28 SECTION I Pediatirc Critical Care The Discipline hadn’t been so fat ” What did the student just learn about sympa thy and respect? In the PICU, doctors, students, and nurses are compressed into a v[.]
28 S E C T I O N I Pediatirc Critical Care: The Discipline hadn’t been so fat.” What did the student just learn about sympathy and respect? In the PICU, doctors, students, and nurses are compressed into a very small, intense space They are all engaged in lifelong learning as they play their separate roles in patient care Life is, after all, an open-book test Thus, throughout our development and maturation as professionals, we in the PICU are continuously learning professionalism and cynicism from our colleagues The team aspect of PICU care adds a dimension to professionalism Not all care providers will be aligned in their views of each patient’s self-interest or society’s collective interest in distributing healthcare resources A good example is care of the dying or severely disabled child We may not all agree on limits of care, management of family members, or end-of-life issues Transfer of primary responsibility at end of shift; division of responsibility among team members such as nurses, physicians, and consultants; and appropriate delegation of tasks (given our job-specific scopes of practice) all stress our ability to work together Collaborative care necessitates that we share our ethical views among team members and include appropriate team members in the decisionmaking process We should clean up our act in the PICU, take care that our words and actions reflect the formal curriculum, fulfill our contract with society, and behave toward our patients—and toward each other—like the professionals we, at first, set out to be The full reference list for this chapter is available at ExpertConsult.com e1 References WHO Global Health Expenditure Database 2015 Available at: http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS Congressional Budget Office Federal Spending and the Government’s Major Health Care Programs is Projected to Rise Substantially Relative to GDP 2013 Available at: http://www.cbo.gov/publication/44582 Frankford DM, Konrad TR Responsive medical professionalism: integrating education, practice and community in a market-driven era Acad Med 1998;73:138-145 Jonsen AR Watching the doctor N Engl J Med 1983;308:1531-1535 ABIM Foundation, ACP-ASIM Foundation and EFIM Medical Professionalism in the New Millennium: a physician charter Ann Int Med 2002;136(3):243-246 Inui TS A Flag in the Wind: Educating for Professionalism in Medicine Association of American Medical Colleges 2003 Available at: https:// members.aamc.org/eweb/upload/A%20Flag%20in%20the%20Wind% 20Report.pdf Wear D Professional development of medical students: problems and promises Acad Med 1997;72:1056-1062 Testerman JK, Morton KR, Loo LK, et al The natural history of cynicism in physicians Acad Med 1996;71:S43-45 Feudtner C, Christakis DA, Christakis NA Do clinical clerks suffer ethical erosion? Students’ perceptions of their ethical environment and personal development Acad Med 1994;69:670-679 10 Marcus ER Empathy, humanism, and the professionalization process of medical education Acad Med 1999;74(11):1211-1215 11 Crandall SJS, Volk RJ, Loemker V Medical students’ attitudes toward providing care for the underserved J Amer Med Assoc 1993;269:2519-2523 12 Coulehan J Today’s professionalism: engaging the mind but not the heart Acad Med 2005;80(10):892-898 e2 Abstract: The medical profession is largely self-regulated by a system comprising state medical licensing boards, subspecialty boards, and credentialing and accrediting bodies This system confers many benefits on its members It is the purview of society to allow us this autonomy To sustain these professional benefits, which include control of entry into our profession and to maintain the autonomy of our credentialing and accrediting bodies, we must honor our contracts with society Professionalism is, in its simplest form, putting the patient first, placing altruism before self-interest, as is expected of us Beyond that, professionalism is a more complete charter that ties altruism to the concrete realities of the doctor-patient relationship and the marketplace in which we practice The Physician Charter is grounded in the principles of altruism, patient autonomy, and social justice It codifies the physician’s contract with society Key Words: Profession, professionalism, autonomy, social justice, conflict of interest Leading and Managing Change in the Pediatric Intensive Care Unit JOHN C LIN “If we could change ourselves, the tendencies in the world would also change As a man changes his own nature, so does the attitude of the world change towards him We need not wait to see what others do.” (in other words, be the change you want to see in the world.) —Attributed to Mahatma Gandhi “And it ought to be remembered that there is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. . . This coolness arises partly from fear . . . and partly from the incredulity of men, who not readily believe in new things until they have had a long experience of them.” —Niccolò Machiavelli The Prince, 1513 Chapter PEARLS • A modern pediatric intensive care unit (PICU) faces constant pressures to implement new clinical care practices, introduce new equipment, or assimilate new systems in response to rapidly evolving healthcare regulatory, economic, and patientcentered demands while maximizing healthcare value • To meet new challenges and advance PICU care optimally, the process of change requires a combination of leadership and management in order to develop an intentional strategy and carry out a structured yet adaptable implementation approach Leading a change initiative in a complex system such as a pediatric intensive care unit (PICU) poses multiple challenges that cannot be accomplished by any single person Just as caring for a critically ill child requires interprofessional team collaboration to achieve a desired patient outcome, introducing new care initiatives also requires a deliberate plan and customized approach Without intentional leadership and management, change initiatives too often fail to achieve the desired outcomes, create tension that undermines a unit’s morale, and are soon forgotten even when initial success occurs This chapter uses examples from successful initiatives in healthcare, specifically from the fields of adult and pediatric critical care medicine, to review the history of change management It also describes models and tools that have been developed and used to facilitate and sustain change • The PICU team can increase the likelihood of successful and sustainable change in care practices by understanding the strengths and weaknesses of existing interprofessional team function and empowering distributed leadership, personal agency, and group identity among the diverse people who comprise the PICU team • The fields of business administration and management, dissemination and implementation science, and quality improvement offer models and tools that can guide a PICU team embarking on new initiatives National Change Day: A Case Study in Leading Change On March 13, 2013, the United Kingdom’s National Health Service (NHS) held a National Change Day1 in response to the 2010 Francis Report.2 This government oversight report condemned systemic and cultural failings on an organizational scale that led to “appalling and unnecessary suffering of hundreds of people [. . . who were] failed by a system which ignored the warning signs and put corporate self-interest and cost control ahead of patients and their safety.” Founded as a grassroots movement, Change Day challenged NHS employees from all positions and professions to “Do Something Better Together” and to identify a concrete change in their own work and behavior that would 29 30 S E C T I O N I Pediatric Critical Care: The Discipline impact positively on an aspect of their local patient care processes The organizers set an initial goal of 65,000 pledges, which doubled to 130,000 by the morning of Change Day, ended the day at 182,000, and reached a total of 189,000 individual pledges by the end of March 2013.3 The NHS Change Day transformed the world’s largest health system and was subsequently awarded the Harvard Business Review/McKinsey Leaders Everywhere Challenge in September 2013 Incredibly, this movement, credited as the single “biggest ever day of collective action to improve healthcare” evolved from an impromptu conversation between a general practitioner and a lecturer speaking on “Building Contagious Commitment to Change.” This chance encounter between a conference attendee and a program lecturer evolved into a core team made up of 12 people: a pediatric resident trainee, a family practitioner, and an NHS graduate management trainee who were mentored by five improvement leaders and supported by one administrator and three social media and communications experts.4 Since then, building on this overwhelming success, the NHS holds Change Day annually Similar movements have spread to 17 other countries The success and spread of Change Day reflect change management principles that developed beginning in the 1960s, have evolved through the ensuing decades, and have steadily been adopted in manufacturing and service industries, including healthcare Change Day serves as a model for creating distributed leadership within a hierarchical system It also highlights the potential for inspirational leadership combined with intentional management to design, implement, and sustain changes in behavior History and Development of Change Management The beginning of change management as a field of expertise began when leaders recognized the importance of addressing the psychology of change as an integral component of leading and managing change This new field of expertise developed insights from the 1969 book On Death and Dying, by Elisabeth Kubler-Ross.5 This seminal book described how terminally ill patients and their loved ones reacted to a health-related event that resulted in the personal loss of a previously held image of both present and future selves Kubler-Ross proposed five stages of grief: denial, anger, bargaining, depression, and acceptance Adopting the psychological insights from the stages outlined by Kubler-Ross to address the common negative emotions triggered by an event leading to the experience of loss of current roles, changes to work environment or status, and a shift from the “old way,”6 initial change management models emphasized the importance of approaching change with more than just an idea and a plan By the 1980s, Julien Phillips at McKinsey & Company proposed three critical components for successful organizational change: (1) new strategic vision, (2) new organizational skills/capabilities, and (3) political support Phillips further described that these three core factors would have to carry out four sequential and often overlapping phases of the change process: (1) creating a sense of concern, (2) developing a specific commitment to change, (3) pushing for major change, and (4) reinforcing and consolidating the new course.7 Over the next decades, Phillips and his contemporaries from the “big 6” accounting and consulting firms of the time helped create the change management industry Recognizing the importance of leveraging a crucial event to trigger Phillips’s first two phases of change, Daryl Conner coined the term “burning platform” based on the 1988 North Sea Piper oil rig fire disaster Soon, the phrase “create a burning platform” became widely used to represent both creating a sense of urgency and establishing a commitment to change.8 Common to all of these initial change management approaches was the implied belief that organizational change could and should be accomplished using a top-down approach that inspired, convinced, cajoled, or forced frontline employees to enact and embrace the changes that leaders deemed necessary By the turn of the century, business leaders recognized the weaknesses of using a top-down approach when trying to enact lasting change Further, as the rapidity of change accelerated, change leaders recognized the importance of distributed leadership This strategic shift promoted individual initiative and created a business environment in which change was encouraged and able to develop incrementally in continuous fashion rather than in large disruptive shifts that occurred in a change-stasis-change pattern Lean management principles, originally focused on elimination of waste, shifted the emphasis of change management to creating a pattern of behavior that allowed and encouraged continuous improvement led by frontline staff that fit within the broader goal of increasing efficiency and quality The role and importance of employee engagement in achieving sustained changes in workplace behavior was formally introduced into change models in 1996 by John Kotter in his book Leading Change In his book, Kotter outlined an 8-step Leading Change Model (Table 5.1) that distinguished change leadership from change management, described the importance of both of these executive skills in guiding change, and highlighted the role of distributed leadership and employee empowerment in the change process.9 The pace of extrinsic forces that drive the need for change has only increased In the preface of his 2012 edition of Leading Change, Kotter highlighted each of these points as the foundation to achieving both efficiency and quality: • Management makes a system work It helps you what you know how to Leadership builds systems or transforms old ones It takes you into territory that is new and less well known, or even completely unknown to you • These trends (of an ever-increasing speed of change) demand more agility and change-friendly organizations; more leadership from more people, and not just top management • Speed of change is the driving force Leading change competently is the only answer.9 Change Management in Healthcare In 2006, the book entitled Redefining Health Care: Creating ValueBased Competition on Results,10 introduced the concept known as “value agenda.” In this approach, the goal of increasing efficiency and quality was reframed as maximizing healthcare value for the patient This replaced simply reducing costs, increasing market share, or improving quality In this sense, the audaciously titled article, “The Strategy that Will Fix Health Care,” defined value as “improving outcomes that matter to patients relative to the cost of achieving those outcomes.”11 In this paradigm, maximizing healthcare quality becomes a balancing force for minimizing or shifting healthcare costs and maximizing market share The NHS Change Day epitomized all these described principles In change management terms, the 2010 Francis Report created the “burning platform” that galvanized not just people ... there is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. . . This coolness... subspecialty boards, and credentialing and accrediting bodies This system confers many benefits on its members It is the purview of society to allow us this autonomy To sustain these professional benefits,... 1996;71:S43-45 Feudtner C, Christakis DA, Christakis NA Do clinical clerks suffer ethical erosion? Students’ perceptions of their ethical environment and personal development Acad Med 1994;69:670-679 10