All teams encounter the same pitfalls, and some fall right in. The key is knowing what the problems are. Teams that recognize when they are stuck can often climb right back out.
Problem 1: Studying the Problem Too Long without Acting
Teams that spend more than four weeks collecting baseline information are stuck. If discussions about data collection dominate team meetings, the team has fallen into an information abyss.
Solution: Collect Just Enough Data
- Use simple sampling techniques, such as "every fifth patient" or "on every Tuesday and Thursday afternoon," for data collection that is good enough.
- Use one or two indicators of the results. For example, including family satisfaction with care may be enough to show that a new communication strategy is working. It would not likely be worth the effort to add 10 more measures just to determine whether a change is an improvement.
- Use available resources. Use paper and pencil methods rather than waiting for the information system to generate the data needed, or use that electronic data if it has what the team needs! Sometimes teams use the electronic data to get the "denominator"-- - and another source to get the numerator (for instance, the percentage of patients discharged from the hospital with heart failure who receive supportive care services).
- Integrate data collection with the daily routine. Making pain a fifth vital sign is an excellent example of building a key measure into everyday practice. So is charting on a flow sheet that can be used for data collection, or keeping a check sheet to mark off events (such as referrals to palliative care).
- Use a related measure as a "proxy." If the team cannot measure continuity directly, measure how many different providers see the patient in one day or one week, or the numbers of families who report not knowing who to call in with questions about patient care.
Problem 2: Getting Everyone's Agreement First
The entire nursing staff need not agree to treat pain differently. Start with the staff members who will be trying the new assessment approach. In health care, we sometimes seek consensus around changes before agreement is needed or warranted, missing the opportunity to try new approaches. Participants need not agree "for all time," only for a while. Most people can make this commitment just to be cooperative.
Solution: Start with Small Groups and Gradually Add People Working on the Change
- Find innovative staff members - the champions - who are interested in testing changes first.
- Have them design and test the changes on a small scale.
- Measure the results and make them visible.
- Gradually bring in successive groups of participants to try the change. For example, recruit another medical group, another nursing unit, or another clinic.
Problem 3: Educating without Changing Structures or Expectations
The most common tool for change in health care is an education program. It is also the least effective if done without other system changes. Education is very useful for helping people adopt new changes that they are motivated to adopt, but education alone does not create lasting change. If your massive education campaign leads to no real behavior changes, you are going nowhere.
Solution: Focus on Powerful Changes
- Choose changes that cause a direct improvement in behavior. Implement a protocol, change a referral pattern, establish specific criteria, or standardize a previously erratic pattern of care.
- Use the right words. When describing the change, be sure to use words such as "revise, improve, implement, establish," not "continue, educate, study, recruit."
- Create prompts for correct behavior. Make it easy to participate - distribute a pain protocol card or an alternative therapy kit, and make these available to everyone.
- If the organization really needs an education program, include education about the PDSA model for change, and integrate education with implementation.
Problem 4: Tackling Everything at Once
A team may be eager to tackle it all - pain management, advanced care planning, and meaningfulness and spiritual support - aiming to improve every problem in patient care at once. However, starting changes in each area simultaneously takes a tremendous amount of staff time and requires tolerance of uncertainty and disruption in many areas at once. If team members feel that they cannot pay attention to all the changes the team wants to make, then the team has taken on too much.
Solution: Focus and Sequence the Changes
- Focus on one area first.
- Choose the change that will be the "easiest." The easiest is likely to be the one with a strong champion, senior leadership support, and popular appeal. Be sure it is a real change, preferably one that will improve patient or family experience, not just education or data collection.
- Let senior leaders know what you need to make progress and ask for help.
- Select subsequent changes based on what the team is already accomplishing. For example, working on advance care planning may naturally lead the team to find ways to improve bereavement support.
Problem 5: Measuring Nothing - or Everything
Having no data is a problem. Unfortunately, good work will not stand on its own merits. If the team cannot describe the effect of the changes it has made, it will not be able to continue with the good ones - or recognize the bad ones. And, as mentioned above, teams need to avoid the comfortable niche of measuring so much that they don't have time to make much happen. We find it a useful rule of thumb to allocate energy this way: "If you have five units of energy to spend on making improvement, use four on change and one on measurement." Be sure not to use much less on change or much more on measurement.
Solution: Just Enough Data (again)
- See problem 1 above!
- Track at least one indicator over time. Measure it at least monthly.
- Use "subjective" data. Ask two or three physicians every month how the pain protocol is working out for them. Ask one or two patients every day how they feel about the planning discussion. Especially as an interim step, these responses will be useful for identifying problems and will also spur you to further (useful) data collection.
Problem 6: Failing to Build Support for Replication
If a team has great results for a few patients, but no one else adopts the changes, it has not made much headway. Early in the process, team members need to tell others about what they're doing - to make colleagues curious to know more - so that others will be more willing to try the team's changes. In this way, teams do good work for their patients while laying the groundwork for further improvements.
Solution: Promote the Project and Engage Senior Leaders
- Announce the improvements being made, including aims and schedule.
- Post results where staff can see them. For example, post a chart showing the percentage of patients on the unit with pain less than 4 out of 10 and update the data each week-- - or each day.
- Promote the topic in newsletters and paycheck stuffers and on bulletin boards.
- Engage senior leaders. Update the senior leader sponsoring the team's work on changes and results and what he or she could do to promote the change. Promotion examples include putting the project on the senior management meeting agenda, mentioning the work at board meetings, writing an article or letter about it, or inviting leaders to attend team meetings or visit patients involved in the intervention.
- Train others to follow the team's lead. Be sure to provide adequate training to the staff members who are beginning replication of the changes.
- Talk to leaders about their own experiences with end-of-life care-- - good and bad-- - to remind them of how important this work is.
Problem 7: Assuming That the Status Quo Is OK
In health care, we have come to accept some very troubling practices. Think, for instance, about patients in the last phase of life who receive futile CPR or doctors who keep prescribing meperidine. Some aspects of the status quo never set off the alarms that they should. If a team cannot think of anything to improve about the way it cares for dying patients, team members are not looking critically at the status quo. Sometimes, under scrutiny, the status quo actually becomes shocking. Sometimes, just measuring the dysfunction in the status quo is so embarrassing that it motivates a readiness to change.
Solution: Think about How It Could Be
- Find the horrible stories. Ask two or three nurses or physicians to tell a terrible experience in end-of-life care and identify the arrangements in the organization's systems or routines that allowed the catastrophe to happen.
- Find the ideal. Ask staff members what would be their ideal for care at the end of life, and discuss what would have to change to make this happen in the organization.
- Ask the patients how it could be. Interview two or three families of patients who died in the system and ask what they thought of the care provided: What was helpful? Upsetting? Good? Bad? What could have made it better?
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