When integrating change into practice, it’s important to understand the threats to integrating quality and safety work and planning for success. This is the third article in a series describing challenges encountered in this area, and it highlights backsliding, knowledge degradation, and large-scale implementation without testing.
Backsliding
Backsliding occurs when there is initial improvement noted after engaging in a project, but then that improvement wanes over time. Why might this happen? Lack of senior leadership support and engagement, including their visibility in these efforts, may send the message to frontline staff that it is no longer important (Harvard Business Review, 2020). Consistent messaging by leadership helps to maintain the engagement of frontline staff and keep the momentum going. In addition, backsliding may occur if the initiative does not include plans for sustainability.
What can help? Starting with the end in mind is key to success. This includes engaging with frontline staff and integrating their suggestions for change. This builds the effort from the ground up and allows them to own it, as opposed to being told what to do.
Consistently monitoring progress with data, sharing this with the team, and celebrating the wins informs and recognizes the team of their efforts. Auditing is one way to monitor progress, typically for process measures in order to keep an eye on compliance. If auditing processes and initial audits show positive compliance, put a plan in place to audit periodically (quarterly or on a schedule that seems reasonable) to ensure that drift in practice has not occurred. Revisiting will help to evaluate if continued adherence to a process exists.
In addition, sharing patient examples of why the efforts are important or how this impacted a patient positively can also help. The value of patient stories cannot be underestimated. People remember stories, and they remind us of why we do what we do every day as healthcare providers. It also maintains the focus on patient-centered care.
Case Example
A labor and delivery unit in a mid-sized teaching hospital has implemented the AWHONN Maternal Fetal Triage Index, with the goal of standardizing the approach to obstetric triage and ensuring timely maternal/fetal assessment. Challenges in the physical layout and integration into the EMR are identified by staff. Limited solutions lead to decreased buy-in from frontline staff. Nonetheless, the initiative is adopted and its value is demonstrated in several patient examples in which patients presented with abnormal fetal heart tracings or vital sign values that were identified immediately due to this process being in place. Positive patient outcomes resulted. These stories were shared with staff to reinforce the value of this program. In addition, audits were conducted initially during implementation and periodically to determine compliance. Any backsliding identified was investigated further and correction plans were put into place.
Knowledge Degradation
Knowledge fades over time. One solution is creating system-level changes that embed the knowledge into everyday practice such that it becomes just the way things are done. Let’s take the example of an initiative to reduce Elective Delivery between the gestational ages of 37w0d-38w6d, the Joint Commission Perinatal Care Core Measure PC-01. There are many pieces involved in this process including the use of a standardized scheduling process, staff education, informatics changes, visual aids, and data analysis.
To begin, a standardized scheduling process involving a secretary of the labor and delivery unit was implemented. The old method involved a provider calling the unit and the secretary or charge nurse adding it to a scheduling book. No double-checking of GA at the time of induction or verifying due dates could occur using this method due to competing priorities, distractions, and lack of verifying information available. In addition, education was initially provided to staff to roll out the initiative including grand rounds and services. Education was added to the nursing and resident orientation process to ensure this information was not lost over time.
To bring this information to the forefront in the day-to-day, changes were integrated into the electronic medical record system to easily identify any patient on the centralized patient board that was between 37w0d – and 38w6d. A banner displayed an alert when in the chart displaying gestational age. Visual aids were added to the unit including posters with pertinent information. Staff were given badge backers with acceptable indications for delivery. These visual tools and informatic aids helped to keep the information in the forefront on a daily basis.
In addition, this information was added to the regularly occurring multidisciplinary team meeting. As each patient was presented, if patients met GA criteria, the indication for delivery was discussed and it was confirmed if the Joint Commission criteria were met. Any circumstances requiring clarification were arced up the chain of command. This discussion served as a good opportunity for learning and reinforcement. Lastly, data was shared with the team on a regular basis including any outliers and opportunities for improvement. If gaps were identified, the process was further refined.
Why did this stick? A multifaceted approach was used that integrated system changes including initial and ongoing education, visual aids on the unit, data sharing, and incorporation into the regularly occurring team communication event.
Large scale implementation without testing
Prior to implementing quality and safety changes, it is recommended to implement the change on a small scale to test it out. This is also referred to as pilot testing. The advantage to doing this is that it enables any barriers or challenges to be identified and corrected prior to large-scale implementation. If large-scale implementation occurs without pilot testing, it may be much more difficult to manage the problems encountered, leading to frustration and lack of engagement by staff.
The following suggestions may be helpful in the rollout of a successful pilot:
- Staff in the pilot area are aware of the changes and engaged
- A process is in place for frontline staff to give and receive feedback
- Key stakeholders are engaged
- Barriers have been identified and removed prior to pilot testing
- Process measures have been identified to ensure the steps in the process are being done
- Outcome measures are identified
- Real-time support is provided
- Multidisciplinary education/training is provided
- Clear communication occurs regarding training and go-live dates (Agency for Healthcare Research and Quality, 2012).
In summary, when integrating change into practice, it’s important to understand the threats to implementation and sustainability in quality and safety work, and what planning for success looks like. Backsliding, knowledge degradation, and large-scale implementation without testing can occur when there is no careful consideration of program development, rollout, and sustainability. This can be mitigated using a multifaceted approach including system changes, engagement of leadership and frontline staff, sharing data and patient stories, small-scale testing, and threading key information into everyday team communication events.
References
Agency for Healthcare Research and Quality (2012). Chapter 4. Developing and Pilot Testing Change: Implementing the Medication Reconciliation Process. (n.d.). Retrieved from https://www.ahrq.gov/patient-safety/resources/match/match4.html
Harvard Business Review (2020, April 03). Why Your Agile Projects Fizzle Out. Retrieved from https://hbr.org/2018/11/making-process-improvements-stick
Copyright by Jeanette Zocco MSN, RNC-OB, C-EFM, C-ONQS
Great points! We have found that continuing to monitor even after the change has been adopted has helped us to maintain changes.
Thank you!