1. Qualitative Findings – EPIC I Madelyn Law & Janet Yamada University of Toronto On behalf of Dr. Bonnie Stevens Sick Kids, University of Toronto EPIC/PHSI Training Workshop, Toronto, Ontario November 9 th -10th

2. A Qualitative Examination of Changing Practice in Canadian Neonatal Intensive Care Units Bonnie Stevens, Shoo K. Lee, Madelyn P. Law, Janet Yamada and the Canadian Neonatal Network EPIC Study Group In press – Journal of Clinical Evaluation and Practice

3. Outline  Brief overview of theoretical background and qualitative methods  Results  What to think of as you move forward

4. Purpose of the EPIC Study  To implement and evaluate a national system for practice change in NICU’s based on evidence and data. Quantitative research component Quantitative research component Qualitative research component Qualitative research component

5. Purpose of the qualitative study The purpose of this study was to identify: (a) existing successes and problems, (b) factors that affect successes and problems, (c) potential challenges to change associated with the implementation of changes to infection control/chronic lung disease practices in NICUs across Canada.

6. Driving Theoretical Basis  Research on change in the Vermont Oxford Network Pediatrics Issue111(4)Pediatrics Issue111(4)  Organizational structure and change (Baker et al., 2003; Pettigrew, 1987)(Baker et al., 2003; Pettigrew, 1987)  The Improvement Cycles (Langley et al., 1998)(Langley et al., 1998)

7. Methodology  13 sites 7 Chronic Lung Disease 7 Chronic Lung Disease 6 Nosocomical Infection 6 Nosocomical Infection  154 participants 76 Individual interviews 76 Individual interviews 14 Focus groups 14 Focus groups  Health professionals representing the full spectrum of NICU services neonatologists, nurses, pharmacists, respiratory therapists, managers, educators, parents neonatologists, nurses, pharmacists, respiratory therapists, managers, educators, parents

8. Data Analysis  Thematic Analysis “…involves the search for common threads that extend throughout an entire interview or set of interviews.” “…involves the search for common threads that extend throughout an entire interview or set of interviews.” (Morse& Field, 1994)  First level of coding – Open coding: Researchers read the interviews line-by-line and descriptive code names are written in the right hand margin of the transcript. Researchers read the interviews line-by-line and descriptive code names are written in the right hand margin of the transcript.  Second Level of coding – Selective Coding: Categorize, recategorize and condense all first level codes into the main categories that will reflect the information Categorize, recategorize and condense all first level codes into the main categories that will reflect the information

9. Results  Three Overarching Themes found at both CLD and Infection Sites: 1) Human resources 2) Organizational Structure 3) Communications

10. Human Resources  Staffing issues Size of staff Size of staff Ratio of educator to staff Ratio of educator to staff Education and experience levels Education and experience levels Staff turnover Staff turnover  Consistency in practice Inconsistencies in practices even after a new practice was introduced Inconsistencies in practices even after a new practice was introduced Need support from the leadership to institute and maintain new changes Need support from the leadership to institute and maintain new changes

11. Organizational Structure  Approval Process Long and tedious with many levels of approval Long and tedious with many levels of approval Loss of momentum for the change Loss of momentum for the change  Multidisciplinary Approach to care Success attributed to the engagement of multidisciplinary teams Success attributed to the engagement of multidisciplinary teams Peer Leaders/Champions from the team to Peer Leaders/Champions from the team to lead the change lead the change

12. Communications  Frequency and consistency of communications Variety of channels for communications Variety of channels for communications Inundated with information Inundated with information Disconnect between the generation of new information and practice to print form (i.e. updating manuals and website) Disconnect between the generation of new information and practice to print form (i.e. updating manuals and website)  Rationale for change Need to know the “WHY” and “HOW” Need to know the “WHY” and “HOW”

13. Communications  Feedback Process Updates and results on how the change had impacted clinical problems in order to help reinforce the new practice Updates and results on how the change had impacted clinical problems in order to help reinforce the new practice Include practitioners in designing, implementing and evaluating change Include practitioners in designing, implementing and evaluating change

14. Unique to Chronic Lung Disease  Identification of Policies related to CLD Participants had difficulty identifying the existing policies and practices that were currently in place to deal with CLD or to help prevent CLD Participants had difficulty identifying the existing policies and practices that were currently in place to deal with CLD or to help prevent CLD Creating a preventive and not reactive focus to the care of CLD Creating a preventive and not reactive focus to the care of CLD

15. Unique to Infection  Unit specific policies for infection Differences in policies in the NICU compared to overall hospital policies Differences in policies in the NICU compared to overall hospital policies  Disconnect between policies and practice Staff are aware of policies and procedures but also stated that these policies were not always followed Staff are aware of policies and procedures but also stated that these policies were not always followed

16. Unique to Infection  Environmental Design of the unit in relation to number of sinks, ventilation, traffic in the unit, etc. Design of the unit in relation to number of sinks, ventilation, traffic in the unit, etc. Visitation in relation to number of people allowed at the bedside and controlled entrances to rooms Visitation in relation to number of people allowed at the bedside and controlled entrances to rooms

17. What to think of as you move forward…..  Context (site) specific barriers What are the barriers related to the practice environment at your hospital? What are the barriers related to the practice environment at your hospital?  The human side of change Inform individuals why and how they should change their practice Inform individuals why and how they should change their practice Provide feedback on new knowledge and results of implementing change Provide feedback on new knowledge and results of implementing change Involve them in the change process Involve them in the change process

18. What to think of as you move forward…..  Structure for successes Focus on the team, champions, culture, readiness for change Focus on the team, champions, culture, readiness for change Address human resources strategies Address human resources strategies  Communicate effectively Communications Plan Communications Plan

19. Create a Culture of Change Greater level of awareness Level 1: Artifacts (meetings, reports, work environment) Level 2 Values (moral codes, philosophies, values in use) Level 3: Basic Assumptions (dominant values that have moved into the organizations members unconsciousness) Visible but often not decipherable Taken for granted Invisible preconscious Schien, 2004

20. Thank You!