1. Strategies to support change in your facility Susanne Salem-Schatz, Sc.D. Program Director, MA Coalition for the Prevention of Medical Errors HealthCare Quality Initiatives sss@HCQI.com 1

2. So far you have heard  Why it is important not to use antibioitics unless absolutely necessary;  How the high prevalence of asymptomatic bacteriuria in the elderly can lead to unnecessary antibiotic use;  Expert recommendations for when to test and when to treat a suspected UTI; 2

3. I’m convinced…  Much of what we heard is not widely understood;  Long standing and habitual practices can actually harm the people we are trying to help.  Changing practices about urine testing and treatment of the elderly is a very reasonable thing to do. 3

4. Time for change  Should be easy  We know the right thing to do  We intend to make a change  We are sure others will follow suit when we share what we have learned.  Not so fast  Change is hard  Intention is not enough 4

5. Good news: we can help 1. Tools and strategies to support practice change (after lunch) 2. Proven organizational approaches to practice improvement  Engagement strategies: from buy-in to ownership  A quality improvement framework. 5

6. Some facts  Knowing is not enough.  Evidence of non-clinical influences on clinical decision-making*  It’s not just what you know, it’s who you know. *Salem-Schatz SR, Avorn J, Soumerai SB. Influence of knowledge and attitudes on the quality of physicians‘ transfusion practice. Medical Care, 1993;31:868-878. 6

7. Problems & Opportunities Awareness Iceberg 4% known to top leaders 9% known to middle managers 74% known to supervisors 100% known to the front line & customers Adapted from study conducted by Sidney Yoshida, Source: Keith McCandless Action unleashed @ the front line 7

8. Including front line staff:  Engages the very people “whose behavior needs to change to solve the problem” to identify existing solutions from within  Front line engagement & ownership can: elicit good ideas that account for day to day realities suppress the “immune rejection response”  8

9. Over and over we discovered staff who had better practices. And staff helped develop even better ideas…. Jasper Palmer discovered a better way to remove gowns and gloves

10. “…when a group of individuals becomes a ‘we’, a harmonious whole, they have reached as high as humans can reach.” ~ Albert Einstein, 1954

11. Harrington staff step up the fight against hospital acquired infections 11

12. What you can do  Expand the circle of your conversation  Don’t rely solely on train-the-trainer  ASK about their experience  What do they know about the problem?  What would they like to know?  What keeps them doing the right thing 100% of the time?  What ideas do they have that might help? 12

13. The Model for Improvement StudyDo PlanAct What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Setting Aims Establishing Measures Selecting Changes *2001 Associates in Process Improvement W. Edwards Deming

14. StudyDo PlanAct 100 percent of CDI patients will be on appropriate precautions (hand hygiene, gloves, gowns, etc) % of CDI patient rooms with precaution signage % of staff donning gowns and gloves before entering % of staff washing with soap and water *2001 Associates in Process Improvement Aim Measures Engage staff in the improvement process Understand barriers to good practice and come up with ideas for change Share results with staff on units Changes Model for Improvement in Action

15. Study Do PlanAct PDSA: Small Tests of Change Plan: 1 small change to test Predict what will happen Decide on what data to evaluate test Do: Run the test Document problems and observations Organize your data Study Analyze your data Compare results t your predictions Summarize what you have learned Act Decide what to do next More testing? Try something else? Finalize the change?

16. Some tips for testing  Small tests of change  Rule of 1  1 patient/resident – 1 staff person – 1 day  Test over a short period of time  If they say weeks, think days  If they say days, think hours \  PDSA Worksheet to plan your test  Call for help! 16

17. Planning your Changes (in your handouts)

18. 18 Using the model for improvement to prevent transmission of CDI: How Franciscan Hospital for Children makes it work.

19. Improve Communication of Current Precautions Status: Cycle 1 19 PLAN: Standardize location of signage Store precautions signage in convenient location near/with PPE DO: Installed sign holder outside room Store one of each precaution signs in each sign holder ACT: Reduce size of signs; magnetize signs to attach to door frame Reconsider signage storage options CHECK: Sign holders too big for available space to accommodate 4 signs per room Sign fit well in holders; concern sign holders will break from continual expansion to remove/replace signs

20. Improve Communication of Current Precautions Status: Cycle 2 20 PLAN: Reduce sign size; magnetize Store extra signs in folder attached to precautions cart DO: Created 4”X3” print area Printed on magnetic sheets Placed on metal door frame Attached plastic folder to cart; filled with one of each precautions signs ACT: Investigate smaller other sign holders Create signs to fit CHECK: Sign was easily knocked off frame. Signs were too small.

21. 21 Aim: Improve Communication of Current Precautions Status Delays in precautions implementation Improved adherence to current precautions AP SD A P S D AP SD D S P A DATA D S P A Cycle 1A: Standardize precautions signage location, test on one room, and get feedback. Cycle 1B: Reduce size, magnetize for doorframe placement. Test on one room get feedback. Cycle 1C:Increase size, post in plastic sign holder, test on one room get feedback Cycle 1D: Educate clinical, ancillary, and support staff on new signage Cycle 1E: Implement sign holders for all rooms

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23. Questions?  We are always available for your questions  Listserve  Email Next?  Lunch  Tools and tips for training and practice change  Program measurement 23