Promoting quality for better health services

Facilitating Change

1. Action Planning

Local Improvement following National Audit Participation 2012

Best practice means . . .

. . completing the clinical audit cycle

What is an action plan?

• • • • Describes the way a group will use strategies to achieve its objectives Live document Turns ideas into reality Includes the following information – What actions will occur – – – – Who will carry them out By when they will take place Who should know what (communication) What resources are needed

Why develop a written action plan?

• As a record of what you are doing – for the audit team / clinical team – and stakeholders • • • For monitoring and accountability – Essential for NHSLA compliance To ensure details aren’t overlooked To save time, energy and resources

Example – extract from an action plan Recommendation Actions required (specify “None”, if none required) Action by date Person responsible (Name and grade) Comments/action status (Provide examples of action in progress, changes in practices, problems encountered in facilitating change, reasons why recommendation has not been actioned etc) Change stage (see Key) Need to incorporate the standard for transfer of patients with fractured neck of femur from ED to ward within 2 hours within the local guideline

Update the local patient management guideline for fractured neck of femur to include standards for the transfer of patients from the Emergency Department to the Orthopaedic Ward within 2 hours of arrival.

31st May 2012 Replace previous version of guideline with updated version on the Trust electronic guideline system.

5th June 2012 Mr R Riding, Lead Consultant for Fractured Neck of Femur 29th May 2012 – Mr R Riding forwarded the updated local guideline to the Clinical Audit Department as evidence that the action has been completed.

Mrs A Smith, Clinical Guidelines Administrator 4th June 2012 – Awaiting Mr M Singh, Clinical Director, sign-off. On annual leave until 10 June 2012

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http://hqip.org.uk/template-clinical-audit-report/

Change stage

•

KEY (Change status)

– – – – – 1. Recommendation agreed but not yet actioned 2. Action in progress 3. Recommendation fully implemented 4. Recommendation never actioned (please state reasons) 5. Other (please provide supporting information) •

The action plan is a live document

– needs constant updating until all the actions have been completed.

Criteria for judging action plans

• • • Is the action plan: Complete?

– Includes all the actions required to achieve improvement Clear?

– Why, what, who, how, when Current?

– Reflects existing practice and anticipates new opportunities and barriers

Dealing with NCA reports

• National clinical audit projects should be on the Trust clinical audit programme • The local lead should take responsibility for the complete audit cycle • What about audits the trust chooses not to participate in – the reports should still be reviewed (by the trust board?) • What is the role of clinical audit staff?

Dealing with NCA reports

• Build on the strengths of the audit – – – stakeholder engagement already in place national recommendations Support from the national audit team?

• Put the national recommendations into local context – – – – – Additional local data collection / analysis?

Process mapping Root cause analysis - fishbone diagrams, 5 x why?

Driver diagrams Other quality improvement tools http://hqip.org.uk/assets/Guidance/Guide-to-Using-Quality-Improvement-Tools-to-Drive-Clinical Audits-HQIP.pdf

Action Planning - the meeting

• • • • WHAT is your role / remit – Change / project sponsor?

– Change agent?

WHO needs to be there?

– Should be inclusive or at least representative Have they read and understood the report?

When should the meeting be held?

– Availability – Urgency

Planning the meeting

• HOW long do you need?

– One long meeting – Two or three short meetings – Sub groups per recommendation • Communications Plan http://www.hqip.org.uk/guidance-support/transforming-clinical-audit-data-into quality-improvements.html

Agenda for planning meeting

• • • • • • Clarify the result areas you are focussing on List the steps necessary for each action Sequence the steps in logical order List the outputs Assign responsibility Resourcing + £££ • Workplan schedule

Pitfalls to avoid…

• Planning to do too much in too short a time • Not planning in enough detail • Not being clear on timelines so scheduling and sequencing is compromised • Not thinking through resource implications – Business plan? Impact on other services?

• Failing to identify barriers – and take actions to overcome them

Action planning exercise

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Recommendation

from the July 2012 report on the National Oesophago-Gastric Cancer Audit:

Standardized tools should be used more frequently in the nutritional assessment of oesophago-gastric cancer patients.

•

In your trust,

the results show almost all patients are assessed, but the assessments are most often carried out by dieticians who use a variety of different tools.

•

How would you act on this recommendation?

Written, ratified….what next?

• • • • • Follow through Keep everyone informed of progress Keep track of what has(n’t) been done Celebrate accomplishments Regular, supportive phone calls

Promoting quality for better health services

Facilitating Change

2. Change Management

Local Improvement following National Clinical Audit Participation 2012

Change is good?

‘ We trained very hard, but it seemed that every time we were beginning to form up into teams we would be reorganised. I was to learn later in life that we tend to meet any new situation by reorganising and a wonderful method it can be for creating the illusion of progress, while producing confusion, inefficiency and demoralisation ’

Gaius Petronius Arbiter (ca. 27 –66 AD), a Roman courtier during the reign of Nero.

Change is good!

But it can be really hard...

• Change involves a loss • Different people react differently • Expectations need to be managed

VISION VISION VISION VISION VISION VISION

Successful change requires:

SKILLS SKILLS SKILLS SKILLS SKILLS SKILLS INCENTIVES INCENTIVES INCENTIVES INCENTIVES INCENTIVES RESOURCES RESOURCES RESOURCES RESOURCES RESOURCES ACTION PLAN ACTION PLAN ACTION PLAN ACTION PLAN CHANGE CONFUSION ANXIETY NO CHANGE ACTION PLAN FRUSTRATION INCENTIVES RESOURCES ACTION PLAN FALSE STARTS

Overcoming the barriers

Every system is perfectly designed to achieve exactly the results it gets

Barriers to change

Limited resources Organisational culture Individual resistance

Drivers for change

National policy Stakeholder expectations Audit results

Facilitation skills

• • • • Empathy • Walking in others shoes Credibility – knowledge / experience Effective communicator Good Listener

Implementing the plan

• Follow through • Lead by example • Keep everyone informed of progress • Regular, supportive phone calls • Go with the willing . . .

Monitoring the process

• Keep track of what has(n’t) been done • Assess the consequences and manage the risks • Celebrate accomplishments – Presentations, posters, internal communications •

“We are successful because we have intelligent, caring, highly successful team members”

• Reporting requirements

Evaluating change

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Outcome measures:

Patient perspective. How has the change affected me?

•

Process measures:

Is the planned system in place. Is it performing as planned?

•

Balancing measures:

Newton’s third law: for every action there is an equal and opposite reaction

Closing the audit loop

• You can only be certain that changes have resulted in improvement if you repeat the data collection.

• Repeating the audit vs. ongoing monitoring • Review the forward plan for the audit programme • Learn from the mistakes

For discussion

• Think about a national clinical audit that you have been involved in.

• Who were the key people who helped make that audit succeed?

• What did they do differently?

• What were the barriers they were able to overcome?