Holding Your Gains and Spreading Change

1
Holding Your Gains and Spreading Change

• Donna Daniel, PhD, Qualis Health
• NNHIC Learning Session 2
• January 13, 2004
• Dallas, Texas

2
Creating a New Order

• Make improvements in your facility
• Hold the gains
• Spread the improvements to others

3
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Act
Plan
Study
Do
4
Q What changes can we make that will result in
an improvement? A NNHIC Pressure Ulcer Change
Concepts
5
Creating a New Order

6
Ease of Losing the Gains

• Old System New
  System

How much effort?
Team
How much effort?
Operations
7
Improvement in LOS for ED
Fast Track Patients
Best Performance
8
Implementation Strategies to Hold the Gains

• Establish and document standard processes
• Use measurement and audits
• Make changes to job descriptions
• Pay attention to orientation and training
• Assign ownership
• Make reversal as difficult as possible

9
Spread Questions

• Spread What?
• Spread To Whom and Where?
• When To Spread?
• How To Spread?

10
Spread What?

• Single change
• Timing of pressure ulcer risk assessments from
  admission to monthly
• Use of patient-specific care cards
• Multiple changes
• System redesigned to incorporate
  multidisciplinary care providers in nutrition and
  hydration
• Model for Improvement

11
Spread to Whom and/or Where?

• Other nursing home staff
• Other types of conditions
• Other wings, units, etc.
• Other nursing homes within system
• Other nursing homes within state (QIO function)

12
When to Spread?

• There is strong organizational commitment to
  spread
• Pressure ulcer treatment prevention is a key
  initiative for the organization
• Senior Leader is responsible and engaged in
  coordination and spread of innovation
• Team at this Collaborative is relatively
  self-sufficient

13
Adopter Categorization (Speed of Adoption)
Cultural change System-wide supports
Source Everett Rogers, 1995.
14
How can we spread innovation?
15
A Framework for Spread
Leadership
Measurement and Feedback
Success-ful Sites
Knowledge Management
Communication Strategies
16
Spreadable Ideas

• Make the case
• reasons why others would want to make the
  changes
• Describe changes
• change concepts and ideas that form the content
  of the redesigned system
• Transition materials
• specific methods, examples and documents to
  assist people in adopting the content

17
Communication Strategies

• Mode
• share information or shape behavior
• Purpose
• awareness or technical knowledge

18
Social System

• Unit
• to whom are you spreading
• Key messengers
• people you will rely on to spread the word
• Listeners/connectors
• people who try to understand the context of the
  receivers and resolve issues impeding change

19
Social System

• Communities of practice
• groups people identify with that can be used to
  facilitate change
• Motivators incentives
• stimulants for action at the local level
• Ability to adapt change
• flexibility in changes and people spreading the
  change

20
Infrastructure

• Staging plan
• plan to reach all units over time
• Technical support
• where people can go with questions
• Knowledge management
• how the new learning will be gathered and made
  available to others
• Measurement/feedback
• monitoring and interacting with people on
  performance

21
References

• Attewell, P. Technology diffusion and
  organizational learning, Organizational Science,
  Feb, 1992.
• Bandura A. Social foundations of thought and
  action. Englewood Cliffs, NJ Prentice Hall, Inc.
  1986.
• Brown J, Duguid P. The social life of
  information. Boston harvard Business School
  Press, 2000.
• Cool et al. Diffusion of innovations within
  organizations Electronic switching in the Bell
  System, 1971-1982. Organization Science
  19978(5)543-559.
• Dixon. Common Knowledge Boston Harvard Business
  School Press, 2000.

22
References, cont.

• Fraser S. Spreading good practice how to prepare
  the ground, Health Management, June 2000.
• Gladwell. The tipping point. Boston Little,
  Brown and Co., 2000.
• Langley J, Nolan K, Nolan T, Norman C, Provost L.
  The improvement guide. San Francisco Jossey-Bass
  1996.
• Lomas J, Enkin M, Anderson G. Opinion leaders vs
  audit and feedback to implement practice
  guidelines. JAMA, Vol 265(17) 2202-07 May 1991.
• Prochaska J, Norcross J, Diclemente C. Changing
  for good. Avon Books, 1995.
• Rogers. Diffusion of Innovations, 4 ed. New York
  The Free Press, 1995.