Now that you’ve carefully planned your patient safety and quality improvement project, the real work can begin. This course will introduce students to the unique challenges encountered when implementing, maintaining, and expanding a patient safety and quality initiative. Students will learn to apply lessons learned from the 4 E model and TRiP into developing specific aims for their QI project. Additionally, students will develop a plan to address the adaptive and technical challenges in their projects including whether their initiative needs to be submitted to an Institutional Review Board (IRB). Finally, students will develop plans to grow their local QI project into a system-wide project.
Introduction to Adaptive Work
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Do curso por Johns Hopkins University
Implementing a Patient Safety or Quality Improvement Project (Patient Safety V)
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case story: technical work meets adaptive work
In this module we will introduce you to a quality improvement project that we implemented in two adult Intensive Care Units, to reduce Central line associated blood stream infections. The learner will develop an understanding of using the Translating Evidence into Practice model into action in developing a technical component to improve patient safety. Learners will become familiar with the Comprehensive Unit Based Safety program (CUSP) and the adaptive work used to implement the quality improvement initiative and change management methods that help achieve success.
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David Thompson DNSc, MS, RNAssociate Professor
Armstrong Institute for Patient Safety and Quality/Anesthesiology and Critical Care Medicine
[MUSIC]
So now we're ready to jump into the adaptive work that went so
far in helping us with our implementation of CLA-BSI.
I want to say that the adaptive work can be challenging, but
it can also be sort of fun because it allows you to think outside the box.
And often we would brainstorm, and we would say if no idea was silly,
how can we get people to do what we need them to do?
So it was actually a great opportunity.
And I'm going to show you how getting the right mix of adaptive and technical work
really does impact your project rather than just saying we're going to do this.
A top-down approach is less likely to be effective.
In fact, people really don't sustain top-down approaches
nearly as much as when they're involved then again as a stakeholder.
So we visit the TRIP model again, and
we're back to that part of walking the process.
So again,
this is how do we know what we need to change before we begin to implement?
And so this is really the second stage.
And we get them to make recommendations.
The other thing that we say, because we are looking at culture change over time,
is that we want you to value the dissenter.
Now that was hard for me to buy,
but there's always somebody that you work with that knows everything all the time.
Those are the people that would say this isn't going to work,
this isn't going to work, it's going to fail.
Those are the people you want to hear from.
You want them to legitimize their feelings.
You want them to tell you why it's going to fail.
And you want to take that into an account and
make changes based on what the dissenter says.
This is the same way as your pilot team.
So if you send a doctor and
a nurse out to implement this, what do they say would make it better?
Or what do they need that's different and
unique to their unit compared to what we've done for them.
And I think that's really important
as we get down closer to the implementation phase.
So identifying the local barriers, as I said, really, really important.
Because if you don't address the barriers, you will never have success.
So what we found is when we didn't hand hold,
educate, train them, show them fast fact sheets,
and all of that, we didn't have the buy-in that we needed.
But when we treated this from an implementation science
perspective where we were not only an interdisciplinary team but
we were a transdisciplinary team, meaning that instead of just a doctor and
a nurse working together, we were looking across disciplines.
So what did the physician say?
What did the nurse say?
What do our human factors engineers say would help with compliance?
What did our organizational psychologist say would help with compliance?
What did people like me who are a health outcomes researcher say the importance
of process measures?
So how often?
And we needed to let them know that after we addressed these barriers,
they would be held accountable to make sure that we could actually implement in
the time frame that we wanted and have the results that we needed to see.
So there's a wonderful thing called change management.
I’m very familiar with it and I’ve read lots of books on it.
And one of the things that I think really helped with us was a book,
Heifetz on Leadership Without Easy Answers.
And he really talks about the adaptive problems.
And I think this quote by him is probably one of the most profound things.
And that is one of the most common leadership mistakes is treating
a problem as technical when really it's adaptive.
And so you think you have the scientific knowledge and that you're
working with educated people, that they will wholeheartedly support your endeavor.
But no, it really is, how do you get them to do it and feel comfortable about it?
It's that adaptive work.
So you can give them all the evidence based bundles or
evidence based practice guidelines that you want, but if you don't address
the elephant in the room, like how is this going to change my practice?
Or how do I need to change this unit?
Especially if the unit has a poor climate, we're really not going to get very far.
So this I also thought was pretty astounding.
So adaptive work eats technical work for breakfast.
And it really does.
If you think about it,
everything that we learned in the technical bundle in the first components
of this video clip is that there is evidence to support everything that we do.
It's not only good evidence but it's actually feasible so
it not only works, it's easily implemented, which I think is important.
Adaptive work has to change the attitudes, beliefs,
and values of your core staff or what we call the local culture.
So if your local culture is one of not always following a policy and procedure or
not always reporting up the chain of command, that's their unit culture.
That's what you have to work with.
So how do you get them to change?
And we have to change for people with a negative organizational culture or
unit culture, that positive culture.
So reinforcing, getting people to speak up when they see problems and
getting people to talk about, as I said, the dissenter.
Why does this not going to be a success?
Because in their eyes, I'm sure that they've been there for many, many years.
And you can learn a lot from the dissenter,
especially when you focus on some of the things that they're pointing out to you.
An example is, so you have an evidence based protocol or the technical piece.
And whether it's on falls or decubitus or
any type of infection prevention or VRE prevention or whatever.
If the staff does not understand it,
if they don't see that it adds value, it just adds more steps to the day.
If it's one more policy that they don't know the background for,
it's not going to take off.
So the adaptive work are those processes that get them to follow the evidence,
to use the protocol and to use it without fail.
Not just for some patients, everybody's entitled to get the same level of care.
And that we don't want to compete on patient's safety.
We want to make sure that we've addressed all those concerns, which is why
I encourage anybody that steps off to do this kind of work, always pilot.
You just won't believe what you will find out about what will be your successors,
and what would limit your success.
It's very important.
So why does the safety culture matter?
And we ask this all the time.
If you have a low, let's say, safety climate,
or teamwork climate, it impacts your patient, it impacts your staff.
What we find, if nurses don't feel that they're being heard, that we're
not listening, a doctor's perspective might be the nurse does what I say.
Where the nurse's perspective should be the doctor should hear my opinion.
They've got years of experience.
So we don't want to put that aside.
Safety culture is directly related to outcomes.
And that's important, because what we're looking for in this
list that you see here now is that these are the things that we all care about.
We didn't become healthcare providers to provide bad outcomes.
We want to pay attention to the process of care to make sure that they're done, and
that when they're done our outcomes are definitely changing.
The other thing that is really important to note is that
the clinician outcomes are also important.
Are they happy with their work?
Do they enjoy doing what they're doing?
And if you have a poor culture, what our organizational psychologists
would be the first to say that when people are unhappy, they talk with their feet.
So you have a high turnover rate.
So listening to everybody and getting their opinion and
letting them know that they're going to be heard.
And we've had numerous incidents that I've heard from many, many hospitals
around the world where people do not feel listened to, they do not feel valued.
And yet their main motivation is to take good care of their patient.
And if they don't feel that they can, they do leave.
So our goal is not only to improve our patient outcomes, but
it's also to make the environment that the physician, the nurse,
the respiratory therapist, the pharmacist works in to be a better place.
So that they actually enjoy getting up and
going to work to do what they were meant to do.
So further, a safety culture will
influence other quality endeavor, shall we say.
And the reason I say that is if you are from
a positive unit that has a positive safety culture,
you will see that they're much more likely to address defects.
In fact, we have set up programs where we have monthly meetings where we
address how is the next patient going to be harmed.
We review adverse events, we look at dashboards, we talk to our HEIC provider.
Do we have a different type of infection occurring?
Is vanc resistant enterococci occurring, are we having C difficile?
These are things that are less likely talked about when you have a poor culture.
If you have a positive culture,
the person is more likely to talk about what needs to change.
And it really does enhance the overall outcome so that when you implement
a quality improvement program like this, it isn't time limited to, okay,
we're going to do this and then two years later we're going to do something else.
No, you don't leave this.
In a good culture, this wouldn't be left alone.
They would seek to maintain all the gains that they had because
the potential loss is quite significant.
Why, after you've proven that you can prevent harm, whether it be CAUTI or
CLA-BSI or VAP, or ventilator-associated pneumonia, why would want to go
back to a time point where these were serious adverse events for your patients?
I think the other thing that needs to be said is that
the best evidence for
anything that we do has a multifaceted approach.
Many components that go ahead and address several of the concerns.
Because what we find is when we use one thing to fix a system error,
there are tons of system errors that impact that other error.
So if we can get people to see what
the difference that they can make and how it impacts long-term,
it really drives something so that it's more permanent.
And I am going to show you our engagement grid.
And the last two, which are, I think,
very important are embedding the practice, and expanding.
So after you know that this going to be a standard of care for
your patient, you take it to the next unit.
And we're going to talk a little bit more about as we come up.
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