Implementing Change: Tips for making change in the clinical environment

Transcription

1 NSAP CQI Webinar Implementing Change: Tips for making change in the clinical environment Robyn Wright Quality & Risk Coordinator Banksia Palliative Care Service 24 April 2013

2 Aim: Use a change management framework to explore implementing an new assessment tool in to a community palliative care service

3 Background Banksia Palliative Care Service (Banksia) was one of 20 palliative care services that participated in the NSAP Collaborative Improvement Project Assessment and Care Planning (CIP: A&CP) Project Aims: All patients have an assessment that is patient centred and holistic All patients have a care plan that is holistic and current, that demonstrates patient involvement Banksia Is a specialist community palliative care service providing home-based care to children and adults with a progressive terminal illness in the local government areas of Banyule, Nillumbik and Whittlesea in Victoria. Care is provided by an interdisciplinary team that consists of nursing, social workers/counsellors, spiritual care worker, music and massage therapists and sessional palliative care physician. The model of care is community based and recognises that the client is the centre of a broader social unit which may include the family, friends and community.

4 Change management model John Kotter s 8-step process of successful change References: Kotter, J. (2007). Leading change: why transformation efforts fail. Harvard Business Review, Jan Kotter, J., Rathgeber, H. (2006). Our Iceberg is melting: changing and succeeding under any conditions. Macmillian: London.

5 8-step process Set the stage 1. Create a sense of urgency 2. Pull together the guiding team Decide what to do 3. Develop the change vision and strategy Make it happen 4. Communicate for understanding and buy-in 5. Empower others to act 6. Produce short-term wins 7. Don t let up Make it stick 8. Create a new culture

6 Step 1: Create a sense of urgency Help others to see the need for change and the importance of acting immediately Communicate the need broadly and dramatically Banksia Long recognised need to review our care plan and client assessment pro forma Participation in the CIP:A&CP created need to for action Accepted into the pilot program One of 20 agencies National program EO signed a commitment to do something, provide data, present our results Committed to the set timeframe May to Dec 2011 Baseline data demonstrated the gaps in holistic assessment, in particular emotional, cultural and spiritual assessment

7 Step 1: Create a sense of urgency Challenges Can be difficult to achieve (failure in this step is high) Tendency to shoot the bearer of bad news particularly if change is in response to poor performance Not easy to drive people out of their comfort zone Lack of patience enough with the preliminaries let s get on with it Overwhelmed or paralyzed by the downside possibilities Staff become defensive Morale drops Events may spin out of control

8 Step 1: Create a sense of urgency When is the urgency rate high enough? Rule of thumb: 75% of management/staff are convinced that the status quo is unacceptable Change begins well when a good leader sees the need for change

9 Step 2: Pull together a guiding team Leadership doesn t rest with the Senior Manager, Executive or Head of Unit Successful change needs a powerful group guiding the change one with leadership skills, credibility (expertise, reputation), communications ability, authority, analytical skills, and a sense of urgency powerful guiding coalition Banksia Working group senior clinicians (nursing and psychosocial team), Department Managers, Quality & Risk Coordinator and Executive Officer (Chair)

10 Step 2: Pull together a guiding team Challenges The guiding team may have no history of working together Important to develop a shared assessment of the problem and opportunities Need to create a minimum level of trust, communication and teamwork Managing changes in the guiding coalition Efforts that don t have a powerful enough guiding coalition can make apparent change for a while but sooner or later opposition gathers itself together and stops the change.

11 Step 3: Develop a change vision and strategy Develop a picture for the future that is easy to communicate with a clear compelling statement of where the change is leading Banksia Project Plan This project will Develop an agreed client assessment framework that is holistic and client centred This project will not include Bereavement assessment Death Audit Intake/triage assessment Referral process Discharge Planning Family meetings Care Coordinator Role

12 Step 3: Develop a change vision and strategy Challenges Without a clear vision change can easily dissolve into mess of incompatible activities Staff become confused or alienated If you can t communicate the vision to someone in five minutes or less and get a reaction that signifies both understanding and interest you ve not completed this phase in the change process

13 Step 4: Communicate for understanding and buy-in Make sure as many others as possible understand and accept the vision and strategy Credible communication (lots and lots of it) using all existing communication channels to broadcast the vision of the change We often signficantly under-communicate the vision for the change Banksia CIP: A&CP Standing item on the monthly quality committee agenda Working group meetings were minuted (simple action style minutes) Storyboard to report progress (displayed in the clinical area) captured the work of the working group Working/draft protocols to support the implementation of the new tool and clarify our thinking Next time..documented implementation and communication plan

14 Storyboard Cycle No. Date Plan Do Study Act Successes Suggestions May 2011 Review literature on Palliative Care Assessment NSAP Literature review & Expert Group Brainstorming comments Palliative care needs assessment guidelines. Newcastle: The Centre for Health Research & Pyscho-oncology (2006) Needs Assessment Tool Progressive Disease - Cancer NAT-PC more specific for referral/intake June 2011 Combined the clinical assessment (Part A) and the psychosocial assessment tool (Part B) into one tool (draft 1) Tools integrated using Gordon s Functional Health Patterns as a framework Gordon s useful framework as it incorporated the language from social science disciplines Duplication of content in both sections Streamline content and reduce duplication Link health assessment to PCOC assessment July 2011 Combine the clinical assessment and the psychosocial assessment into one tool and streamlined content and incorporated PCOC (draft 2) Test face validity of the combined tool with project team/clinical staff (KH, JG) Clear simple format Comprehensive Include more prompts GP details Other service providers Rearrange order to match workflow Draft Aug 2011 Draft 3 order of content arranged to match workflow Test face validity of the combined tool with project team/clinical staff (KH, JG) Content consistent with workflow Concept is clearer Related well with PCOC Assessment Broaden definition of ACP Include assessment of carer needs in Part B Reduce font size Include prompts for falls, Press/Ulcer risk Draft Aug 2011 Draft 4 Ensure content for health assessment is based on best available evidence Minor changes Draft 5 trial on clients 6 30 Aug 2-11 Draft 5 Trial of tool Minor changes Draft October Draft 6 Feedback on trial Trialed on 4 clients Prompts & Tick boxes useful Workflow okay Comprehensive All information in one tool Consider removing PCOC assessment Client label on all pages Separate nutrition/metabolic Psychosocial terminology issues (different language nursing and psychosocial team) Draft 7

15 Step 5: Empower others to act Remove as many barriers as possible so that those who want to make the vision a reality can do so Banksia Force field analysis prior to implementation of the new assessment tool Driving forces Restraining forces

16 Step 5: Empower others to act Driving Forces Comprehensive health assessment Combines physical and psychosocial Holistic not just medically focused Consistent with National Palliative Care Standards Clinical Tool Consistency in approach to assessment Less subjective Facilitates collection of client data Can be scanned into Bankpall (Electronic Client Record) Good foundation to establish a client centred care plan Comprehensive assessment comprehensive care plan Prompts to promote follow up actions Workforce driven Opportunity to be part of National project with collective goals of being holistic and client centred Restraining forces More paperwork/forms (need to be a trade off) Terminology New Confronting Difficulty containing the assessment interview emotions solicited by the interview questions Need to complete the assessment may be a barrier to a good discussion 7 pages/too busy Time Variation in skill set /confidence in assessment How much detail is required in first visit if the admission is urgent?

17 Step 5: Empower others to act Challenges No organisation has the momentum, power or time to get rid of all the obstacles focus on the big one

18 Step 6: Produce short-term wins Real change takes time at risk of losing momentum Create some visible, unambiguous successes as soon as possible Banksia Celebrated minor breakthroughs Acknowledgement of the different worldview that each discipline holds Agreed framework Establishing a common language Initial response for clinical staff was very positive Look for small successes that may come in the form of words instead of deeds

19 Step 7: Don t let up Press harder and faster after the first successes until the change has sunk into the organisational culture the new approach is fragile and subject to regression Tackle the broader problems (structures and systems) that are consistent with the new process Banksia Implemented the tool in March 2012 reviewed in 3 months May audit for completeness demonstrated that further work required in psycho-social assessment and a review of workpractices in undertaking an initial assessment. In the process of introducing a validated assessment tool for anxiety & depression (HAD) On the back of this health assessment we have modified our interdisciplinary care plan. It was the logical follow on from the changed assessment framework.

20 Step 8: Create a new culture Hold onto the new ways of behaving, and make sure that they succeed, until they become strong enough to replace old traditions Banksia Demonstrate that the new approach will improve performance Documentation audits - completion of a comprehensive clientcentred assessment (physical, social, cultural, spiritual and emotional) Increase referrals to the psychosocial team More comprehensive assessments of pain on admission (Victorian PCCN clinical pain indicators)

21 Questions?