About the Clinical Innovation Agency Dept of Human Services, Victoria

Patient Flow CollaborativeSustainability Toolkit

Department of Human Services

About the Clinical Innovation Agency

Dept of Human Services, Victoria

Enter toolkit

About the Patient Flow Collaborative

Acknowledgements

Patient Flow Collaborative sustainability toolkit

Dr Jenny Bartlett Chief Clinical Advisor Project Director Patient Flow CollaborativeDepartment of Human Services, Victoria

Ruth SmithActing ManagerClinical Innovation AgencyDepartment of Human Services, Victoria Dr Marcus KennedyClinical Lead Patient Flow CollaborativeDepartment of Human Services, Victoria

Kim MoyesPlanning Group Member Patient Flow Collaborative

Rochelle Condon Improvement LeadPatient Flow CollaborativeDepartment of Human Services, Victoria

Fiona DicksonImprovement LeadPatient Flow CollaborativeDepartment of Human Services, Victoria

John T WalkerCommunications and Logistics LeadClinical Innovation AgencyDepartment of Human Services, Victoria

AcknowledgementsIntroduction

Toolkit goals

Overview and strategy

Health service teams

Leadership

Change concepts

Diagnostics and tools

Resources

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Introduction

What is the patient flow sustainability toolkit for?

This sustainability toolkit has been designed for teams working to improve patient care throughout the patient journey.

The toolkit provides a sustainability framework, risk screen and self assessment tool, additional reading material and key contact information.

What are the aims of the toolkit?

The Patient Flow Collaborative (PFC) aims to improve patient flow throughout the whole system by eliminating key bottlenecks identified by each health service. It is recognised that the successful innovations developed during the PFC will need to be sustained and become mainstream for organisations to continue to deliver timely and safe treatment for all the patients accessing the health care system.

Who should use the toolkit?

The toolkit will promote discussion and innovative solutions to support sustainability of initiatives undertaken in the PFC. Anyone with responsibility for managing patient care, units and departments will benefit from this tool.

How should the concepts be implemented from this toolkit?

Local Patient Flow Collaborative teams should discuss tools and concepts, adapting these to their local context.

How to navigate through the toolkit.

Use the menu on the left side to select information areas on sustainability. For sections with multiple pages, hit the “click to continue” button located at the bottom right of screen.

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Toolkit goals

Introduction

The toolkit has been produced as part of the Patient Flow Collaborative and is designed to assist with sustaining innovation in patient flow.

Goals

Key elements to sustaining patient flow innovations are:

• effective management

• good communication

• planning for relapse

• managing resistance

• ongoing measurement

• making innovation mainstream.

Strategies that will facilitate your sustainability initiative include:

• maintaining the innovation/change concept

• eliminating dual pathways

• defining and building on accountability

• providing sufficient support to managers and clinicians leading the initiative.

The sustainability of patient flow innovations ensures improved patient care by providing timely access to services through the elimination of unnecessary delays in the patient journey.

Your feedback

Feedback on this version of the Patient Flow Collaborative Sustainability toolkit is welcome and will be used to update future versions.

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What is sustainability?

Sustainability in this context can be described as an innovation in patient flow that has been made and does not change over time. In addition the innovation has been effectively adopted in the attitudes, culture, working practice and daily working lives of staff.

How is sustainability different to spread?

The terms spread and sustainability are often used together when discussing health care innovation, however they are quite different.

For example:

• Sustainability of the initial innovation/change concept overtime is desired, this is transferred or spread to another process, environment or clinical area.

• Spread of the initial innovation/change concept may be desired but may need significant adaptation to be adopted across difference processes, environment, clinical areas or organisationally.

How do we plan sustainability?

Planning for sustainability should occur from the outset of any change initiative. Predicting barriers to the change and engaging key stakeholders are essential elements of this, as is streamlining processes and having clear lines of responsibility for tasks. Activities to assist with planning sustainability can be found in the Diagnostics and tools section of this toolkit.

What is meant by making it mainstream?

An innovation can be considered part of the ‘mainstream’ when responsibility for the monitoring and maintenance has been allocated, resources have been assigned and the organisation accepts the improvement as the standard to meet.

Once mainstreamed, the innovation deserves recognition and celebration to acknowledge the improved way of working.

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Planning for relapse

Building in accountability

Eliminating dual pathways

Making it mainstream

Ongoing measurement

Managing resistance

Sufficient support to line managers

and clinical leaders

Celebration

Maintenance of the innovation/change

concept for a sufficient time

Overview and strategy Elements of a sustainability model

Scalability

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Ongoing measurement

Managing resistance

Sufficient supportto line managers


Celebration



Scalability

Scalability

As we go through the plan-do-study-act process, starting with small samples, moving into larger involvement we start to identify how to scale up the innovation/change concept.

Key features for successful scale up of innovation include:

Warning!

As the detail and complexity of your improvements increase, potential for scalability decreases. So remember to keep it simple, steady and supervised. Flexibility to adopt the innovation is beneficial while keeping to the original elements/themes of the concept.

Strategy

Scalability

• peer to peer discussion and involvement; doctor to doctor, nurse to nurse, pharmacist to pharmacist

• innovation/change concept is low in complexity and practical in application and does not increase in detail (commonly described as making life easier)

• scale up has been part of initial planning.

An example is Box Hill Hospital’s creation of a traffic light system, prioritising the provision of daily discharge medications to the specified patients. The successful trial of this specific change concept allows for the trial to be expanded across the organisation (scaled up).

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Ongoing measurement

Managing resistance



Celebration



Scalability


Relapse or reverting to the ‘old ways’ of working is a natural part of human behaviour. Some key elements that may contribute to this phenomenon include:

• failure to plan for the relapse• decrease in accountability and monitoring• underlying premise of change did not hold up over time• compliance was not factored into assessment/reward systems• system allowed ‘two roads’ dual pathways• poor example from leaders• removal of barriers to change was temporary• low personal confidence in ability to maintain change• inadequate training and mentoring• lack of value and praise in how change has improved patient care• lack of support while staff are in discomfort of change.

As people experience the discomfort of change it is easy to return to the comfort of the previous process/system. To sustain innovation, support and attention will need to be given to behaviours, attitudes, processes and systems. Relapse to the previous way of working is natural and should be dealt with sensitively.

Strategy


• allocating time and effort during the change process to normalise, predict and plan for relapse

• attempting to eliminate alternative pathways

• rewarding compliance to the new way of working

• team leaders setting good examples

• monitoring barriers to change

• being serious about accountability and responsibility

• honestly reviewing the original premises for change.

Be prepared - plan for the relapse phase by:

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Ongoing measurement

Managing resistance



Celebration



Scalability

Managing resistance

Just as there may be some resistance when you started implementing changes in your organisation, we also know that resistance can in fact increase during the maintenance phase. Therefore, managing resistance is crucial when planning for successful sustainability and the move to mainstream.

Overcoming resistance always requires listening

The key skills in dealing with resistance begin with active listening. Active listening involves asking open ended questions, reflecting back to the person what you have been told, using short summaries and acknowledging emotions. Responding to all resistance in all forms may lead to even better innovation ideas.

Strategy

Managing resistance

Remember that:

• resistance can take many forms

• working with resistance is not about ‘proving you’re right’

• focusing on solutions is the most productive way of moving forward

• resistance is often only a reflection of where the particular individual or group is on the journey of change.

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Ongoing measurement

Managing resistance



Celebration



Scalability

Positive challenging

Empathise with the paradox“It must be difficult trying to care for your patient, on the one hand you believe X and yet you also feel Y”

Explore barriers and create ownership“What would you do to change this situation for all our patients?”

Strategies for working with people who do not want to change patient care• seek detailed explanation of concerns• empathise with the difficulties they have• seek suggestions to how things can be improved• place clear and accountable boundaries• do not place boundaries that you are unable or unwilling to enforce• agree on a timeframe for review.

Strategy

Over-agree“So there is no possible way you could follow through on this program, even though there is so much potential harm to our patients not accessing or departing from the system when they need to?”

Solution focus“What would the change look like to overcome this issue?”

Explore ambivalence“What would be the advantages of changing? What would be the disadvantages?”

Managing resistance

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Ongoing measurement

Managing resistance



Celebration



Scalability


When sustaining change it is important to remove all alternative or dual pathways to the new way of working. This will give a true reflection of the benefits of the change and help to achieve compliance.

When removing dual pathways remember the following:

inform key stakeholders that alternative methods or ‘old methods’ of working are no longer acceptable

communicate why the change has occurred

educate staff about the improved ‘new way’ of working

reward compliance

promote the benefits of the innovation for the patient

provide opportunities to discuss concerns, anxiety or stress of adherence to the new way of working.

If dual pathways exist people will be tempted to revert to the ‘old ways’ of working especially at times of adversity (such as times of stress or emergency) despite knowing the beneficial aspects of the change. If the temptation is removed, the patient will always benefit regardless of the work environment.

StrategyEliminating dual

pathways

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Ongoing measurement

Managing resistance



Celebration



Scalability

Maintenance of the change concept/innovation for a sufficient time

When sustaining change it is important to give the process time to become mainstream or the ‘standard way’ of working. Ultimately during the change process you want the change/innovation to transition from the ‘new way’ to ‘the norm’ and this takes time.

The timescale to become the ‘norm’ will depend on implementation, size of change, how often the new way of working is used in normal daily tasks and training for staff change overs.

It is important not to abandon the innovation before adequate time has passed to allow for this transition. Do not automatically assume innovation failure if the transition is taking longer than expected. It may just be that unpredicted or unplanned issues are causing the delay. If the innovation is a true benefit to patient care it will become mainstream or ‘the norm’ over time. You may wish to set review dates to assist with monitoring the adoption of change.

StrategyMaintenance of the innovation/change


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Ongoing measurement

Managing resistance



Celebration



Scalability


Accountability is one of the most important factors in sustaining change.

When people are made responsible for specific tasks during the sustainability phase of change, they are more likely to comply with the change itself and also encourage those around them to do the same. It is a fantastic way of creating ownership, empowering staff and building team work when ongoing system and process management is required.

To build accountability and promote success, remember:

• accountability must be clear and consistent

• boundaries on the scope of accountability must be set

• accountability must be enforced

• accountability should be reviewed over time

• praise should be given for taking active accountability.

Strategy

If accountability for sustaining change does not exist, relapse may occur, dual pathways will develop or resurface, resistance will increase and the change concept /innovation may be in danger of failing. An example of accountability being integrated into a role and position description is the newly created Patient Flow Coordinator position at Melbourne Health. Among the varied responsibilities of this role, a chief component is to maintain the successful processes that have been developed.


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Ongoing measurement

Managing resistance



Celebration



Scalability

Sufficient support to line managers and clinical leaders

In order for change to be sustained, line managers and clinical leaders heading the initiative must be supported by their peers and senior management to assist with dismantling barriers, engaging key stakeholders and financing the improvement strategies required.

If line managers and clinical leads are not supported there is a high risk of the following:

• removal of barriers may only be temporary

• leadership of the initiative may wilt when significant resistance is met

• existing culture may sabotage the initiative

• being happy with only ‘some’ success

• islands of improvement.

Strategies to support managers and clinical leads

• be available

• listen

• communicate with key stakeholders

• motivate and encourage

• define accountability

• celebrate and promote success.

Strategy

Sufficient support to line managers


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Ongoing measurement

Managing resistance



Celebration



Scalability

Ongoing measurement

Ongoing measurement of a change concept will assist in maintaining focus and provide teams with information about their progress, as well as support the impetus to maintain or extend the change itself.

The adage “you cannot manage what you cannot measure” is paramount when sustaining change.

Ongoing measurement is also a powerful tool for determining the positive effects of change and can assist in highlighting success. Bendigo Health Care Group undertook development of their own program measures and statistical process control charts from very early in the collaborative and are an excellent example of sustaining success via sustained measurement.

Strategies for ongoing measurement:

The team should select one or two key measures they feel really captures the essence of what they did and what they would like to see sustained.

Build these measures into an existing system within the organisation to ensure regular and automatic reporting.

Feedback results through staff meetings and formal reports.

Any reduction in performance is to be quickly recognised and actions taken to address this by the people responsible for the system.

Strategy

Continuing to measure the change concept and the impact on patients will allow you to intercept problems early and redesign processes to minimise any negative affect. For example, it can highlight potential or actual relapse or resistance, identify if any dual pathways exist and areas which need more planning.

Ongoing measurement

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Ongoing measurement

Managing resistance



Celebration



Scalability


When discussing giving a change concept adequate time to become ‘the norm’ we touched on the concept of moving to mainstream. Making it mainstream does not only refer to the time required to make an improvement ‘the norm’, but also takes into consideration the following issues:

Strategies to ensure the change becomes mainstream

Make sure the change features within regular reporting mechanisms of the organisation and business planning cycle.

The change should be celebrated within the annual report.

The ‘new way’ of working should be built into job roles, job descriptions and also be reflected in the performance management appraisal system.

The team which created the change could come together from time to time to review whether it has been sustained.

• Is this new process aligned with the values, vision and goals of the organisation?

• Is it someone’s responsibility to ensure that the improvement maintains or even progresses? (Refer to building in accountability)

• Has resource been allocated to support the continuation of the new way of working?

• Are things set up to support the change?

Strategy


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Ongoing measurement

Managing resistance



Celebration



Scalability

Celebration

We often celebrate the initial improvement efforts, but maintaining the improvement may draw little attention. Make the effort to celebrate periodically the fact that the improvement has stayed at the target level over time. For example, “We are celebrating six months of effective bed management using the web tracker. The percentage of patients transferred to Ward B from the Emergency department in less than 6 hours is 97%”

Celebrating is an effective method of renewing motivation for the improvement and can act as a stimulus for aiming even higher.

Strategies to assist with celebration and target renewal

make definite plans in advance to celebrate continued success

set a new goal or aim, and try to improve even more

make it a continuous improvement effort, never really settle into simple maintenance mode

monitor weakening targets and satisfaction with progress so far

use the excitement of improvement to keep the issue in peoples mind.

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Health service team

It is essential for patient flow sustainability to have a skilled, trained and committed innovation team. The team should consist of representatives of all staff groups involved in patient flow and patient/consumers.

Management clinical/non clinical

Nursing enrolled and registered nurses who manage patient flow

Clinical medical officers who provide patient care

Technical health service staff members whose services impact on patient flow eg. pharmacists and allied health staff

Administration quality managers who monitor safety and organisational progress towards departmental targets

Patient/consumer patient in long term care or consumer who is not presently receiving treatment

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When leading an improvement initiative through the sustainability phase it is important to avoid the following pitfalls:

having no clear leadership

trying to fix a process rather than changing it

focusing on theory of sustainability rather than processes

failing to address the people issues

doing six things at once.

Tips to assist leaders to sustain improvement work

clear leadership must be established

data is king - don’t rely on anecdote

the story of why change was needed has to be told incessantly

evaluation of the improvement must involve more than one person

no mistakes mean no change

share decision making responsibilities

plan! plan! plan!

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Aim

To sustain patient flow improvements beyond the length of the PFC.

Change concepts

allocate time and effort during the change process to normalise, predict and plan for relapse

manage resistance via active listening

remove dual pathways

make people accountable for the sustainability of the improvement

provide support to line managers and clinical leaders sustaining the improvement work

continue to measure performance at least quarterly

make the improvements mainstream

make definite plans in advance to celebrate continued success

build a patient safety team.

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1. Sustainability Risk Screen

2. Sustainability Assessment Tool

Diagnostics and toolsIntroduction

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ResourcesIntroduction

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Engaging individual staff in service improvement: How does it happen? Who should be engaged? A Discussion Paper - June 2004

The Spread of 'See and Treat' Research into Practice. Summary Report No.11 March 2004.

Layers of Leadership: Hidden Influencers of healthcare improvement. Research into Practice. Report No.10. March 2004.

Spreading Sustainable Improvement. Case Study Research: National Booking Programme Summary Report No.9. February 2004.

Evaluation of 4th Wave 'Moving to Mainstream‘. Summary Report No.8 February 2004.

No Going Back. A review of the literature on sustaining organizational change. Literature Summary. Research into Practice Report No.7 November 2003.

A 'Deep Think' Day on Sustainability. Meeting Summary - report number 6.

Teamworking for improvement: Planning for spread and sustainability. Summary Report No. 5 - August 2003

Spread and sustainability of service improvement: factors identified by staff leading modernisation programmes. Summary Report No. 4 - February 2003

Spreading and sustaining new practices: sharing and learning from the Cancer Services Collaborative (CSC). Summary Report No. 3 - October 2002

NBP Sustainability and Spread in the National Booking Programme. Summary Report No.2 - September 2002

From Scepticism to Support - what are the influencing factors? Summary Report No. 1 - July 2002


Gollop, R. Whitby, D. Ketley, D. ‘Influencing sceptical staff to become supporters of service improvement: a qualitative study of doctors’ and managers’ views’. Quality and Safety in Health Care Journal. Vol.13 2004

Improvement Leaders Guide to Sustainability and Spread – NHS Modernisation Agency, UK 2002.

Fraser, S and Greenhalgh, T. ‘Coping with complexity: educating for capability.’ British Medical Journal Vol.323 Oct 2001.

Fraser, S. ‘Spreading good practice.’ Health Management. June 2000

Berwick, D. ‘A primer on leading the improvement of systems.’ British Medical Journal Vol.312 Mar 1996.

References

Patient Flow Collaborative

Clinical Innovation Agency, Department of Human Services

Modernisation Agency, NHS

British Medical Journal

Institute for Healthcare Improvement

Quality and Safety in Healthcare

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The Patient Flow Collaborative is an ambitious innovation program designed to eliminate delays throughout the patient journey and to improve the quality and safety of patient care.

The Patient Flow Collaborative is designed to assist health services to systematically analyse the barriers to the flow of patients through the continuum of care. The key to the collaborative is the use of the Breakthrough series methodology, which is complimented by whole system tools and techniques, process data and complexity system theory. The key aims of the Patient Flow Collaborative are to:

• reduce unnecessary waits and delays within the continuum of care• embed innovations tools, techniques and service improvement skills in Victorian health services.

For further information: Patient Flow Collaborative

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http://www.health.vic.gov.au/patientflow/

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The Clinical Innovation Agency (CIA) is delivering the Patient Flow Collaborative on behalf of the Hospital Demand Management Strategy and the Chief Clinical Advisor.

The role of the Clinical Innovation Agency is to: • lead large scale programs designed to improve patient care via the development of innovative systems • test innovations in access, safety and quality • train, embed and discover new service improvement tools and techniques.

The CIA is responsible for:

Patient Flow Collaborative

Victorian Travelling Fellowship Program

Clinical Innovation Fund

Contacts

Jenny Bartlett Ruth SmithChief Clinical Advisor Acting Manager, Clinical Innovations [email protected] [email protected]

About the Clinical Innovation Agency, Department of Human Services, Victoria. Introduction

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About the Clinical Innovation Agency Dept of Human Services, Victoria