Download - Challenges to successful quality improvement HAIVN 2012

Challenges to successful quality improvement

HAIVN 2012

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

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.

Challenges in implementing QI

• Site/Organization level

• Individual/team level


• 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• Strong leadership commitment to

quality/QI• Multidisciplinary teams willing to

work together

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.

• Replacing blame when gaps are found with working towards improvement

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

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

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

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?


• Site or Organization level

• Individual or team level

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 exerciseWhy 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

JSI and HAIVN Training April 2012 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

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


Reasons people resist change (1)

1. Do not believe there is a problem2. Worry that things may get worse with change3. 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 overwhelmedAdapted from “Overcoming Resistance to Change: Top Ten reasons for Change Resistance, AJ Schuler

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Reasons people resist change (2)7. Worry they don’t have the resources8. People want to be sure it is a good idea9. People worry why the people wanting change

are doing this 10.People feel threatened by the proposed change11.Concern about having more work12.Worry leadership will not support13.People really believe the change is a BAD IDEA

Don Berwick’s resistance to changeExample – review of performance data

• Four stages of resistance

–Stage I: “The data are wrong…” –Stage II: “The data are right, but it’s

not a problem…”–Stage III: “The data are right, it’s a

problem, but it’s not my problem…”–Stage IV: “The data are right, it’s a

problem, it’s my problem…”

Adapted from the National Quality Center and IHI

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”


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Resistance to change: How to manage (2)

• Ask everyone’s 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

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


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 ½-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


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

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

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.

Thank you!

Questions?

Download - Challenges to successful quality improvement HAIVN 2012

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