Change through influence without authority: introducing

cancer supportive care screening into health care services

Tracey Tobias, Jill Beattie, Lisa Brady

Congratulations!

You’ve been appointed to lead a change initiative!

It’s success hinges on the cooperation of several people across multiple organisations over whom you have no formal authority

Southern Melbourne Integrated Cancer service (SMICS):

• Established in 2004• To facilitate the implementation of the Victorian

Government cancer reforms across southern Melbourne • A joint initiative of Alfred Health, Cabrini Health,

Peninsula Health and Southern Health. • The health services are collectively known as SMICS

member health services• Collaborative relationship • Does not have the capacity to enforce initiatives• Has therefore adopted a position of influence

Developing SMICS’ supportive care agenda

Aim: Develop supportive care priorities across southern Melbourne’s cancer services Method: Consultation mapping project of current supportive care services

Results: Seven inter-related priorities were agreed:• increasing the profile of supportive care• improving access to a skilled supportive care workforce• screening for supportive care needs• patient communication and access to information• access to emotional support, counselling, psychology and mental health

services• access to palliative care resources• continuity and integration of care

Influence not Authority

• command and-control leadership—the “I leader, you follower” approach—is not applicable in this context

• Networking, coalition building, persuading and negotiating.

The method of influence

A constellation of capabilities:• Networking • Constructive persuasion and negotiation • Consultation• Coalition building

Johnstone, 2003

Project Approach

Primary purpose: to pilot an agreed supportive care screening tool to identify the needs of all new patients a SMICS member organisation.The project deliverables included:• designing and testing an agreed supportive care screening

tool, confirming referral pathways for identified needs, education of staff, evaluation and data analysis.

A Working Group was established and chaired by the Operations Director, membership included a broad representation from all relevant stakeholder groups including consumers

The Screening Tool

National Comprehensive Cancer Network (2010).

Patient Survey Responses

1. Tool easy to complete2. Able to understand3. Helped patients think

about their day to day needs

4. Time spent discussing tool was useful

5. Patient felt they could ask questions

6. Felt responses helpful7. Found experience useful

Question 1

Question 2

Question 3

Question 4

Question 5

Question 6

Question 7

0

2

4

6

8

10

12

1 = Strongly disagree

2

3

4

5 = Strongly agreeNo

. of p

atien

ts

Staff Survey Responses

Question 1

Question 2

Question 3

Question 4

Question 5

Question 6

Question 7

Question 8

Question 9

0

1

2

3

4

5

1 = Strongly disagree2345 = Strongly agreenot applicable

No. o

f sta

ff

Staff feedback regarding the usefulness of the screening tool was poor at the post implementation phase.

Patient identified problems

Childcar

e

Housing

Insuran

ce/Fin

ancia

l

Transp

ortation

Work/

school

Dealin

g with

child

ren

Dealin

g with

partner

Depres

sion

Fears

Nervousn

ess

Sadness

Worry

Loss

of inter

est in

usual

activiti

es

Spirit

ual/rel

igious c

oncerns

appea

rance

bathing/d

ressin

g

chan

ges in

urinati

on

consti

pation

diarrh

oeaea

ting

fatigu

e

feelin

g swolle

nfev

ers

getting a

round

indigesti

on

memory/

concen

tration

mouth sores

nausea

nose dry/

conge

sted

painsex

ual

skin dry/

itchy

sleep

tingling i

n hands/f

eet

0

2

4

6

8

10

12

14

16

18

20

Num

ber o

f pati

ents

Patients concerns

Patients’ three most important concerns

23%

20%

11%

13%

27%

7%

physicaldiagnosis and treatmentdying/survivalpracticalfamilypsychological

Patient identified levels of distress

0 = no distress 1 2 3 4 5 6 7 8 9

10 = extreme dist

ress0

2

4

6

8

Distress Thermometer score

No.

of p

atien

ts

Focus group study: Method

• Qualitative multi-site study (3 sites)• Drawing on a quality improvement approach

– supports working in partnership with staff to evaluate and inform further development in practice

• Purposive sampling – all Chemotherapy Day Unit registered nurses and allied health professional

staff – who provide direct cancer care

• Focus groups– Four semi-structured questions– one hour, audio recorded, transcribed verbatim– content analysed to identify enablers and barriers

• Ethical approval from Monash University Human Ethics Committee and study site ethics committees.

Focus group study: Results

• Sample– 3 focus groups with registered nurses (n=21) and allied health staff

(n=3)

• Barriers– Uncertainty about purpose of the tool– When to screen and re-screen– Competing priorities with high workload– Screening without providing the service– Under-resourcing of allied health staff– Patient anxiety at time of screening– Patients refusing referrals– Staff perception that they already identify supportive care needs

Focus group study: Results cont…

• Enablers– Engaging staff in design & implementation– Allocating a specific time & person to complete the screening– Developing a resource folder– Triggers, such as having the tools visually accessible when

patients’ present– Staff support

• Benefits of supportive care screening– Holistic tool that increased awareness of needs– Useful for monitoring change– Normalisation of the stress response to cancer diagnosis

Focus group study: Results cont…

• Recommendations– More education of staff & patients– Refinement of the tool– Review of the distress score cut-off point– Increase accessibility to allied health professionals

• Conclusion– Important findings for informing future workforce

planning and activities needed to improve implementation of supportive care in practice

Screening Rates

Chemotherapy Day Units2009 – 0%2011 – 65%2012 – 85%

Total Patient Population2011 – 2%2012 – 17%2013 – 51%

Conclusion

Through the implementation of supportive care screening for cancer patients, SMICS

has demonstrated that influential leadership rather than holding a position of

authority has the ability to impact on meaningful service improvements

Thank You

“The secret of my influence has always been that it remained secret.”

― Salvador Dalí