“There is evidence that up to 70% of all organisational change fails to survive.” – U.K. National Health Service Institute for Innovation and Improvement
Formal quality improvement (QI) efforts have become integral to many facets of improving vaccination rates. For example, the American Academy of Pediatrics (AAP) offers two tracks for the “EQIPP: Immunizations - Strategies for Success” program: one focused on children ages 19 through 23 months and the other focused on adolescents. Many reading this column may recognize that while there is often momentum for getting a QI project up and running, sustaining change is difficult.
Consider the analogy of weight loss. If a person is dieting to fit into wedding attire, it is very likely that after the festivities the successful dieter’s weight will rebound, returning to the original weight or higher. Similarly, if office changes are made solely to address the QI project du jour, when the initial energy fades, vaccination rates may return to their baseline.
Understanding some of the barriers to sustaining change can help ensure long-term success for your next initiative. In this issue of “Technically Speaking,” we outline 6 tips that can be integrated into any improvement project to ensure that QI efforts are sustained.
1. Attention, please!
Leadership must prioritize quality through communication about goals and ongoing progress. At the beginning of a project, a QI team should be multidisciplinary and inclusive to ensure that all stakeholders have opportunities to provide input. While team members often have an initial formal, time-limited engagement to plan and study change, usually fewer team members are committed to the sustain phase — and that’s OK. However, leaders should continue to track the initiative, bringing other team members back together intermittently to communicate about progress and barriers until the changes are deeply ingrained and the goals sustained over a long period of time.
2. Remember that habits last but ‘efforts’ fade.
Habits are formed by doing the same thing visit after visit. The QI term “standard work” refers to a “written or visual outline of current best practices for a task and provides a framework to ensure that changes that have improved patient care are consistently and reliably applied to every patient encounter.” Standardization of vaccination processes — from provider to provider, from well care to acute care — supports the development of habits.
Ensure your initiative has infrastructure to build these habits by making the right thing the easy thing. The team will go through a series of improvement cycles (commonly, “Plan-Do-Study-Act,” though others exist) to come up with the new system and ensure that it fits seamlessly into the office’s workflow. Understanding that extra or time-consuming processes are not likely to survive in a busy office is critical. Ideally, the new process is even leaner than the previous process. Integration of the change into the standard operating procedures is essential to sustain change.
3. Show us the data!
Use accurate data and nonpunitive feedback to drive continuous learning and improvement. To understand the need for ongoing efforts, providers and clinical staff need to see data regularly. Some best practices for data review include:
- Use simple, accessible visuals, such as bar graphs.
- Display data in one or more locations accessible to your staff, such as shared in an email, presented as a slide or handout during practice meetings, or posted on a “performance board” that is visible in the huddle area.
- Show the outcome measure, goal and, as appropriate, process measures.
- Plan for regular data reviews that are meaningful to clinical personnel and demonstrate the importance of the project.
Regular data review supports identifying areas of success to motivate your team, highlights breakdowns in compliance with the new process, and may uncover the need for additional improvements. Depending on what your data reveals, project leaders can reengage certain stakeholders or select office staff for ongoing improvements or training.
4. Emphasize adaptability.
In healthcare, change is a constant. Unfortunately, it’s often an uncomfortable constant. A key part of QI is understanding this discomfort, whether experienced by the staff or patients and families. As circumstances change, your workflow may need to change, too. Improvement huddles — short, regular meetings among staff — are important times to hear concerns about what is challenging. These huddles can be used to help with adaptation and improve outcomes.
5. Build a culture of QI.
While there is no simple, quick tip for developing an environment that supports high quality care and sustains positive change, culture can be built and changed over time. Leaders must place continued emphasis on the value of quality through their actions and words. Messaging must be consistent and believable. Supporting involvement across the office is critical. For example, the work should be regarded as a job responsibility rather than an extra volunteer effort. Empower people who do the work to own the project. As Silver et. al. wrote in “How to Sustain Change and Support Continuous Quality Improvement”:
Even when quality improvement methods are properly applied, the success of a project still depends on contextual factors. Context refers to aspects of the local setting in which the project operates. Context affects resources, leadership support, data infrastructure, team motivation, and team performance. For these reasons, the same project may thrive in a supportive context and fail in a different context.
6. Celebrate often.
Recognize and celebrate achievements and milestones related to the improvement even if small. Positive reinforcement encourages continued engagement and motivation among staff and stakeholders. It’s important to remember that it’s not the pizza that motivates us, it’s the sincere recognition for our hard work.
Resources
- EQIPP: Immunizations - Strategies for Success
- How to Sustain Change and Support Continuous Quality Improvement (Silver SA, McQuillan R, Harel Z, et. al. Clin J Am Soc Nephrol. 2016)
- The Institute for Healthcare Improvement (IHI):
Contributed by: Sharon G. Humiston, MD, MPH, FAAP
“There is evidence that up to 70% of all organisational change fails to survive.” – U.K. National Health Service Institute for Innovation and Improvement
Formal quality improvement (QI) efforts have become integral to many facets of improving vaccination rates. For example, the American Academy of Pediatrics (AAP) offers two tracks for the “EQIPP: Immunizations - Strategies for Success” program: one focused on children ages 19 through 23 months and the other focused on adolescents. Many reading this column may recognize that while there is often momentum for getting a QI project up and running, sustaining change is difficult.
Consider the analogy of weight loss. If a person is dieting to fit into wedding attire, it is very likely that after the festivities the successful dieter’s weight will rebound, returning to the original weight or higher. Similarly, if office changes are made solely to address the QI project du jour, when the initial energy fades, vaccination rates may return to their baseline.
Understanding some of the barriers to sustaining change can help ensure long-term success for your next initiative. In this issue of “Technically Speaking,” we outline 6 tips that can be integrated into any improvement project to ensure that QI efforts are sustained.
1. Attention, please!
Leadership must prioritize quality through communication about goals and ongoing progress. At the beginning of a project, a QI team should be multidisciplinary and inclusive to ensure that all stakeholders have opportunities to provide input. While team members often have an initial formal, time-limited engagement to plan and study change, usually fewer team members are committed to the sustain phase — and that’s OK. However, leaders should continue to track the initiative, bringing other team members back together intermittently to communicate about progress and barriers until the changes are deeply ingrained and the goals sustained over a long period of time.
2. Remember that habits last but ‘efforts’ fade.
Habits are formed by doing the same thing visit after visit. The QI term “standard work” refers to a “written or visual outline of current best practices for a task and provides a framework to ensure that changes that have improved patient care are consistently and reliably applied to every patient encounter.” Standardization of vaccination processes — from provider to provider, from well care to acute care — supports the development of habits.
Ensure your initiative has infrastructure to build these habits by making the right thing the easy thing. The team will go through a series of improvement cycles (commonly, “Plan-Do-Study-Act,” though others exist) to come up with the new system and ensure that it fits seamlessly into the office’s workflow. Understanding that extra or time-consuming processes are not likely to survive in a busy office is critical. Ideally, the new process is even leaner than the previous process. Integration of the change into the standard operating procedures is essential to sustain change.
3. Show us the data!
Use accurate data and nonpunitive feedback to drive continuous learning and improvement. To understand the need for ongoing efforts, providers and clinical staff need to see data regularly. Some best practices for data review include:
- Use simple, accessible visuals, such as bar graphs.
- Display data in one or more locations accessible to your staff, such as shared in an email, presented as a slide or handout during practice meetings, or posted on a “performance board” that is visible in the huddle area.
- Show the outcome measure, goal and, as appropriate, process measures.
- Plan for regular data reviews that are meaningful to clinical personnel and demonstrate the importance of the project.
Regular data review supports identifying areas of success to motivate your team, highlights breakdowns in compliance with the new process, and may uncover the need for additional improvements. Depending on what your data reveals, project leaders can reengage certain stakeholders or select office staff for ongoing improvements or training.
4. Emphasize adaptability.
In healthcare, change is a constant. Unfortunately, it’s often an uncomfortable constant. A key part of QI is understanding this discomfort, whether experienced by the staff or patients and families. As circumstances change, your workflow may need to change, too. Improvement huddles — short, regular meetings among staff — are important times to hear concerns about what is challenging. These huddles can be used to help with adaptation and improve outcomes.
5. Build a culture of QI.
While there is no simple, quick tip for developing an environment that supports high quality care and sustains positive change, culture can be built and changed over time. Leaders must place continued emphasis on the value of quality through their actions and words. Messaging must be consistent and believable. Supporting involvement across the office is critical. For example, the work should be regarded as a job responsibility rather than an extra volunteer effort. Empower people who do the work to own the project. As Silver et. al. wrote in “How to Sustain Change and Support Continuous Quality Improvement”:
Even when quality improvement methods are properly applied, the success of a project still depends on contextual factors. Context refers to aspects of the local setting in which the project operates. Context affects resources, leadership support, data infrastructure, team motivation, and team performance. For these reasons, the same project may thrive in a supportive context and fail in a different context.
6. Celebrate often.
Recognize and celebrate achievements and milestones related to the improvement even if small. Positive reinforcement encourages continued engagement and motivation among staff and stakeholders. It’s important to remember that it’s not the pizza that motivates us, it’s the sincere recognition for our hard work.
Resources
- EQIPP: Immunizations - Strategies for Success
- How to Sustain Change and Support Continuous Quality Improvement (Silver SA, McQuillan R, Harel Z, et. al. Clin J Am Soc Nephrol. 2016)
- The Institute for Healthcare Improvement (IHI):
Contributed by: Sharon G. Humiston, MD, MPH, FAAP