Challenges to successful quality improvement

HAIVN 2013

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

3

Does this make you excited or nervous?

Image from wwww.diabetesmine.com

Challenges in implementing QI

• Site/Organization level

• Individual/team level

Challenges in implementing QI

• Site/Organizational level

• Individual/team level

For QI to be successful there needs to be an environment for

change

Some components for successful QI at an organization

• A culture of quality and improvement• Multidisciplinary teams willing to

work together• Strong leadership commitment to

quality/QI

What is a “culture of QI”

• Commitment to patient safety, quality and improvement.

• Openness to reviewing a clinic’s performance and discussing reasons for a gap.

• When gaps are found: Replacing blame with discussion and working towards improvement

QI is a team effort• Teams are stronger and more effective than an

individual “champion”• 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

Leaders are essential for 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• Celebrate successes

WHO. Operations Manual for Delivery of HIV Prevention, Care and Treatment in High-Prevalence, Resource-Constrained Settings, 2010

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

Challenges in implementing QI

• Site or Organization level

• Individual or team level

13

Change

Drivers Resisters/Barriers

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

5 minute reflection

• Write down one time when you have tried to get change but encountered resistance

• Write down one time when you resisted a change someone else was trying to make

• Be ready to share

Resistance to change• What Does it Look/Feel/Sound Like?– “We don’t have time for this activity”– “The problem is out of our control “– “You can’t tell me what to do”– “My patients are sicker than the other clinic…”– “That’s fine for other clinics, but it won’t work

here – our situation is different”– “We don’t have enough staff”– “It’s not my job”– “It’s up to the clinic chief”

Adapted from the National Quality Center

JSI and HAIVN Training April 2012 17

Why do people resist

Three main factors:• Background

• Experience

• Knowledge

JSI and HAIVN Training April 2012 18

Reasons people resist change (1)Background

What one has been taught and accepts as true

1. Do not believe there is a problem2. Worry that things may get worse with change3. Based on what they know, people really

believe the change is a BAD IDEA

Adapted from “Overcoming Resistance to Change: Top Ten reasons for Change Resistance, AJ Schuler

19

Reasons people resist change (2)Experience

1. People feel comfortable with how things have always been done

2. People worry why the people wanting change are doing this

3. Worry leadership will not support

Reasons people resist change (3)Knowledge

1. People fear they lack the knowledge and skills to make the change

2. Do not understand what you are trying to do3. No role models or teachers for the new

activity

Other reasons• Doubt-have tried to make changes in the past and

nothing worked• Fear-lose position, status or quality of working life• Overwhelmed, overloaded, no time• No incentive• It will take more resources and they really do not

have them• Conflict: resistance to person asking for change

Group discussion

• Look back at the personal resistance examples you shared.

• What were some of the possible reasons for resistance?

• 15 minute – pair up

23

We can work to solve resistance….

Increase the drivers

24

We can work to solve resistance….

Increase the drivers Decrease the

resistance

Strategies to manage resistance to change

http://www.elca.org/Who-We-Are/Our-Three-Expressions/Churchwide-Organization/Global-Mission/Where-We-Work/Asia/Vietnam.aspx

http://www.plasticsurgery.org/for-medical-professionals/resources-and-education/foundation/psf-newsletter/september-2010-foundation.html

Strategies to manage resistance to change

27

Overcoming Resistance to change (1)

• Need to know what change you want people to make

• Need to understand WHY people are resisting change– What are the drivers which could move change?– What are the barriers?

• By understanding can effectively work to overcome

Overcoming resistance to change (2): Resistance is normal

• Recognize that resistance to change is normal

• Should be met with facts, understanding and ongoing discussion.

Adapted from the National Quality Center

29

Overcoming resistance to change: Provide knowledge (3)

• Make sure everyone understands:• the data•why it matters• the goals of improvement

• Understand what new knowledge/training may be needed

Ref Lisa Hirschhorn

30

Overcoming resistance (4): Engage people in the change

• Recognize: “People do not resist change, they resist being changed”

• Provide an opportunity for people to express concerns–Understand what they hope will happen–Understand what they fear–What suggestions do they have?

Ref Lisa Hirschhorn

31

Resistance to change (5): Engage all members in the change

• Make sure everyone understands and agrees with moving forward and the goals for QI– Not one person’s “job”

• Ask everyone on the team to give possible reasons for the gap.

Overcoming resistance (6):Answer questions and discuss fears

• Provide a clear picture of the future–Answer questions about what work flow will

look like• Listen to the concerns of those most affected

by a problem and solution and try to address.

Adapted from the National Quality Center

Overcoming resistance (7):Encourage leadership

• Work closely with management to get their support and agreement and encourage their involvement (more on day 3)

Adapted from the National Quality Center

Summary (1)

• Many opportunities for coaching to overcome resistance

• Four important factors for successful QI implementation:– A culture of QI– Leadership support– Functioning multidisciplinary QI team– Time, training and opportunity to overcome

resistance

Summary (2)

• Resistance may occur because those factors are not in place or may exist even with those things in place 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.

References

• JSI• National Quality Center• WHO. Operations Manual for Delivery of HIV

Prevention, Care and Treatment in High-Prevalence, Resource-Constrained Settings, 2010

• “Overcoming Resistance to Change: Top Ten reasons for Change Resistance, AJ Schuler

37

Homework (1)

• Go back to the list of your personal resistance to change examples and possible reasons

• Start to think of approaches to address them. Write down and be ready to discuss tomorrow.

Homework (2)

• What do you think are the goals of a successful QI coach?

• Write down 2-3 goals

Thank you!

Questions?