challenges to successful quality improvement haivn 2012
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Challenges to successful quality improvement HAIVN 2012 Slide 2 Objectives Upon completion of this presentation, participants will be able to: Identify potential challenges in implementing quality improvement (QI) at a clinic Discuss reasons and solutions of resistance to change Slide 3 So now we know what quality of care is, how to measure it and how to improve. It should be easy from here right? Not always. Slide 4 Challenges in implementing QI Site/Organization level Individual/team level Slide 5 Challenges in implementing QI Site/Organizational level Individual/team level Slide 6 For QI to be successful there needs to be an environment for change Slide 7 Some components for successful QI at an organization A culture of quality and improvement Strong leadership commitment to quality/QI Multidisciplinary teams willing to work together Slide 8 What is a culture of QI Commitment to patient safety, quality and improvement. Openness to reviewing a clinics performance and discussing reasons for a gap. Replacing blame when gaps are found with working towards improvement Slide 9 How leaders can support QI Create and support a vision for quality/QI Establish a multidisciplinary QI team Build staff capacity and motivation for QI Support effort to measure quality, discuss gaps and work together to improve Support open discussion without blame of both successes and challenges Celebrate successes WHO. Operations Manual for Delivery of HIV Prevention, Care and Treatment in High-Prevalence, Resource-Constrained Settings, 2010 Slide 10 QI is a team effort Teams are stronger and more effective than an individual champion Different members may provide unique understanding of a gap based on their role in the process as well as how to improve Membership represents range of staff (and ideally patients) involved All members are equal May need coaching in how to move forward and believe that change can happen Slide 11 If leadership support and a team are not in place there may be (more) resistance to doing QI But even with these things in place there still may be resistance in the beginning Slide 12 What do you need to move long QI? 5 minute discussion What resistance to QI do you think there might be at your clinic? What is in place to help overcome and what else is needed? Slide 13 Challenges in implementing QI Site or Organization level Individual or team level Slide 14 Resistance to change The push-back one experiences when trying to change or improve a process or system. Can occur from one individual or from an entire team. Adapted from the National Quality Center and IHI Slide 15 5 minute exercise Why do people resist change? Turn to your neighbor and discuss 2-3 reasons that people may resist changing a process in the clinic in order to improve quality Be prepared to present back to the group Slide 16 Why do people resist Three main factors: Background What one has been taught and accepts as true Experience This is the way I have always done it, change never works Knowledge Do not have the information and skills needed to drive the change JSI and HAIVN Training April 201216 Slide 17 Resistance to change What Does it Look/Feel/Sound Like? We dont have time for this activity The problem is out of our control You cant tell me what to do My patients are sicker than the other clinic Thats fine for other clinics, but it wont work here our situation is different We dont have enough staff Its not my job Its up to the clinic chief Adapted from the National Quality Center Slide 18 Reasons people resist change (1) 1.Do not believe there is a problem 2.Worry that things may get worse with change 3.People have a connection and feel comfortable with how things have always been done 4.No role models or teachers for the new activity 5.People fear they lack the knowledge and skills to make the change 6.People feel overloaded and overwhelmed Adapted from Overcoming Resistance to Change: Top Ten reasons for Change Resistance, AJ Schuler JSI and HAIVN Training April 201218 Slide 19 Reasons people resist change (2) 7.Worry they dont have the resources 8.People want to be sure it is a good idea 9.People worry why the people wanting change are doing this 10.People feel threatened by the proposed change 11.Concern about having more work 12.Worry leadership will not support 13.People really believe the change is a BAD IDEA 19 Slide 20 Don Berwicks resistance to change Example review of performance data Four stages of resistance Stage I: The data are wrong Stage II: The data are right, but its not a problem Stage III: The data are right, its a problem, but its not my problem Stage IV: The data are right, its a problem, its my problem Adapted from the National Quality Center and IHI Slide 21 Resistance to change: How to manage (1) First - Recognize that resistance to change is normal Most people go through stages that should be met with facts, understanding and ongoing discussion. Recognize: People do not resist change, they resist being changed Adapted from the National Quality Center Slide 22 Resistance to change: How to manage (2) Ask everyones opinion Get everyone on board Understand what they hope will happen Understand what they fear What suggestions do they have Provide a clear picture of the future and answer questions-what will the work flow look like Ref Lisa Hirschhorn 22 Slide 23 Resistance to change: How to manage (3) Listen both one on one and in groups Make sure everyone understands the data and the goals of improvement. Provide an opportunity for people to express concerns Form a team which includes those most affected by a problem and solution and try to address concerns. Ensure leadership support Establish a culture of quality improvement that encourages identifying and dealing with problems Incorporate QI into routine clinic activities Adapted from the National Quality Center Slide 24 Group exercise Your clinic has found a problem with patients not showing up for appointments and a decision is made to o a QI project Split the group in -one group are the changers and one are the resistors 10 minutes-hold a QI project meeting and the changers work to understand why the resisters do not want to do the QI Identify one reason together and start a plan how to help them agree to start to look into change Be ready to report back Slide 25 What if it really seems hopeless? No one thinks change is possible Try making it worse Take a problem High rates of loss of pre-ART patients Brainstorm how to make it WORSE Then ask what happens if you do the opposite JSI and HAIVN Training April 201225 Slide 26 Summary (1) Four important factors for successful QI implementation: A culture of QI Leadership support Functioning multidisciplinary QI team Time, training and opportunity to overcome resistance Slide 27 Summary (2) Resistance may occur because those factors are not in place or at the individual/clinic team level Resistance at the individual level is important to address expected in the beginning handle with information/knowledge dissemination, discussion, encouragement and reassurance. Slide 28 Thank you! Questions?