events for 5-7 days/off positive pressure

• Lower heart rate alarm settings may be permissible in convalescing preterms

• Only include spontaneously occurring events– Brief, isolated, spontaneously resolving bradys do not count

– Events during PO feeding typically do not count

Recommends making a unit protocolEichenwald & Committee on Fetus and Newborn. 2016. AAP Clinical Report: Apnea of Prematurity. Pediatrics 137.

Nursing Survey

How satisfied are you with MD decision making regarding A/B/D events?

Mean: 59.5

Median: 58.0

Very satisfied Not satisfied at all

Is there consistency in MD determination of clinically significant events?

Mean: 64.6

Median: 66.5Always Never

How satisfied are you with discharge planning surrounding A/B/D events?

Mean: 59.3

Median: 59

Very satisfied Not satisfied at all

How satisfied are you with the current documentation of A/B/D events?

Mean: 57.3

Median: 62.0Very satisfied Not satisfied at all

EMR Documentation

Driver Diagram

Clinical Consensus – Operational

Definitions

A clinically significant event to be documented: Brady <80,

Sat < 85 more than 5 sec and/or apnea > 20 sec

Discharge 5 days after last documented event

Consider discontinuation of caffeine at 34 weeks CGA

Infant should be off caffeine for at least 10 days prior to

discharge

Events during PO feeding documented in “infant driven

feeding” flowsheet

At 34 weeks CGA, the heart rate lower limit alarm is

decreased to 80 BPM

Aim Statement

By July, 2018, for infants born less than 36 weeks

gestation in the HUP ICN, we aim to decrease

variation by standardizing days to discharge after

the last documented cardiorespiratory event,

where the baseline range is 0-6 days (mean 3.6)

to a goal of 5 days.

Outcome Measure

Balancing Measure

Nursing Survey Post-implementation

Adapt in Action

Spread to other NICUs

Revised EMR flowsheet

Biggest Challenge:

What to do with PO feeding events

Thank You!

IF YOU HAVE THOUGHTS,

QUESTIONS, OR IDEAS, I

WOULD LOVE TO TALK MORE!

Katherine.coughlin@sharp.com