Chapter 15 Improving the performance of health services and programmes
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- Unit 35: Quality and quality improvement
- Case studies
- Unit 36: Tools for reducing wastage and working more efficiently
- Case studies
- Unit 37: Change management
- Case studies
- Unit 38: Implementation gaps
- Case studies
Unit 35: Quality and quality improvement
When you have completed this unit you should be able to:
- Define quality healthcare.
- Understand the importance of quality care.
- Explain why patient satisfaction is important.
- Plan a quality improvement cycle for your workplace.
35-1 What do we mean by “quality” healthcare?
The quality of healthcare refers to how close the standard of healthcare is to the following goals:
- Safe: It avoids harming patients.
- Effective: Services actually provide a benefit to patients.
- Timely: Waiting times and delays are reduced as much as possible.
- Efficient: Waste of time, effort or resources is avoided.
- Equitable: Services are provided in a way that does not discriminate between people because of their personal characteristics, such as race, gender or economic status.
- Person centred: Patients’ needs and values are respected.
Quality care is safe, effective, timely, efficient, equitable and person centred.
35-2 Is “quality of care” a luxury in underfunded and overworked health systems?
No. When resources are limited, it is even more important to make sure that available staff and equipment are used as effectively and efficiently as possible, and that the best possible results are achieved. Quality improvement is the best way of reaching this goal.
35-3 Does providing quality mean more expensive services?
No. It can be more expensive to provide poor quality services because they don’t achieve their aims, can result in complications and mean that patient trust is lost. Quality means doing things well first time around, and that can be the cheapest way to do things. Think of the unnecessary costs involved in an admission to intensive care for a patient whose operation was done by an unsupervised junior doctor, and which has now gone wrong.
A high quality service does not necessarily mean an expensive service.
35-4 Is patient satisfaction important in low- and middle-income countries?
Patient satisfaction is very important in low- and middle-income countries. Patient satisfaction is not about comfortable waiting rooms and good food, although those are nice to have. It is about whether people feel they are treated with dignity and respect and whether they feel they have been listened to and properly treated. When that happens, patients are more likely to be adherent to treatment and to come for scheduled follow-ups. They are also less likely to “shop around” for different answers and make unscheduled visits, particularly to emergency centres. It is challenging to listen to patients properly when clinics are overcapacity and to treat patients with dignity and respect when staff are under pressure, but it makes a difference to clinical outcomes.
Patient satisfaction depends on receiving care with patience, dignity and respect.
35-5 What are the stages in a quality improvement cycle?
There are many different approaches to quality improvement, but a widely used, tried and tested approach is called the Model For Improvement (MFI).
The Model For Improvement has a preparation stage and an action stage. The preparation stage should be done by a quality improvement team, and the following 3 questions are asked:
- What is the aim of the quality improvement project?
- What should be measured to see whether changes are improvements?
- What changes can we try in order to reach our aim?
The action stage of the Model For Improvement involves testing changes to see if they result in improvements. These tests are called “PDSA cycles”.
35-6 What is a PDSA cycle?
A PDSA cycle is a “Plan, Do, Study, Act” cycle. The changes suggested by members of the quality improvement team are tested out on a small scale to see if they result in improvements:
- P= Plan. Decide which change is going to be tested, decide how it is going to be done, and choose some measures.
- D = Do. The change should be implemented on a small scale. For example, if farm managers are to be recruited as DOTS supervisors, this might be implemented on one farm to begin with.
- S = Study. The team then checks whether their change resulted in an improvement by looking at the indicators they have selected, and discusses why it might have succeeded or failed.
- A = Act. If the change results in an improvement, it can be scaled up or made part of routine practice. If it has not resulted in an improvement it can be modified or abandoned. Something else can then be tried.
A quality improvement process will typically involve many PDSA cycles, some of which might be quite small.
PDSA cycles consist of planning, doing, studying and acting.
35-7 Why is it important to try things out on a small scale first?
The reasons for problems, available resources, attitudes and relationships all differ from place to place. A solution that works in one clinic or facility may not be the best solution for another. Solutions must often be adapted to fit the local circumstances. Some trial and error may be necessary to find out what works best locally. The local circumstances are often referred to as the “context”. Trying something out on a small scale is sometimes called a “pilot study”.
Usually several small PDSA cycles aimed at different underlying reasons are necessary for quality improvement as the underlying reasons for a problem are likely to differ in different facilities.
35-8 Who should be in the quality improvement team?
The team should include people who are close to the problem. This will depend on what the problem is. For reducing the rate of bedsores in a ward, the team might just include nursing staff. For problems where the solution is not clear, such as long waiting times, the team might include representatives of the medical and nursing staff, portering, housekeeping, pharmacy and probably a community representative. Supervisors should be kept informed.
The team should start by drawing up an aim statement.
The quality improvement team should include those people close to the problem.
35-9 What is an aim statement?
An aim statement states how much improvement is required, and by when. It should be quite specific. An example of a good aim statement would be:
“We will have completion or cure rates for TB treatment of at least 80% within 12 months”.
A weak aim statement would be:
“We will improve our completion or cure rates for TB”.
An aim statement should be ambitious enough that it makes people excited about the prospect of improvement, but not so ambitious that it cannot be achieved.
35-10 What should be included in the list of improvement measures?
There are 3 main types of improvement measures:
- An outcome measure looks at how close the team is to reaching their goal. For example, percentage of patients completing a 6-month course of TB treatment. It is necessary to think about where this information is going to come from and it is useful to show it on a chart so that the whole team can see progress.
- A process measure looks at the quality and quantity of the activities that are chosen to reach the aim. For example, number of adherence counselling visits by community health workers, or proportion of patients having treatment delivered to their homes.
- A balancing measure is meant to capture unintended “side effects” of a quality improvement project. Balancing measures are not always used, but it is important to think about them. For example, an appointment system might be tried out in a quality improvement project to improve waiting times at an asthma clinic. This might reduce clinic waiting time but might also mean that asthmatics find it more difficult to get routine or urgent care. A balancing measure would be to monitor admissions to the nearby emergency unit with acute asthma.
Note that the measures do not always have to be numbers. They can also include opinions, for example feedback about how easy a new form is to use.
35-11 Who should suggest possible changes?
An important feature of the Model For Improvement is that it allows small changes to be tested to see if they result in improvement. The quality improvement team should include, and seek the opinions of people who work close to a problem because they are often in the best position to suggest changes. For example, a community health worker might indicate that agricultural workers have often already gone to work when she arrives to give them supervised treatment (DOTS), and as a result they often drop out of treatment. She might suggest rather recruiting farm managers or workers to act as DOTS supervisors.
35-12 How should the team decide which changes to test first?
Generally, if it is a good meeting, the quality improvement team will have many suggestions for changes. It is necessary to prioritise them. The team should decide together both how easy it will be to carry out the change, and also how big an impact the change is likely to have. An easy way to do this is to write down all the suggestions for change and then give each suggested change 2 scores, one for ease (1= very difficult to 5= very easy) and one for the likely impact (1=low impact to 5= high impact). The suggestions with the highest total scores (easiest, highest impact changes) should be prioritised.
Case study 1
St Jude’s Hospital is a district hospital in a small town. There have been many letters to the local newspaper sharing negative opinions about the outpatient department. The letters say that the department is dirty and that people sometimes spend days waiting to be seen. There are photographs of broken toilets and patients sleeping on the floor. The superintendent was not available for comment.
Sr Dlamini has recently been put in charge of the outpatient department and decides it is time for a quality improvement project. As a first step, she puts together a team.
1. Whom should she include on the team?
She should include people who are close to the problem. As well as representatives of the medical and nursing staff, she should include somebody from portering, housekeeping, pharmacy and records, and probably a community representative. The medical superintendent should be kept informed as she is in a position to block or support changes, and may wish to take credit for some of the improvements, but she does not necessarily have to be part of the team.
2. Sr Dlamini’s team meets and she asks them to come up with an aim statement. What is included in a good aim statement, and what would you suggest if you were part of the team?
A good aim statement includes “how good” they want to be and “by when”. It should be ambitious, but achievable within a given time period. An example of this might be: “We will have 75% of outpatients satisfied or very satisfied with their treatment within 12 months”.
Case study 1 continued
The team discusses some of the problems getting in the way of good patient care. Many problems are raised, but Sr Dlamini decides to focus on the problem of patients not being seen on time.
Nursing staff reported that many patients arrived at the clinic well into the afternoon when many of the doctors had already left. This is why some patients were waiting in the clinic overnight. The porter reported that as far as he could see, most patients were arriving early in the morning. It seemed that patients were waiting several hours for their folders and as a result arrived late at the clinic. The head of records said this was true, and that their filing system was chaotic – it was like that when he arrived and nobody seemed interested in doing anything about it. One of the cleaning staff said that she doesn’t know why they can’t pull the folders the day before. The head of records says that only half of the patients are booked patients, and he is not sure if his staff will have the time to pull the folders the day before. The same cleaner says that as far as she can see, there is nobody left in the records office after 3pm. She also mentions that her niece was a student at the local community college doing clerical and business studies and they were looking for internships for practical experience and it is a pity there are no jobs for the students when everybody else is going home early.
The team decides that the first change they will try will be for the record team to pull the folders of the booked patients the day before their appointment. Sr Dlamini will also enquire in the meantime about the possibility of internships for clerical students. The superintendent is informed and she supports the plan.
1. What would be a suitable outcome measure for the aim of the team’s project and process measures for the change the team wishes to implement. Are there any balancing measures you would wish to add?
The outcome measure looks at how close the team is to achieving the project aim. If the aim is “75% satisfied or very satisfied by the end of 12 months” the team would have to design a short customer satisfaction survey that they might do monthly and plot their progress on a chart. They will not need to do a very big survey, about 20 patients a month is enough, but they will want to make sure that the patients they ask reflect the experiences of most of the patients.
The process measures look at the quality and quantity of activities that are supposed to meet this aim. In the change the team has decided to try, they will probably want to track the proportion of folders of booked patients that are successfully found the day before and are ready when the patient arrives. In addition, they need to record the waiting times for booked patients, between arriving at the records desk and being seen by the doctor or nurse practitioner.
It would be important to make sure that the unbooked patients are not waiting longer as a result of this change, so as a balancing measure the waiting times of unbooked patients should also be assessed.
2. The head of records will have to use the PDSA approach to make the suggested changes. What advice would you give him?
The important thing is to start small and use as much information as he can to make the change work as well as possible:
Plan: He should decide what to do and discuss it with his staff.
Do: He should start small and do it on one day.
Study: He can then discuss the trial with his staff what went well and what didn’t, and get ideas for doing it better.
Act: They can scale-up the process, adapt it and if needed try something slightly different, or try something different altogether. They go through the same process of monitoring the changes until they are happy with the results.
The head of records should also report back to the quality improvement team for feedback and more ideas.
Unit 36: Tools for reducing wastage and working more efficiently
When you have completed this unit you should be able to:
- Identify sources of wastage in your work place.
- Apply the 80/20, the 5-S tool and visual management tools to reduce wastage of time and materials.
- Describe what is meant by a standardised care plan and how you go about creating one.
- Explain what is meant by flow management.
36-1 Is wastage a problem in healthcare?
Yes. Healthcare systems, particularly public health facilities, can be very wasteful. They can waste the provider’s time:
- When you can’t find what you need.
- When you are continually being interrupted.
They can waste the patient’s time:
- Long waiting times, sometimes only to find that the services they have been waiting for are not available.
- Unnecessary administrative requirements.
They can block access to services for other patients:
- When you’ve discharged your patient but find he can’t go home.
Government health services can also be very wasteful of financial resources. For example:
- Large overstocks of drugs and materials that then expire.
- Inappropriate use of investigations or treatments.
- Water left running in unrepaired toilet cisterns.
- Air conditioning left on in offices over weekends and holidays.
Health systems in public health facilities can be very wasteful.
36-2 Why is it important to identify sources of waste in healthcare?
Important reasons are:
- There is a proven relationship between inefficient, wasteful systems and poor patient outcomes, with an increased waiting times leading to patient frustration and increased staff workload. This leads to poor staff morale and an “unhappy system”.
- When budgets are exceeded before the end of the financial year, ordering may stop and stock outs increase. New staff may not be employed.
36-3 Can lessons from industry help us to understand waste?
Yes. In recent years, lessons from manufacturing industries have been applied to healthcare and fit surprisingly well. Using these industrial approaches is sometimes called “Lean” healthcare.
The Toyota car manufacturing company identified 7 types of waste in its manufacturing process. The types of waste found in manufacturing can all be found in healthcare. Examples include:
- Time: Time wasted waiting, looking for things, duplicating of tasks, and using professional staff for administrative and non-skilled labour. Up to 70% of a professional nurse’s time is wasted doing non-nursing tasks, for example answering phones, portering patients and opening files.
- Defects: Mistakes and clinical judgement calls that turn out to be wrong require time and resources to put them right. This is why the “hands on” presence of senior clinical staff is necessary.
- Motion: The intravenous fluids, cannulae, giving sets, alcohol swabs and plaster required to put up a single drip are all kept in separate clinical areas.
- Transportation: Moving patients, staff or equipment unnecessarily.
- Overproduction: Patients choose to attend for emergency care when their condition could have been managed by a primary care nurse during the day, or self-managed at home.
- Inventory waste: Stock lost, opened and not used, or expired.
- Processing waste: i.e. “routine” bloods, unnecessary X-rays.
36-4 Which tools can be used by clinicians to improve efficiency in their workplace?
Important tools that can help are:
- The 80/20 rule
- The 5-S tool
- Visual Management
- Standardised Care Plans.
- The 80/20 rule is also known as the Pareto principle.
36-5 What is the 80/20 rule, and how can it help?
The 80/20 rule states that 80% of outcomes (or 80% of the work) come from 20% of the causes (or 20% of the problems). This means that 20% of the tasks will take up 80% of the time, and the top 20% of presenting complaints will take up 80% of your time. It is important to identify the tasks that are done all the time and the types of cases you see all the time and focus on making these tasks easier for yourself.
The 80/20 rule says that 80% of outcomes result from 20% of causes. It is efficient to identify the cases and procedures that you deal with most commonly and focus on them.
36-6 What is the 5-S tool?
5-S means Sort-Store-Shine-Standardise-Sustain. It is an organisational tool that reduces waste by organising the work environment so people don’t have to look for things:
- Sort: Identify what you need and what you do not need in your work area. You may be surprised by how much “junk” there is in clinical areas. Dispose of items that are definitely not needed or are broken. Items that may possibly be needed should be stored away from the main work areas. Colour coded rubbish bins and sharps containers must be easily accessible and all staff firmly encouraged to use them.
- Store: Organise equipment, disposables and stationary according to the frequency with which they are needed. There are some items that will be needed for just about every patient, and these should be stored within arm’s reach where possible. Items required only a few times a day should be a stored within a short walk. Less frequently accessed “nice to have” items should be stored in departmental store rooms. In addition to making commonly used things more easily available, this approach means that the items that will most quickly run out are all in a predictable place, making stock management easier.
- Shine: End users need to take responsibility for keeping clinical areas clean and safe. This means disposing of waste appropriately and immediately, not leaving it on work areas. Try to make sure that bins for clinical waste (usually red bags) are not used for non-clinical waste such as paper towels and packaging, as the disposal of clinical waste is expensive.
- Standardise: Examination cubicles should be stocked a standard way, and all resuscitation trolleys in a facility should be organised the same way. This means that professional staff who use more than one clinical area do not have to familiarise themselves continuously with their work environment. Standardisation also allows people quickly to recognise what is missing from a room. Standardisation does not mean that everything must be completely identical. Most of the items required in, for example, gynaecology and surgical outpatients are the same, such as linen, syringes, specimen bottles, gloves and so on. However, the equipment required for special examinations and procedures will differ. You can produce standardisation by organising cubicles so that “special equipment” is always in a particular area and the general items are organised in the same way in all cubicles and clinics.
- Sustain: This is the most difficult part of the 5-S tool. During this phase you ensure that things don’t get forgotten. Continually work to improve your working environment further. You may have to change the layout of your work spaces as you use them. For example, if you continually find you have to clear gloves off a particular surface, consider whether a bin is required in that area.
5-S stands for Sort-Store-Shine-Standardise-Sustain.
36-7 What are visual management tools?
Visual Management tools allow you to know exactly what is going on in your work area at a glance. Visual management tools help providers:
- To see where items are stored by using large labels. These can also be colour coded. For example, blue labels for intravenous fluids, cannulae, and giving sets, and red labels for anything to do with taking blood samples.
- To make invisible processes visible. Most clinical work revolves around invisible processes. A typical problem is the patient waiting for blood results who has no identifying marker that separates her from another patient who is waiting to be seen. Visual management tools are methods of making this work “visible” so that staff know exactly what needs to be done next and don’t have to continually check with folders, the patient or each other to find out. Thus the clerk will be able to identify his or her work, the same with nurses, doctors, and porters.
36-8 How can visual management tools show invisible processes?
There are various different types of visual management tools, which are developed in response to the unit needs. The most common tools are:
- Coloured stickers for different categories of patients
- Bed markers
- Whiteboard notes.
36-9 How can coloured stickers be used?
Coloured stickers can be attached to patients’ clothing so that they can be easily recognised at a distance. Coloured stickers can also be attached to clinical folders to identify certain patients.
36-10 What are bed markers?
Bed markers are usually simple coloured labels that identify the next step for the patient. For example, if a patient has been delivered to a clinical area by the emergency medical services a coloured label could be attached to their bed indicating that the patient has not yet been triaged. Nursing staff can then see at a glance who are the new patients needing triage. Patients waiting for X-ray could have a different coloured label so that the porter can see at a glance who needs to be taken to the X-ray department.
36-11 What are whiteboard notes?
A “jobs list” on a white board can also be placed in an easily visible position, with separate sections for each discipline. For example, in an emergency centre if a patient needs to be taken for X- ray, the bed number and “X- ray” is written in the porter’s section. The disadvantage of this system is that the bed number refers to a bay in the clinical area and the patient may be “parked” in a different bay when they return from X- ray. This can cause confusion if there are outstanding requests on the “jobs list” that refer to the original bay.
36-12 How can defects and processing waste be reduced?
The Visual Management and “5-S” tools create efficiency by reducing wastes of time and motion. Other waste, such as defects and overproduction are harder to prevent but can be addressed by standardising clinical management using:
- “Best practice” guidelines.
- Standardised care plans.
36-13 What do we mean by “Best Practice”?
Best practice means providing quality care to achieve the best possible outcomes using the fewest possible resources. “Best practice” guidelines are frequently developed by specialists in secondary and tertiary level hospitals, and may not be relevant to healthcare services in more rural and remote areas. Practice guidelines may need tailoring to the specific setting and it is probably more realistic to think of “good practice” rather than “best practice” guidelines.
36-14 What is a Standardised Care Plan?
Standardised care plans involve the use of “best practice” guidelines, but also define the expected illness progress in hospital. If the patient deviates from expected progress, there should be a second review, or perhaps extra investigations or a referral. For example, in a simple community acquired pneumonia, the patient’s temperature is expected to return to normal within 24 to 48 hours. If this doesn’t occur it is necessary to start looking for factors like a non-sensitive infection, including TB. Similarly, a patient lying in a district hospital on “drip and suck” who has not improved after 24 hours should be discussed with a surgeon.
Standardised care plans combine “best practice” care with the expected clinical course of the patient.
36-15 How should a Standardised Care Plan be drawn up?
While the concept of Standardised Care Plans is easy to grasp, the creation of one is more difficult. As a first step, we need to apply the 80/20 rule and identify the most common causes for admission. Then, a group of people who routinely treat these patients needs to sit together with best practice guidelines for the illness and adapt them for their resources. For example, there is no point advocating physiotherapy for a patient with pneumonia if you have no physiotherapist available. Decisions need to be made about what constitutes best practice in your unit and work needs to be arranged to minimise the length of stay. Those who have experience of treating these conditions should plot out the patient’s expected clinical course.
36-16 What are the advantages of standardised care plans?
The knowledge that would be used by more experienced clinicians in assessing the patient’s progress is formalised and then made accessible to guide the less experienced health workers. With a standardised care plan:
- It is possible to identify potential “red flags”, together with alternative courses of action if the patients does not improve as expected.
- Appropriate referrals can be made to allied health professionals at the right time.
- Discharge planning can start when the patient is admitted.
When standardised care plans are used, less experienced clinicians can identify problems and intervene earlier.
Once it has been decided what the standard care will be, then checklists and paperwork need to be developed and systems put in place to ensure the system works as planned. For example, how will the diabetic counsellor know there is a diabetic patient in the ward she needs to counsel on Day 1? What has to be in place for the Social Worker to start looking for placement of an elderly stroke patient?
36-17 What is meant by “flow management”?
“Flow” means a steady movement. As there is usually a steady movement of patients into a health facility, “flow management” means organising patient care so that they move steadily through a care pathway and are discharged with as few obstacles as possible. Flow management is important because if patients meet obstacles that slow their movement through the system, a facility becomes more crowded and it becomes more difficult to deliver good quality care. An obstacle to flow is often called a “bottleneck”.
Flow management makes sure that patients move steadily through a health facility without any holdups.
36-18 How can patient flow be assessed?
Patient flow can be assessed by getting together a team of people involved in managing a patient, including clerical staff and porters. The major steps that a patient passes through are identified and drawn as a diagram of boxes and arrows on a flip chart with a marker pen. When the team has agreed on this, the next step is to go into the details of what happens at each step. The aim of the exercise is to identify unnecessary duplications, unnecessary waits and steps where staff do inappropriate tasks.
Examples of obstacles to patient flow include:
- Patients needing to queue and register more than once in the same facility.
- Porters needing to return to their base for each new task when more than one task could be incorporated into the same journey.
- Nurses doing administrative tasks that could be done by clerks.
- Patients not being discharged because there is no transport.
36-19 How should obstacles to patient flow be managed?
Once bottlenecks have been identified, they can be tackled with a PDSA cycle. Changes made to reduce one bottleneck may make things worse at another, so it is particularly important to try out the change and study what happens before a new policy is made. An example of a change to remove a bottleneck in a hospital is the use of a discharge lounge. Patients can sit here after discharge and receive refreshments rather than wait in overcrowded wards. Meanwhile ambulances that have delivered patients to the facility and would otherwise be returning empty to different districts can then pick up passengers from the discharge lounge and take them home.
Case study 1
It is Dr Prudence’s first week on call in St Jude’s casualty ward. She has several patients to admit and needs to take bloods and put up intravenous lines for adult and paediatric patients. She has to spend an extra 15 minutes on each patient searching in several clinical areas to find the correct cannulae, syringes, blood tubes and dressings. Lastly, she has to search for the duty matron because the bags of intravenous fluid are in the store room and the matron has the key. Exhausted, she meets Sr Dlamini in the tea room the following morning and describes her night on call. Sr Dlamini recognises unnecessary waste and suggests they go to see Mr Nkosi, who is in charge of casualty.
1. Which efficiency tools will best help them to tackle this waste of time and effort?
The 80/20 rule, the 5-S tool, inventory management and visual management. 5-S is the tool for organising the work place so that people do not have to look for things. Visual management (large, clear labels) will allow clinical staff to see where things are kept, and also encourage people to re-stock items in the correct place.
2. It is Saturday night and Dr Prudence is again on call. She needs to suture in a chest drain, but cannot find any suture material. She again has to go to the store cupboard, but all she finds is a whole shelf full of 3.0 chromic catgut, which she knows is not strong enough, and several boxes of a very tiny eye suture that have all expired. What type of wastage is happening here?
There are 2 types of waste here. There is a waste of time as Dr Prudence searches for the correct material while her patient needs his chest drain. There is also inventory waste. Suture materials are very expensive (particularly the very tiny ones). The eye sutures will have to be discarded because they have expired, they should probably not have been in casualty in the first place. Chromic catgut is also not a very useful casualty suture, it might be possible to swap it out with the operating theatre but it is quite old fashioned and may also be eventually thrown out.
3. Which tools will help in this situation?
Flow management, 80/20 rule, inventory management and visual management. Starting with the 80/20 rule, the team will need to decide which suture materials are used on most of their patients (“high use items”), and which are the “nice to haves”. Anything else should not be in casualty.
The 5-S tool can be used to make sure that these high use sutures are always to hand in the clinical areas. Doctors should not be rummaging around in store cupboards looking for high use items. It is fine to keep the “nice to haves” locked in the store.
Inventory management is necessary to prevent inventory waste. The team will need to decide the minimum and maximum stock levels for the high use items and the “nice to haves”.
Visual management that clearly indicates the maximum and minimum stock levels means that these items can be replenished from the store cupboard, or re-ordered from the main stores before they expire.
Case study 2
It is the Christmas season. Dr Prudence is again on call. This time, she has been left by herself, with cover from a general practitioner in the town. On Monday, she sees an elderly patient who has abdominal pain and vomiting, with a distended abdomen and some dilated bowel loops on his X-ray. She thinks he probably has a bowel obstruction, but it might also be gastroenteritis. She remembers “drip and suck” for bowel obstructions, so she places a nasogastric tube and an intravenous drip and admits him to the ward. She carefully sees him every day, and each day he says he thinks he is feeling a little bit better. However, 5 days later it is Friday afternoon and she can see he is weak. She transfers him to the surgical service of the regional hospital. On Saturday, she receives an angry call from the surgical trainee who says that the patient had some dead bowel, he asks how she could possibly drip and suck somebody for a whole week?
1. How could this situation have been avoided using the tools in this chapter?
This is a situation when a standardised care plan would have been useful. A standardised care plan need not be very complicated, but it sets out the expected progress of the patient. The more experienced doctor knew that a patient who was not better after 24 hours of “drip and suck” in a district hospital was not likely to get better by himself, but Dr Prudence did not and there were no guidelines to help her. The surgical team at the regional hospital is responsible for producing guidelines for standardised care of patients with common surgical problems. These guidelines can also be used at the referring hospital.
Unit 37: Change management
When you have completed this unit you should be able to:
- List the steps in change management.
- Explain the role of good communication in successful change management.
- Design a change management process in your workplace.
37-1 What is change management?
Making a change is easy. It may also be easy to show that a change is an improvement in the short term. The difficult part is getting other people to accept change and to maintain change, because people do tend to slip back into old ways of doing things. The process of making changes in a way that is accepted and sustained is called change management.
Change management is a way of making acceptable and sustained changes.
37-2 Why is change resisted?
There are several reasons why people may resist change:
- They may have been doing things the same way for years and are comfortable with it.
- They don’t see the need for change.
- They see change as a criticism of the way they already do things.
- They may feel that change will mean more work.
37-3 What are the steps in change management?
The steps are:
- Raising the issue.
- Determine your authority to make change.
- Find out who in your team are the enthusiasts and who are likely to resist.
- Make sure that the option you are changing to is the best one.
- Once you have made the change, don’t give up at the first sign of difficulty or resistance.
- Support the change until it becomes part of routine practice.
37-4 How should you raise the issue?
You will need to be sensitive when you raise the matter of making a change. It will often imply a criticism of the way things have been done before. Phrases such as “does anybody else have a problem with..?” can be a useful way of raising awareness.
All change management implies criticism of how things were done before. Be sensitive to this.
37-5 Why is it necessary to determine your authority to make changes?
It is a mistake to think that you can just make changes when you find something problematic in your workplace. You need firstly to find out why things are done in a certain way, and this will also tell you who has the authority to make changes. For example, you may find that filling in a particular form is a pointless nuisance, but if the form is required by the Department of Health, you will not get very far trying to change it in your hospital or clinic. For issues within the facility, you also need to find out who is responsible for making decisions. For example, you might want to change the layout of the equipment in your resuscitation trolley and decide to ask the senior professional nurse to arrange the trolley your way. Your attempt at change will not succeed if the current layout was decided at some time in the past by an administrative matron or by the nursing college and your colleague feels that it is still the “correct” way specified by those in authority.
Change management will fail if you do not have the authority to make changes.
37-6 What should you do if you do not have the authority to make changes?
If you do not have the authority to make changes yourself, find out who does and get them on board to support you.
37-7 Why is good communication important?
“Change imposed is change opposed”. This means that if people feel you are making them do something that does not suit them, they will not go along with it. If you are lucky, they will simply disagree with you. The more difficult situation is where they appear to agree but just don’t do it. Good communication is essential to avoid a sense of imposed change. Remember communication is about listening as much as talking and you need to listen carefully to the opposition you are receiving, whether it is loudly spoken or quietly opposed. Allow the others who will be affected by this change the opportunity to be listened to and honestly consider their concerns.
Without good communication change management is very difficult.
37-8 How can you get people on board to support you?
You will have to spend some time working out “who is who” in your team, talking to them, but also listening to their input. You will identify some enthusiasts, who will be happy to run with a new project, but you will also identify resisters. Resisters are important and useful, but you need to know who they are. Stress that the changes needed are to improve patient care and not simply to meet your own needs.
37-9 How do you know if you have chosen the right alternative?
You need to know that your changes will be acceptable and result in improved processes or outcomes that will benefit patients. The best way of doing this may be to use a quality improvement process. Otherwise, make sure you have discussed widely with your team and considered other options for tackling the problem, and the potential pitfalls of your proposal. Resisters are particularly useful at these meetings because they are more likely to point out any flaws in your plan. If their input is welcomed, they may start backing the change. Make sure that you are aware of any extra resources that may be needed, particularly demands on human resources.
37-10 How can you get people to be positive about a change?
You need to communicate your own enthusiasm to other staff members. When you discuss the change, always bring it back to the goal, which will usually be improved patient management, just to remind everybody why this is a worthwhile effort. Change resisters can be your allies here. If you have been able to bring them into your team and given them some ownership of the change, you may find that they are leaders of more silent resisters and they will bring those people with them.
Spend some time planning and discussing your change. Talk, but also listen to people’s objections and doubts
Good communication involves talking, but also listening and taking note of what others say.
37-11 Why is it important that you stick with the decision you have made?
There will be problems and pitfalls with your change, and you will only find out about some of them after you have implemented it. You can modify your change, but don’t go back to the original situation as soon as difficulties arise. There was a reason why you made a change, and if you have spent enough time talking and listening to your colleagues, and trying things out on a small scale where necessary, you can be reasonably confident that you have made the right choice. Communicate your ongoing commitment to the change despite the pitfalls.
37-12 How can you maintain the change you have started?
There is always a tendency for things to slide back to their previous situation. You need to keep supporting the change. Make sure that the changes are communicated to all the shifts, even if that means you have to give up some of your off time to do it yourself to get the correct message across with the needed level of enthusiasm. Remember your biggest resister maybe someone who doesn’t work with you on a daily basis, for example somebody on a night shift.
37-13 How do you know when you can relax your vigilance?
You can relax your vigilance and know your change management has been a success when new staff members are told by existing staff “this is the way we do it here”.
Case study 1
Dr Prudence reads up about 5-S and decides to implement it in her casualty workspace. After clinic, she returns to casualty and clears away large volumes of expired and rarely used materials. She buys a desktop organiser and neatly stacks the forms for X-ray requests, laboratory requests and discharge letters in it. She finds some plastic tubs that she labels for syringes, some trays for the 19G and 21G cannulae that she uses all the time, and labels a shelf with the IV fluids and giving sets that she uses for most patients, together with a minimum and maximum stock level. She is satisfied that she will be able to find easily all the important items on her next call. Two days later she returns to casualty. Her desktop organiser has disappeared and the workspace looks as chaotic as it did before her improvements.
1. What has happened, and what could she have done differently?
Without meaning to work against her, the staff just continued to use and re-stock clinical areas in the same way as before, with the result that the workspace very quickly returned to its “normal” state. It is likely that somebody did not know why the desk organiser was in the workspace, and stored it for safekeeping because it was clearly new.
As a new community service doctor, she probably did not have the authority to make permanent changes in the layout of casualty. Although she should certainly be able to organise her workspace, she is also asking the nursing staff to work in a different way and to respect and maintain the way she has organised things. The change is more likely to be sustained if she gets the support of the nursing manager, Mr Nkosi, who has the authority to ask the nurses to work in a different way. It will also be necessary to explain the changes to those working on all shifts. It will probably take some time and persistence before Dr Prudence’s change becomes the new way of organising the clinical workspaces in casualty.
Unit 38: Implementation gaps
When you have completed this unit you should be able to:
- Identify the main global health treaties and explain why they are not well implemented.
- Explain the factors that may prevent effective public health laws from being passed.
- Explain why the scale-up and roll-out of programmes often fails.
- Appreciate the importance of patient acceptability and uptake in the success of programmes.
38-1 How important are implementation failures in public health?
They are very important. It should be clear by this point that a great deal is known about the underlying causes of ill health and the solutions to these problems. One of the surprising things about both public health and clinical care is that, despite this knowledge, and in many cases despite good policies and plans to deal with the problems, many health indicators in a country like South Africa show only a modest improvement. Some, like the rates of stunting in children, have changed very little.
The gap between knowledge of the best solutions and their implementation to produce better outcomes is a worldwide phenomenon. Because better use of known solutions is likely to bring greater benefits than any new discoveries, there is growing interest in the science of implementation. Several barriers to implementation are well-known and it is worth discussing them together here.
38-2 Why may solutions to public health problems not be implemented?
Solutions to public health problems may not be implemented because:
- The right laws or policies are not made.
- The right laws or policies are made, but the people in a position to carry them out do not do so.
Also a solution may work well in one setting, but fail to be scaled up because it does not work so well in other settings. This is usually because the context (the people and the environment) is different.
- Some people use the term “implementation science” in health to mean the study of reasons why “evidence-based practices” often fail to be scaled up.
38-3 What are the important global health treaties?
All member states of the World Health Organisation (WHO) have signed 2 global health treaties, the International Health Regulations (IHR), and the Framework Convention on Tobacco Control.
The International Health Regulations are designed to improve global surveillance and provide rapid response for emerging infectious diseases. Under this treaty, each country should have a surveillance system together with a system to respond to outbreaks of infectious disease. Outbreaks of importance should be reported to the World Health Organisation and its Director General has the responsibility for declaring an International Public Health Emergency. The World Health Organisation should then take the lead in directing clinical guidelines, travel advisories and doing scientific research into the outbreak.
38-4 How well have these global health treaties been implemented?
A failure to implement the International Health Regulations was clearly seen in the 2014 Ebola outbreak in West Africa. National governments had not put the agreed surveillance systems and laboratories in place, and the World Health Organisation Director General declared an International Public Health Emergency very late.
The 2005 Framework Convention on Tobacco Control involves a series of measures to reduce tobacco consumption using pricing and advertising restrictions, together with measures to reduce exposure to smoke in public places. In the 2014 progress report, 73% of countries submitted a report and one third of those reporting had not yet passed legislation required by the convention.
Partial implementation of these international treaties, which had serious consequences in the case of Ebola, is a result of:
- No mechanism for “policing” international treaties.
- Failures in leadership from some national governments and, in the case of Ebola, from the World Health Organisation.
38-5 Why might national legislation for public health not be passed?
Public health legislation is affected by political will (how important a new law is to politicians), but also by other political considerations. These include:
- International treaties
- Upsetting large companies who may then take their business (and jobs and investment) to another country.
- Upsetting voters. For example, increasing tax on cigarettes or putting a tax on junk food restaurants would increase prices. This would probably mean that people smoked less and ate less unhealthy food, but might also upset many voters who consider smoking or junk food to be important.
38-6 What does it mean to “scale-up” or “roll-out” a national, regional or local programme?
When a change in practice has resulted in an improvement at one site, managers often wish to scale-up or roll-out the change. The terms “scale-up” or “roll-out” mean the same thing. It is expanding the reach of a policy or practice across different sites and different contexts. However, scale-up or roll-outs often fail.
38-7 Why do scale-up or roll-outs often fail?
They can fail because:
- The context may be different from that at the pilot site. For example, there may be differences in the supply chain, staffing levels, caseload and acceptability to patients that make a change less effective. Managers often wish a change to be implemented in a rigid way and there may be no mechanism to allow health providers to adapt and customise solutions for their own context and needs.
- There may not be an understanding of why the intervention worked well at the pilot site. For example, a surgical checklist developed in the United States was very effective at reducing complications during surgery. The same improvement was not found when the checklist was rolled out to other countries. This is probably because an important part of the checklist was identification of possible problems by surgeon, anaesthetist and scrub nurse before the operation, and discussion about how those problems would be handled. When this was not understood, the checklist became just another piece of paperwork.
- There is the usual resistance to change found in most health facilities and health systems, and nobody is driving the change from within.
- Often there is an enthusiast or champion at the pilot site while there may be no one passionate to drive the programme at other sites.
38-8 Is uptake and adherence by patients or the public an important factor in programme success?
Yes. Although patient factors are not usually considered to be a part of implementation, the uptake by the “end users” is a critical factor determining how successful programmes will be. For example, in South Africa mothers generally take their infants for their immunisations, the last of which is given at 18 months. However, they are much less likely to take them for the later clinic visits where they receive growth monitoring and vitamin A supplements but no immunisation. Forty percent of South African children are vitamin A deficient.
Case study 1
Sr Dlamini has now been promoted to the district office. After her successes at St Jude’s, she has been made Coordinating Primary Care Manager. One of her first actions is to roll-out the use of community care workers as adherence counsellors for diabetes at other facilities. She finds out that most of the other facilities in the district already employ half-day community workers for hospice outreach, TB or HIV care. She has convinced the senior managers that her scheme is cost effective because it saves money on admissions, so she is authorised to extend the hours of 5 care workers at each site for the second half of the day. She sends a circular to all the facility managers together with a package of training materials. Unfortunately, the scheme fails and no difference in diabetic admissions is seen at any of the roll-out sites.
1. Why might this be?
There has been a failure in implementation. This is probably a result of the context being different at the other sites, a lack of understanding about what made the pilot project a success and the usual resistance to change. Perhaps the care workers did not want to work full time because they had afternoon commitments such as child care. If they were working with TB and HIV, it is also possible that the diabetic patients did not want the care workers to visit at home because of fear of being stigmatised by the community. In the St Jude’s project, the workers were aware that they were part of a special pilot project and were likely to have been more enthusiastic. Also, Sr Dlamini was not present at the roll-out sites communicating her enthusiasm and driving the change. The circular is likely to have been seen as another imposed change from District Office. Remember that “change imposed is change opposed”.
2. What could she do differently?
It is important to understand the context of the change and adapt the programme accordingly. It is equally important to communicate the reason behind the improvement and to try to identify allies who will act as agents of change at the roll-out sites.