Strategies for Effective Implementation and Spread of Quality
Improvement Initiatives
“Managing change in the health care setting is always
challenging, especially when it involves transforming entrenched habits
grounded in professional expectations.” (McMurray, Chaboyer, Wallis &
Fetherston, 2010, p. 2581). Healthcare
organizations are continually challenged to improve the quality and safety of
patient care and to spread the innovations throughout their facilities. According to Pearson, Upenieks, Yee, Needleman
(2008), spread is defined as the active dissemination from one health care
setting to another of new ways of organizing or providing care. There is substantial amount of literature
describing health care facilities incorporating various change programs, such
as The Productive Ward, Transforming Care at the Bedside and ThedaCare
Improvement System who apply various change theories and Lean management
principles. According to the Queensland
Government (2010), despite the range of approaches, common factors for
delivering successful change exist. Since
successful change drives sustainment and spread of innovations, understanding
factors that effect change management will likely enhance understanding of
effective strategies for spread. The
focus of this paper is limited to identifying key factors that influence
successful change management. Three
effective process improvement strategies identified from the literature will be
explored. These are listed as
organizational support, widespread communication and stakeholder
champions. Thereafter, the paper will
describe strategies for effective spread of a quality improvement initiative.
Organizational Support
Literature consistently reports that
a successful widespread quality improvement initiative requires commitment,
visibility and support of senior leadership (Armitage & Higham, 2011;
Barnas, 2011; Blakemore, 2009, Robert, Morrow, Maben, Griffiths & Callard,
2011; Martin, Greenhouse, Merryman, Shovel, Liberi & Konzier, 2007; Roussel,
Buckner, Salas & Brown, 2012; Steed, 2012; Wilson, 2009). According to Robert, et al. (2011), each
ward is a vital cell of a larger structure therefore, unit-specific initiatives
are to align with the overall organizational visions and goals (McMurray et
al., 2010) and be part of a supportive organizational infrastructure (Kliger,
Singer, Hoffman, & O’Neil, 2012; Robert et al., 2011). Proponents of change management through Lean Thinking
site senior administration as the “most critical requirement” for achieving
success in all stages of the change and spread process (Steed, 2012). The Advisory Committee on Primary Care Renewal
(2007) supports this belief saying there is “never too much executive level
support” and executive sponsors "must identify the change as a key
strategic initiative…publicly proclaim” their endorsement of the
initiative. Tsasis & Bruce-Barrett
(2008) go further to say that with leadership support, the change becomes
implemented throughout an organization and the overall organizational culture
changes accordingly, resulting in development of engaged and empowered staff. This culture becomes a safe and supportive
infrastructure which encourages, sustains and spreads process improvement
initiatives (Tsasis & Bruce-Barrett, 2008).
A study report by McMurray, et al. (2010) suggests staff’s global
perspective and understanding influences their ability to design, implement and
sustain quality improvement initiatives at the unit level and contributes to successful
implementation, commitment and sustainment of change initiatives. Barnas (2011)
claims that success is dependent on senior executives’ commitment to the
fundamental change initiative, acknowledgement and understanding of the impact that
the change imposes, and actively demonstrating support to those participating
in the change process.
Throughout
literature, the concept of support takes multiple forms. These include assisting with removal of
process barriers (Barnas, 2011, Martin, et al., 2007; Pearson, et al., 2008),
collaborating with patients and staff in testing new ideas and to lend
credibility and sustain momentum (Blakemore, 2009; Martin, et al., 2007;
Pearson, et al., 2008;), aligning appropriate financial and personnel resources
(Barnas, 2011; NHS Institute for Innovation & Improvement, 2010), publicly
communicating support (Holleman, Poot, Mintjes-de Groot & Achterberg, 2009),
monitoring,
measuring and reporting progress ( McMurray, et al., 2010), maintaining transparency and accountability
by tracking of patient and staff satisfaction and financial targets (Steed,
2012), visibly and actively engaging with frontline staff to empower innovation
strategies (Blakemore, 2009; Roussel, Buckner, Salas, Mosley & Brown, 2012),
and acknowledging and respecting individuals involved in the change process,
being attentive to their need for reassurance and encouragement (McMurray, et
al., 2010).
Widespread
Communication
The
Advisory Committee on Primary Care Renewal (2007) identifies need for a
strategic communication plan to effectively spread innovations; the Institute
for Healthcare Improvement indicates the communication needs to help staff
understand they process they are spreading and its effect on patient care (Agency
for Healthcare Research & Quality, 2012). Holleman, et al. (2009) identify three studies
which support the idea that presentation of clear rationales improves group
focus and progress. Creating awareness
and understanding of the change and highlighting potential transformation
benefits to the lives of patients and staff can contribute to achieving success
(Burston, Chaboyer, Wallis & Stanfield, 2011; NHS Institute for Innovation
& Improvement, 2010; Queensland Government, 2012). In addition, the framing and delivery of the
message influences people’s preconceptions and impacts their adoption of the
change (Barnas, 2011). Johnson, Smith,
& Mastro (2012 ) report that since leaders typically under communicate during
organizational change, attentiveness to frequent and specific communication
strategies is the key to achieving and sustaining quality improvement efforts,
and creating an “ongoing culture of care delivery change” (Martin, et al., 2007,
p. 451). At the same time, Steed (2012)
claims research reveals inconsistencies in the extent to which leaders assume ownership
for the communication plan. Despite
different approaches used by institutions to navigate the change process, literature
consistently identifies communication as a key factor in successful change
management and describes various communication methods to collaborate, motivate,
address concerns, inform and build awareness.
(Armitage & Higham, 2011; Kliger, et al., 2012; Steed, 2012; Wilson,
2009).
Communication
in the form of crucial conversations with frontline staff promotes exploration
and understanding of individuals’ concerns and resistance to change and thereby
reduces the risk of failure to meet desired process improvement objectives (Fagerstrom
& Salmela, 2010; 5
Million Lives Campaign, 2008; Tsasis & Bruce-Barrett, 2008). According
to
Kliger,
et al. (2012), collaboration amongst other teams involved in the change project
promotes shared learning and shared accountability, further contributing to
successful sustainment of process improvements.
Armitage and Higham (2011) note that a shift work system can present a
challenge to consistent information sharing.
A strategic communication plan ensures information reaches all members
to enable effective teamwork and sustainment of change. Measuring the effect of the initiative and
providing frequent feedback and acknowledgment of staff’s accomplishments and
challenges, generates better ideas, enhances staff engagement, accountability, empowerment
and overall sustainability (Agency for Healthcare Research and Quality, 2012;
Blakemore, 2009; Martin, et al., 2007; Pearson, et al., 2008; Steed, 2012; ).
Stakeholder Champions
After
critically reviewing several contemporary approaches to change management Burston, et al. (2011), report that although
incorporating a variety of strategies is recommended, “the engagement of
front-line staff emerges as fundamental to sustaining these approaches.” Literature consistently supports involvement
of individuals who have knowledge of the process improvement opportunity and who
also have a stake in its solution (Burston, et al., 2011; Fortier, 2012;
Holleman, et al., 2009; Johnson, et al., 2012; Kliger, et al., 2012; Pearson,
et al., 2008; Roussel, et al., 2012; Tsasis & Bruce-Barrett, 2008). Blakemore (2009), Martin, et al. (2007) and
Snyder & McDermott (2009) add that a multidisciplinary team consisting of
clinical and non-clinical staff, experts from other disciplines, individuals
involved in similar change initiatives and patient participants enhances success with implementation and
spread. This collaborative approach broadens
understanding and facility-wide commitment to the new initiative (Martin, et
al., 2007). Roussel, et al. (2012)
explore how nurses commit to effective transformational change and found that “staff
engagement in improving the work environment and patient care processes is
paramount to change” (p. 203). Experts
in Lean management believe staff’s participation in action-orientated work
sessions for process change produce high engagement (Johnson, et al., 2012). The
success of implementing this form of thinking is very much dependent on a
receptive organizational culture that embraces active participation at the
grass roots level (Tsasis & Bruce-Barrett, 2008) and one that carefully orchestrates effective
executive support with the ability to relinquish control to frontline staff (Burston,
et al., 2011). Facilities utilizing this
bottom-up approach report a cultural transformation of the organization where
change and learning is embraced and is part of continuous, daily workflow
management (Tsasis & Bruce-Barrett, 2008).
Blakemore (2009), Burston, et al. (2011), Johnson, et al. (2012),
Martin, et al. (2007) and Tsasis & Bruce-Barrett (2008) show evidence of engaged,
empowered, motivated staff that embrace, own, lead and sustain the change; Roussel,
et al. (2012) report there is little evidence on effective interventions to
promote employee engagement. According
to Armitage & Higham (2011), the 2010 National
Nursing Research Unit’s Learning and Impact Review suggested a potential
for development of ward level leadership could be an unexpected benefit but
requires further research.
There
is overall agreement in literature that innovations require a behavioral change
and attempts to change behavior are likely to be dependent of the functioning
of a team (Armitage & Higham, 2011; Blakemore, 2009; Kliger, et al., 2012;
Martin, et al., 2007; Snyder, 2009).
Holleman, et al. (2009) mention that the Disney studios have ascribed
their success to the dynamics of the group rather than individual
abilities. Howard Schultz, chairman and former CEO of
Starbucks, relies on teams to become involved with daily system improvements
and attributes business success to engaged, empowered and enthusiastic
individuals who function as partners in the company (Michelli, 2007). Although the literature review by Holleman,
et el. (2009) reveals that “due to weak research methods, the relevance of team
characteristics and team directed strategies was not clearly demonstrated” (p.
1263), Armitage & Higham (2011), Blakemore (2009), NHS Institute for
Innovation & Improvement (2010), Robert, et al. (2011), Pearson, et al.
(2008) and Wilson (2009) support selection of teams based on their track record
for high performance, leadership, energy, enthusiasm and ability to champion
innovative ideas. Blakemore (2009)
reports successful implementation of Productive Ward programs in England where
wards that are doing reasonably well and require no radical reform are chosen
to participate in the improvement initiative to expedite change and motivate
staff. Pearson, et al. (2008)’s study of
successful spread reveals that although most sites focused on maximizing the
likelihood of success by choosing stable units, some focused on addressing
challenges by selecting units characterized by high turnover or histories of
resistance to change in order to convert them into supporters in the early
stages of spread. Regardless of team
selection, literature consistently indicates an effective change process and
spread requires good planning, proper allocation of resources, training and
overall leadership support (Armitage & Higham, 2011; Johnson, et al., 2012;
Pearson, et al., 2008; Steed, 2012).
Strategies for Spread
Adoption
and spread of innovation is a “process rather than a discrete event” (Robert,
et al., 2011, p 1206). Through their
experience, Nolan, Schall, Erb & Nolan (2005) indicate that an effective
operational system will spread much more slowly than, for example, a new drug
for pain and symptom management. Kliger,
et al. (2012) and Pearson, et al. (2008) agree that even though widespread
continuous quality improvement initiatives are needed throughout healthcare, a
major challenge is how to move a successful project from one or two pilot units
to a hospital wide effort and maintain the level of staff intensity and focus. The Institute for Healthcare Improvement (2006)
summarizes organizational challenges to include the characteristics of the
innovation, the willingness or ability to adopt the new idea, and the
organization’s culture and infrastructure to support the change. Nolan et al. (2005) report that in 2000, the
Institute for Healthcare Improvement began testing an approach to spread that
resulted in the evolution of a Framework for Spread. Literature consistently reports successful
application of this framework to a spread initiative (Kliger, et al., 2012;
Martin, et al., 2007; Nolan, et al., 2005; Pearson, et al., 2008) and in March
2007, the Advisory Committee on Primary Care Renewal (2007) presents this framework
to spread good practice. The Framework
for Spread includes Leadership, Set-up, Better Ideas, Communication,
Measurement and Feedback, and Knowledge Management (Massoud, Nielsen, Nolan, Schall, & Sevin, 2012). Strategic and effective use of these
components enhances success of organizations to close the gap between best
practice and common practice.
To
apply this framework, strategies for spread activities include prepare for
spread, establish a goal, develop a plan, and execute and refine the spread
plan.
Prepare for Spread
Leadership is
emphasized as a key factor in laying the foundation and supportive
infrastructure and in providing overall guidance and oversight (Institute for
Healthcare Improvement, 2006; 5 Million Lives Campaign, 2008; Pearson, et al., 2008; Nolan, et
al., 2005; NHS Institute for Innovation & Improvement, 2010). Nolan, et al. (2005) assert the need for effective
leadership support from many levels including senior executive to front line
managers. As the process improvement
aligns with the organization’s own strategic initiatives, senior leadership’s
ability to explicitly link and articulate the value of the project throughout
the organization is vital to success. Nolan,
et al. (2005), Snyder (2009) and Steed (2012) suggest the use of an executive
sponsor to oversee the spread, provide visual endorsement of the project,
ensure continued alignment to organizational goals, and to provide appropriate
support. The manner and extent of
involvement needs to be assessed according to the scope and magnitude of the
spread initiative. The NHS Institute for
Innovation and Improvement (2010) and Nolan, et al. (2005) identify benefit to
designate spread organizers, managers, team leaders or stakeholder champions in
the initial planning of the spread project as a way to secure the vision of the
program. Nolan, et al. (2005) and
Roussel (2012) discuss collaboration with sites who had successfully
implemented the initiative and early involvement of staff from pilot units as
essential elements of successful spread.
The initial preparation and set-up might also include the infrastructure
changes and realignment of organizational goals to achieve the goals of the
initiative (Nolan, et al., 2005; Snyder & McDermott, 2009; Steed, 2012).
Establish
a Goal
According to Institute
for Healthcare Improvement (2006), Nolan,
et al. (2005), Simon & Canacari (2012), determining a goal for the spread
initiative should include identifying the target population for the spread
activity, scope of spread, expected goals and objectives, specific improvements
that will be made in the target population, and the time frame for the process.
Develop a Plan
Despite major
differences in organizational settings and overall spread approaches, the
Institute for Healthcare Improvement (2006), Martin, et al. (2007) and Pearson,
et al. (2008) agree to the importance of planning a spread process. This plan should address the method of
spread, communication, metrics and measurement methodologies, potential
infrastructure changes and anticipated actions to embed the changes into the
organization’s operational system.
Consideration and application of factors influencing successful change
management, along with the process improvement strategies delineated early in
this paper, should be an integral aspect of this spread plan.
Execute
and Refine the Plan
Delivery and
execution of the spread process involves all levels of participation, according
to the established spread plan. While
applying the aforementioned strategies for process improvement, attention to
timing and preparatory work with the target group, communication, resources and
leadership support are critical to successful delivery and implementation.
Literature
consistently identifies measurement and feedback as a vital component of
improvement (Barnas, 2011; Pearson, et al., 2008; Institute for Healthcare
Improvement, 2006; Nolan, et al., 2005).
This information serves to monitor the progress of the plan, demonstrate
the outcome of the implemented changes and track the adoption of each
intervention over time (Institute for Healthcare Improvement, 2006; 5 Million Lives Campaign,
2008). Transparency of data collection
and reporting is essential for all levels within the organization, including
leadership and front line workers, to provide feedback to adopters, generate
accountability for results, support and encourage success (Advisory Committee
on Primary Care Renewal, 2007). Use and
evaluation of rapid experiments is a critical part of the process of adapting interventions
to each unit’s work flow as a way of accepting and normalizing failure,
adopting a non-punitive culture and enabling sustainment of process
improvements (Barnas, 2011; Kliger, et al., 2012; Simon & Canacari, 2012). Involvement
of frontline staff to test the changes, collect and analyze the data, and
decide whether the change is abandoned, adapted or adopted is further supported
by Martin, et al. (2007); literature does not address strategies on how to deal
with efforts of sabotage by individuals or units. Consideration of language and cultural
diversity should be integrated in the spread plan; however, there is lack of
discussion in literature related to spread events.
Conclusion
Managing
process improvement initiatives is a challenging endeavor. The need for rapid, widespread implementation
of patient and safety health initiatives along with the complexities associated
with change management necessitates a strategic approach. Successful implementation, sustainment and
spread of the initiative requires understanding the effects of organizational
support, communication, involvement of stakeholders, and the appropriate
application of these factors to a well-planned and strategically-designed
project for spread. Further review of
literature would be beneficial in identifying specific strategies to manage
acts of change-sabotage. There is also
need for additional research regarding strategies to manage process
improvements with consideration to language and culture diversity in health
care settings.
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