Transcript Slide 1

Virtual Session #1 Track 2:
The Human Side of Change
By Robert Lloyd, PhD & Dave Williams, PhD
Institute for Healthcare Improvement
Kim Werkmeister, RN, Cynosure
Wednesday, August 21, 2013
1
Robert Lloyd
Robert Lloyd, PhD is Executive Director of Performance Improvement for the
Institute for Healthcare Improvement (IHI). Dr. Lloyd provides leadership in
the areas of performance improvement strategies, statistical process control
methods, development of strategic dashboards and building capacity and
capability for quality improvement. He also serves as lead faculty for various
IHI initiatives and demonstration projects in the US, the UK, Sweden,
Denmark, New Zealand and Africa. Before joining the IHI, Dr. Lloyd served as
the Corporate Director of Quality Resource Services for Advocate Health Care
(Oak Brook, IL). He also served as Senior Director of Quality Measurement for
Lutheran General Health System (Park Ridge, IL), directed the American
Hospital Association's Quality Measurement and Management Project
(QMMP) and served in various leadership roles at the Hospital Association of
Pennsylvania. The Pennsylvania State University awarded all three of Dr.
Lloyd’s degrees. His doctorate is in agricultural economics and rural sociology.
Dr. Lloyd has written many articles and chapters in books. He is also the coauthor of the internationally acclaimed book, Measuring Quality Improvement
in Healthcare: A Guide to Statistical Process Control Applications (American
Society for Quality Press, 2001, 5th printing) and the author of Quality Health
Care: A Guide to Developing and Using Indicators, 2004 by Jones and Bartlett
(Sudbury, MA).
Dave Williams
David M. Williams, PhD, Improvement Advisor, truesimple
Consulting, is also on the teaching faculty of The George
Washington University School of Medicine and Health Sciences.
He is also a Six Sigma Black Belt and serves as faculty and an
Improvement Advisor (IA) for the Institute for Healthcare
Improvement, supporting teams through leading system changes
using the Model for Improvement. Dr. Williams started his career
as an urban street paramedic. For the last decade, he has acted as
an internal and external IA to governmental agencies, hospitals,
and for-profit and not-for-profit organizations. He works with
clients to improve their organizations by enabling appreciation of
systems, understanding of data and variation, testing changes,
and recognizing the influence of psychology. He has published
nearly 100 articles, led intensive workshops, presented at major
conferences to thousands of attendees, and writes a popular blog.
Kim Werkmeister
Kim Werkmeister, RN, BA, CPHQ is a National Improvement Advisor
working with the American Hospital Association / Health Research
Educational Trust Hospital Engagement Network (HEN). As an
Improvement Advisor, she is responsible for working directly with State
Hospital Associations to drive improvement in hospital acquired
conditions and patient harm in hospitals across the country. In addition,
she is the lead Improvement Advisor for the Hospital Engagement
Network for the Perinatal Harm initiative, the VTE Reduction initiative and
the Psychiatric Affinity Group initiative.
Prior to this, Ms. Werkmeister worked with hospitals across California to
improve patient outcomes, implement best practices, set up Quality/Risk
programs, and prepare for and respond to licensing and accreditation
activities. She served as an improvement advisor for both the California
Public Hospital Improvement Collaborative and the California Partnership
for Health/Patient Safety First Collaborative. She also served as the lead
improvement advisor for the ICU Mortality Reduction Collaborative, a
project focusing on reduction of mortality and morbidity in ICU care
across the state of California.
Ms. Werkmeister is a Registered Nurse and graduated with a Bachelor of
Arts degree from California State University Fullerton.
4
Where are you today?
5
Discussion Topics
• The critical role of Human Behavior in improvement
• Everett Roger’s adoption & diffusion journey
• Kurt Lewin’s unfreezing to refreezing journey
• Personality profiles & communication
Note that the material addressed in this session draws heavily upon the IHI Open
School pre-work assignments. If you have not completed QI 105 Lessons 1 & 2
please take time to do so after this session.
The Sequence of Improvement
Spreading a
change to other
locations
Implementing
a change
(HTG)
Make part of
routine
operations
Test under
a variety of
conditions
Theory and
Prediction
Testing a
change
Developing a
change
Source: Robert Lloyd, IHI 2013
Act
Plan
Study
Do
The Sequence of Improvement requires an
understanding of Human Behavior
Spreading a
change to other
locations
Implementing
a change
(HTG)
Make part of
routine
operations
Test under
a variety of
conditions
Theory and
Prediction
Testing a
change
Developing a
change
Source: Robert Lloyd, IHI 2013
Act
Plan
Study
Do
Deming on the role of Psychology
“Psychology helps us to understand people,
interaction between people and
circumstance, interaction between
customer and supplier, interaction between
teacher and pupil, interaction between a
manager and his people and any system of
management.”
W. Edwards Deming, The New Economics, 2000, page 107
Important Concepts from
Psychology and Change Management
Differences in people:





Motivations
Preferences
Aspirations
Learning styles
Beliefs, Values & Culture
Most changes aimed at improvement will have to recognize the
differences in people and account for them.
See Appendix A for details on these differences
Opening Dialogue on
Human Behavior
•
So how have your interactions gone?
•
Consider for a moment, the impact of human behavior on your
HEN improvement efforts.
1. What has worked well?
2. What has not worked so well?
3. What will you do differently as you move forward?
•
Type your reflections into the Chat Box.
Pursing Perfection for VTE
Jane Northcutt, RN
Chief Quality Officer
Hospital Overview
• Located in Birmingham, Alabama
• One of 15 General Acute Care Hospital Providers
in the Birmingham MSA (4-County)
• Licensed Beds - 534
– 17 Rehabilitation Beds
– 64 Psychiatric Beds
•
•
•
•
Employees - 1,686
Physicians & Allied Health on Staff: 698
Population for Primary Service Area - 437,957
Population for Secondary Service Area - 608,771
VTE - HEN Specific Run Charts
Project Title: Reducing VTE by Improved compliance with VTE Measures
Date: 8/10/2013
Hospital Name: Trinity Medical Center
State: Alabama
Self Assessment Score = _5__
Lessons Learned
Aim Statement
Aim?:
By December 2013, 100%
of patients will receive VTE
prophylaxis by defined protocols,
patient assessments or have
documentation of contraindications.
Run Charts
Medical VTE Prophylaxis
Important?
VTE is the #1
preventable cause of death in
hospitalized patients.
•Build in discharge documentation tools in
electronic system to populate on all patients.
•Identify patients from radiological studies for
identification of needed overlap therapy and have
PharmD review for appropriate coverage.
•Set required timeline actions before the timeline
actually ends.
•Order set with physician to design with physician
driven education to medical staff.
•Use PI Referral Form for staff involved to
document why variance occurred and lesson
learned.
Changes Being Tested,
Implemented or Spread
Recommendations and
Next Steps
•Assessment of patients for VTE
prophylaxis is completed for
Inpatients and ICU patients.
•Protocols are implemented timely.
•VTE Discharge Instructions are
completed.
•Patients requiring overlap therapy are
identified with measures
implemented.
•Surgery patients are assessed for
appropriate prophylaxis.
•Re-assess protocols and current actions
with identified variances.
•Evaluate effect of new electronic clinical
documentation on compliance.
Team Members
© 2012 Institute for Healthcare Improvement
CQO
Core Measure Analyst
PharmD
Physician Liaison
Director of Surgical Services
CNO
ICU Nursing Director
Med-Surge Nursing Director
Lesson 1: Overcoming Resistance to Change Course:
QI 105: The Human Side of Quality Improvement
Many People Don’t Like Change
Have you ever walked into your house or office and discovered that something is different?
Maybe your roommate rearranged the furniture. Maybe your spouse repainted a wall. How did
you feel? If you are like most people, you were probably a little bit annoyed, a little bit frustrated,
and maybe even anxious to undo the change. Needless to say, you probably didn't jump right in
and embrace it.
Change in health care is not perceived all that differently from change in any other context. When
organizations make changes to care processes, procedures, and policies — even if those changes
are improvements — the people involved with those processes, procedures, and policies are
often a little bit annoyed, a little bit frustrated, and maybe even anxious to figure out a way to go
back.
When we talk about change and improvement, we often focus on the numbers, the processes,
and the graphs. And we sometimes forget the people. In this lesson, you will learn about barriers
to change as well as different ways that people might respond to change in a social system. You’ll
also be introduced to a basic model of change that includes unfreezing the old way we do things,
moving to the new way, and then refreezing the way we want the future to be.
So what does change look
like?
Add Text Subtitle
• Add Text, Graph, Picture
Add Text Subtitle
• Add Text, Graph, Picture
So what does change look
like?
Add Text Subtitle
• Add Text, Graph, Picture
Add Text Subtitle
• Add Text, Graph, Picture
Lesson 1: Overcoming Resistance to Change Course:
QI 105: The Human Side of Quality Improvement
Your Turn
Think back to a time when you were confronted with a new process in a familiar
setting. Maybe you were asked to swipe a card, rather than insert cash or tokens,
when boarding the bus or train. Or maybe your entire country switched off analog TV
broadcasting, making it impossible to watch your favorite show without a digital
converter box.
Once you’ve got a process in mind, write down your answers to the following
questions:
1. What emotions did you experience when first presented with this change?
2. Did you resist embracing the change? If so, what were the reasons?
3. At what point did you accept the change, if ever? What factors helped you accept
it?
Enter your response to each question into the Chat Box.
Source: IHI Open School, QI 105 Lesson 1
Reasons for Resistance to Washing
Your Hands with Hand Sanitizer
Did your list include any of the following reasons?
• “Hand washing is incredibly basic. I don’t see why I need a special policy to
tell me how to wash my hands.”
• “What’s wrong with regular soap and water?”
• “There’s no way I’ll remember to use the sanitizer. Things are just too busy
and this change is not a priority.”
• “That alcohol-based stuff is going to dry out my hands.”
• “With all I have to do, I just don’t have time to use the sanitizer before
every patient visit.”
• “I bet the dispensers won’t be located in a convenient place.”
• “This sanitizer stuff is just a marketing gimmick.”
• “This is just another new policy that’s here today, gone tomorrow.”
Source: IHI Open School, QI 105 Lesson 1
Let’s consider two of these reasons for
resistance
Source: IHI Open School, QI 105 Lesson 1
In his book The Limits of Organizational Change (Tuscaloosa: University of Alabama Press;
1971), Herbert Kaufman identified a number of barriers that can affect the implementation of
significant change in health care, including the following:
The expected autonomy or independence of health care workers: Often, health care
professionals perceive themselves as single providers working independently to provide patient
care. If a health care provider feels a change may reduce or alter that autonomy, he or she may
be reluctant to embrace a change.
Example: “Hand washing is incredibly basic. I don’t see why I need a special policy to tell me
how to wash my hands.”
Stability that comes with routine: Routines such as standard operating procedures, certain
recurring behaviors, or institutionalized ways of communicating create stability for people. This
is reflected in the common statement, "We've always done it this way, and I’m comfortable
with it, so why change now?"
Example: “What’s wrong with regular soap and water?”
Anticipating Barriers to Change
As a reminder, the following are some of the barriers we considered for
adopting the new hand hygiene policy and potential responses to these
barriers:
Barriers
• “Hand washing is incredibly basic. I don’t see why I need a special policy
to tell me how to wash my hands.”
• “What’s wrong with regular soap and water?”
Response
Provide education on the value of using hand sanitizer to reducing the
possibility of infection. Include evidence grounded in good research and
information on the growing numbers of hospitals relying on this new practice.
How Can We Foster the Adoption
of Successful Change Ideas?
The traditional approaches
Adoption is a SOCIAL thing!
A better
idea…
…communicated through a
social network…
…over
time
Diffusion of Innovations
(1st edition1962)
A theory for understanding how people respond to innovation…
… and how to use those
responses to drive needed
change
Diffusion of Innovations (1962)
An innovation, according to Rogers, is “an idea, practice, or object that
is perceived as new by an individual or other unit of adoption.”
By this definition, the hand sanitizer example in this Open Scholl
Lesson is an innovation, regardless of how long hand sanitizer has
been on the market.
“If the idea seems new to the individual,” Rogers wrote, “it is an
innovation.” And for many, washing their hands according to defined
practice with sanitizer is innovative, even though it is not a new idea.
Source: IHI Open School, QI 105 Lesson 1
E. Roger’s Stages of Adoption
How
Adopters
Adopt
1.Awareness
2.Persuasion
3.Decision
4.Implementation
5.Confirmation
Adopter Categories See
(see page 8 of QI 105 Lesson 1 for descriptions of the categories)
Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.
How Can We Foster Adoption of
Successful Change Ideas?
A somewhat more
sophisticated approach…
An Early Adopter
An Early Adopter
Adopter Exercise 1
• Change 1: All primary care physicians should
be required to provide on-line consultation to
their patients.
• Lets see where each of us would place our self
in the adopter curve:
– Innovators, early adopter, early majority, late
majority or laggard
Adopter Exercise 2
• Change 2: Each person in our country should
have a: “medical information” chip inserted
into their arm so they literally ‘carry their
medical history with them.”
• Lets see where each of us would place our self
in the adopter curve:
– Innovator, early adopter, early majority, late
majority or laggard
The “Tipping Point”
“The name given to that one
dramatic moment in an epidemic
when everything can change all
at once.”
Spread of Chronic Care Model Across Clinics
- M. Gladwell
- E. Rogers
Percent of clinics implementing CCM
“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.”
100
90
80
Total of 80 Clinics in
Organization
70
60
50
40
30
20
Tipping
point
10
0
Sep- Oct Nov Dec Jan- Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan- Feb
98
99
00
Valley Regional Hospital
Michael Lessard, RPh, MBA
Director of Pharmacy
About Us
 Critical Access Hospital
 7 Physician practices
 General and Ortho
surgeries
 Infusion Center
 Home Health division
 JC Accredited
 Serving about 24,000
residents
37
Project Title: Reducing ADEs by Pharmacy Warfarin Dosing Date: 6/10/2013
Hospital Name: Valley Regional Hospital State: New Hampshire
Self Assessment Score = _5__
Run Charts
Aim Statement
Lessons Learned
Aim?: Reduce the incidence of
•
harm due to high-alert
medications by 50% by
December 2013.
•
•
Why is this project
important?: Medications
are the most common
intervention in healthcare
but are also most commonly
associated with adverse
events in hospitalized
patients. At least 20% of all
harm is associated with
medication errors.
Six Month Totals
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
0
0
0
2
0
2
10
17
12
7
18
75
0.00%
0.00%
0.00%
28.57%
0.00%
2.67%
Over-Coagulated (INR>6)
0
Patients Receiving 11
Warfarin
% INR > 6.0
0.00%
May-13 Totals
Recommendations and
Next Steps
• Re-assess protocol for
elderly
Changes Being Tested,
Implemented or Spread
•
•
•
•
Note in eMar when patient is
receiving no dose of warfarin
Set up order so pharmacy has
daily printouts for warfarin
patients
Note daily INR and wafrarin
doses in vital signs on emar so
MD/nursing have running view
of dosing
•Look at interaction
evaluation process
Pharmacy dosing of
warfarin in all
Ortho/surgery patients
Pharmacy dosing of
warfarin as requested of
any other in-patients
Pharmacy monitoring of all
warfarin patients
Team Members
Michael Lessard, RPh
Michael Saracino, PharmD
Richard Martin, RPh
© 2012 Institute for Healthcare Improvement
Pharmacist INR Clinic in Family
Practice
Therapeutic INR by Year
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
INR Therapeutic (2-3)
2009
2010
2011
2012
2013
Basic Model for Understanding the
Change Process
So far in this lesson, we have discussed some common barriers to
change, and we have seen that not everyone adopts change at the
same time or in the same way. Being conscious of this behavior can Kurt Lewin
reduce your frustrations, and help you to work with the people
(1890-1947)
involved in the change process.
So how can an organization help different types of people adjust to
change?
Let’s take a look at one more model for understanding change in
organizations. This mode, proposed by the psychologist Kurt Lewin,
provides a simple way to understand the change process.
Lewin’s Change Model
(see page 10 of QI 105 Lesson 1 for descriptions of the stages)
Lewin proposed that organizational change occurs in the following
three stages:
1. Unfreezing
2. Change or transition
3. Freezing (or re-freezing)
In other words, Lewin suggests that in order to effect long-lasting
change, you have to recognize that people have to be loosened from
their old way, transitioned, and then molded into their new way.
It’s a conscious process that involves preparing people for change,
actually managing the change, and then working to ensure that the
change stays in place.
Source: IHI Open School, QI 105 Lesson 2
Lewin’s model requires and
understanding of Motivation!
Motivation Assumptions Inventory
•
•
•
•
•
I know I am motivated when …
I know I am lacking motivation when …
I know people are motivated when I see…
I know people are not motivated when I see …
I know the organization has de-motivated people when I see…
Stephen Brookfield, Becoming a Critically Reflective Teacher
Type your responses into the Chat Box
Lesson 2: What Motivates People to Change
QI 105: The Human Side of Quality Improvement
Using Assessment Tools to Understand Team Dynamics
There are many assessment instruments that can help the members of a
team better understand their individual strengths and preferences. For
instance:
• StrengthsFinder 2.0
• Myers-Briggs Type Indicator (MBTI)
• Strength Deployment Inventory (SDI)
• DiSC Profile
• Riso-Hudson Enneagram Type Indicator (RHETI)
Each tool is different and the decision of which tool to use, if any, often relies
on personal preference. Some tools require qualified professionals to
administer and interpret. Each tool takes a different look at people, but they
all offer a lens into understanding our diversity and openness to change.
Source: IHI Open School, QI 105 Lesson 2
44
45
46
An equation for achieving results…
Q
X
A=E
Adapted from General Electric’s approach to Six
Sigma quality improvement
An equation for achieving results…
Q
Quality
X
of a
Solution
X
A=E
Acceptance
of a Solution
=
Effectiveness
of a Solution
Adapted from General Electric’s approach to Six
Sigma quality improvement
The Primary Drivers of
Improvement
Having the Will (desire) to change the current state to one that is better
Will
Developing
Ideas that will
contribute to
making
processes and
outcome better
QI
Ideas
Execution
Having the
capacity to apply
CQI theories,
tools and
techniques that
enable the
Execution of the
ideas
How prepared is your organization?
Key Components*
• Will (to change)
• Ideas
• Execution
Self-Assessment
• Low
• Low
Medium High
Medium High
• Low
Medium High
*All three components MUST be viewed together.
Focusing on one
or even two of the components will guarantee sub optimized
performance. Systems thinking lies at the heart of CQI!
So, what
forces are
driving you
forward?
And what
forces are
holding you
back?
Force Field Analysis Worksheet
Issue or Project: _______________________________________________
Driving Forces (+)
Restraining Forces (-)
Actions to reduce the Restraining Forces:
•
•
•
Deming on the role of
Psychology
“Psychology helps us to understand
people, interaction between people and
circumstance, interaction between
customer and supplier, interaction
between teacher and pupil, interaction
between a manager and his people and
any system of management.”
W. Edwards Deming, The New Economics, 2000, page 107
Appendix A:
Key Points on Motivation
1. Differences in People
Fact: We each have our own preferences, aspirations,
motivations, learning styles.
Fact of Life: Most changes aimed at improvement will have to
recognize the differences in people and account for them.
2. Behavior is Driven By Motivation
Fact: Behavior does not often give us a clear window into
what is motivating someone’s behavior.
Fact of Life: Understanding what is motivating someone rather
than relying on our interpretation of the behavior can help us
take appropriate actions to build commitment to change.
Appendix A:
Key Points on Motivation (continued)
3. Fundamental Attribution Error
Fact: We make this error when explaining or rationalizing our
behavior in terms of the situation while holding others
accountable for their own behavior.
Fact of Life: It is often easier to blame people than to take a
hard look at how the system affects behavior.
4. Intrinsic and Extrinsic Motivation
Fact: Commitment to an activity will decline as extrinsic
motivators are reduced or eliminated.
Fact of Life: When a change is proposed, leaders need to
explain the why of the change in terms of the organization’s
values.
Appendix A:
Key Points on Motivation (continued)
5. Attracting People to Change
Fact: Building commitment to change requires
leaders to understand that change involves
more than just the tangible and technical
aspects of an activity.
Fact of Life: People will resist change if they do
not feel included or understand the benefits of
the change to the organization or to themselves.