31CHAPTER 5 Leading and Managing Change in the Pediatric Intensive Care Unit Author Name Principles Kurt Lewin Theory of Planned Change 1 Unfreeze • Determine what needs to change • Ensure strong supp[.]
CHAPTER 5 Leading and Managing Change in the Pediatric Intensive Care Unit 31 TABLE Change Leadership/Management Models 5.1 Author Name Principles Kurt Lewin Theory of Planned Change Unfreeze • Determine what needs to change • Ensure strong support from senior management • Create the need for change • Manage and understand doubts and concerns Change • Communicate often • Dispel rumors • Empower action • Involve people in the process Refreeze • Anchor changes into culture • Develop ways to sustain change • Celebrate success Ronald Lippitt Phases of Change Theory 3 4 5 6 7 Identify the problem Assess motivation, capacity, and readiness for change Identify available resources Define desired change Define change agent’s role (e.g., advocate, facilitator, consultant, expert) Maintain the change Terminate change agent’s role Everett Rogers Five-Stage Change Theory (Diffusion of Innovation Theory) 3 4 5 Knowledge: Expose individual to the new idea Persuasion: Convince individual to adopt the new idea Decision: Individual decides to adopt or reject the new idea Implementation: Individual adopts the change Confirmation: Individual accepts the change as advantageous John Kotter Leading Change Model 3 4 5 6 7 8 Establish a sense of urgency Create the guiding coalition Develop a vision and strategy Communicate the change vision Empower employees for broad-based action Generate short-term wins Consolidate gains and produce more change Anchor new approaches in culture within the NHS but also the public at large The report criticized and described the systemic failures of the NHS, misguided focus on healthcare costs rather than healthcare value, and provided a multitude of examples in which the inability of the NHS to address its known flaws led to unnecessary patient suffering This unmitigated language created an overwhelming and uniformly shared sense of urgency and concern that led to a unifying commitment for change from political leaders and the British public at large, allowing development of a guiding coalition.2,3 The inclusion of social media and communication experts among the core leadership team ensured that the vision for change was communicated broadly and consistently Local groups were empowered to seek out input from community members and leaders about how the NHS could better serve patients’ needs and improve their healthcare value Individuals were encouraged to each participate in their own way As a result, a broad-based network of leaders, unified under the umbrella of the Change Day initiative, pursued and led team-specific actions and change initiatives While this all-accepting approach allowed participants to make individual pledges as simple as “to meet and greet patients with a smile,” it also created space for city and regional health commissions to fold their local efforts into a national movement Subsequent analysis of the psychological factors that led to Change Day success highlighted the impact of allowing daily participation and commitment to self-initiated, small tests of change These small successes, in turn, affirmed both personal agency and group efficacy, promoting and restoring a sense of “vocational and organizational identity.”12 Models and Tools to Facilitate Change Leadership and Management Theories of Change Others have described change theories with many similarities to Kotter’s eight-step model Examples include Lewin’s Theory of Planned Change,13–15 Lippitt’s Phases of Change Theory,16 and Rogers’s Diffusion of Innovation Theory17 (see Table 5.1) The advantages of Kotter’s model over these four include the treatment of change as a continuous rather than a discrete event (Lewin), establishing distributed leadership and empowering frontline 32 S E C T I O N I Pediatric Critical Care: The Discipline initiative and action rather than focusing on the change agent and a top-down approach (Lippitt), and description of active leadership rather than passive management and subsequent undirected diffusion of ideas and change (Rogers) Despite these advantages, Kotter’s Leading Change model lacks specific details on how to best accomplish each of the eight steps Additionally, Kotter’s model does not include a step that assesses current attitudes and receptivity for change or a step that focuses on identifying facilitators and barriers to change Understanding current organizational culture, behavior, biases, attitudes, and knowledge provides extremely useful guidance Change leaders and managers increase the likelihood of success if they analyze how various aspects of the existing organization must interact with internal and external variables when implementing a specific intervention Without this tactical step that defines how to accomplish the strategic goal, the inspirational vision remains nebulous and can be dismissed as a grand idea but too hard or even impossible to enact Bringing Theory to Practice The Consolidated Framework for Implementation Research (CFIR)18 provides a bridge between the inspirational vision and practical question of “How we get there?” Proposed by Damschroder et al in 2009 as a framework to understand adoption of new initiatives in health services, the CFIR gives a roadmap not only for accomplishing implementation research but also for achieving successful implementation of a proposed change.18 Five domains comprise the CFIR: intervention characteristics, outer setting, inner setting, individuals involved, and the implementation process (eFig 5.1) In turn, key constructs define each of these domains and are explicitly defined to facilitate use Within years of introduction, the CFIR model was described in 26 separate publications, a testament to the framework’s success and utility when introducing change in the form of new healthcare initiatives.19 One of these studies used the CFIR model to evaluate the implementation of the ICU Liberation improvement initiative across five adult ICUs and two additional specialty care units in a single tertiary care academic medical center The authors outlined in great detail how their adoption of the ICU Liberation initiative fit within the CFIR model and provided a “lessons learned” summary of points to consider during ICU Liberation implementation.20 By applying the CFIR to their work, this multiprofessional group of ICU specialists outlined a roadmap to guide other centers seeking to replicate the work Tools for Assessing Readiness for Change Kotter’s change model and the inner setting domain of the CFIR require change leaders to understand their team’s culture, readiness to accept change, capacity to absorb new information, and willingness to adopt new practice Interprofessional team collaboration encompasses these aspects and can be assessed using several different surveys One example, the Assessment of Interprofessional Team Collaboration Scale (AITCS), prompts participants to answer 37 questions in the three domains of partnership/shared decision-making, cooperation, and coordination in order to understand how people perceive the quality of interactions among team members during their daily work.21 During the ICU Liberation collaborative, adult and pediatric participating centers used the AITCS to assess their degree of interprofessional collaboration before and after ICU Liberation participation.22,23 Staff responses allowed each site’s change leaders to identify specific domains in which implementation work should focus Among the pediatric centers, the before and after responses suggested that participation in the ICU Liberation quality initiative coincided with higher AITCS domain scores.23 While the AITCS discerns team culture, it does not specifically address an organization’s openness to adopting a specific clinical care initiative For this, the Organization Readiness for Change Assessment (ORCA) provides insight.24 Developed by the Veterans Health Administration, the ORCA asks respondents to answer questions directed to a specific change initiative Designed to be administered as part of the preparation for introducing a new clinical practice initiative, the ORCA asks 20 questions within the three domains of evidence, context, and facilitation The evidence domain assesses baseline understanding and perception of the strength and quality of medical evidence upon which the planned clinical practice change is based The context domain overlaps with the AITCS questions about teamwork but attempts to draw a distinction between whether resistance to change is based on the specific proposed intervention or is a more global resistance to change of any sort Last, the facilitation domain of the ORCA focuses on understanding how respondents perceive their leadership and management team’s ability to develop consensus, define clear roles and responsibilities, ensure adequate resources, and regularly and transparently report the impact of the change initiative on meaningful patient outcomes When used together with the AITCS, the ORCA can further focus implementation activities and resources on expressed needs and concerns, help identify facilitating and resisting forces impacting change, and predict the likelihood of success at change implementation given the current inner setting as described by the CFIR model Additional tools to identify individual tasks needed to enact change must also be applied within the CFIR model Lewin’s Force Field Analysis presents one mechanism to identify the driving forces that facilitate change, the restraining forces that resist it, and the relative impact each force has in promoting or preventing movement to the new desired state (Fig 5.2) Once identified and assigned a relative level of importance, each of these identified forces can then be analyzed further using process improvement tools The Institute for Healthcare Improvement (IHI) has assembled an open-access 10-item quality improvement (QI) toolkit to guide healthcare teams in this work (Table 5.2).25 With this toolkit, the guiding coalition and bedside PICU team members can work with implementation facilitators to develop not just a step-by-step plan to achieve individual aims but also to determine appropriate performance measures that demonstrate the impact, success, or failure of the work in meeting the stated goals Conducting focus groups can also be extremely useful in prioritizing issues and needs, eliciting common opinions that might facilitate or resist the change initiative, and generating new ideas on how to approach change planning The Agency for Healthcare Research and Quality describes focus groups as “a collection of several individuals who all discuss a particular subject, voicing and discussing their opinions and ideas on that subject.” Focus groups should be led by a facilitator with specific training and experience in leading these discussions to maximize open and honest exchanges among participants while preventing off-topic conversations that derail the discussion Exact composition, size, and number of sessions held can vary greatly depending on the 32.e1 Inner setting Individuals involved Intervention (adapted) Adaptable periphery Core components Outer setting Core components Adaptable periphery Intervention (unadapted) Process • eFig 5.1 Consolidated Framework for Implementation Research (CFIR) domains.18 Intervention: This do- main refers to the characteristics of the planned intervention A key element of this domain relates to how well the intervention fits within the current team dynamics and function In most instances, any externally designed intervention must be adapted in some way to meet the specific characteristics and needs of the team As the puzzle piece cutout of the figure displays, without adaptation, a poor fit occurs Team member perception of the intervention’s legitimacy will also impact implementation success Aspects impacting perception include whether the intervention was developed externally or internally, the expertise and reputation of the developers, the quality of supporting evidence, the applicability and advantages over other options, and the quality and comprehensiveness of the presentation Tactical considerations will also impact acceptance of the intervention These include whether the intervention can be adapted to meet local requirements and needs, if it can be first tested on a small scale and easily reversed if proven ineffective, and how disruptive the change would be to existing workflow Last, the cost of intervention implementation will be important Costs include needed time and effort, money, equipment, and opportunity costs of implementing the change Outer setting: This domain reflects how factors external to the people carrying out the intervention will impact implementation Factors include patient needs, perceived value to the patient, peer pressure from external competitors doing the same work, and existing organizational policies and incentives that impact the ease with which the change can be completed Inner setting: This domain addresses the team’s structure, existing behaviors and culture, communication quality both among team members and to external groups, the ability to and readiness for change, and capacity and resource availability to implement the intervention Individuals involved: This domain addresses characteristics of the individual members of the team Aspects include skill and educational level, self-belief that one’s skills and knowledge are sufficient to perform the intervention, sense of personal agency and identity as a valued part of the team, and other personal character traits that impact individual response to change Process: This domain addresses the way in which the clinical practice change and intervention are planned and executed Factors include the engagement of formal and informal team leaders and influencers, recruitment of change champions, input from external consultants, and the transparency and quality of quantitative and qualitative reporting of the intervention’s impact on meaningful outcomes CHAPTER 5 Leading and Managing Change in the Pediatric Intensive Care Unit Beginning State Current State 33 Desired State Driving Forces Restraining Forces CHANGE CONTINUUM force field analysis In any change process, a continuum exists defined along time or specific milestones From a beginning to a current to a desired end state, various forces can facilitate or hinder movement along the continuum These forces can be strong or weak (line width), continuous or intermittent (solid or dashed line), or begin or end at different points along the change continuum.18 • Fig 5.2 Lewin’s TABLE Institute for Healthcare Improvement Quality Improvement Essentials Toolkit 5.2 Tool Purpose Cause and effect diagram Identifies individual causes and their relationships that contribute to a specific outcome Typically, five categories of causes are considered: people, environment, materials, methods, and equipment This is also known as a fishbone diagram Driver diagram Identifies the primary and secondary forces or drivers that contribute to the overall aim of the change initiative In contrast to the Cause and Effect Diagram, the Driver Diagram develops specific interventions designed to impact behaviors or processes and permits small tests of change Failure modes and effects analysis Specifically evaluates steps in the process in which adverse or undesired actions (i.e., failure modes) could occur, what causes contribute to those failures, and the potential consequences (i.e., failure effects) of those failures on the overall system Flowchart Develops a visual graphic of each step in the current process to create a shared understanding among all team members As part of the brainstorming process for designing the change initiative, this provides a valuable tool for identifying steps that create bottlenecks or that not add value, steps in which communication breakdowns can occur, and points in which interventions identified in the Driver Diagram can be tested Histogram Presents summary data and metrics in graphic form Pareto chart Evaluates the frequency of individual factors that impact an overall effect in order to identify the smaller subset of factors that have the largest contribution to the end result Plan-do-study-act worksheet Allows repeated evaluation of the impact of small tests of change Project planning form Provides a timeline representation of each of the action steps identified in the other tools in this list Run chart and control chart These two graphs provide visual presentation of metrics such as guideline compliance and discrete outcomes After compiling at least 15 points for the Run Chart, a Control Chart allows a higher-level summary and takes into account common and uncommon variation to create an expected vs unexpected range of variation (i.e., upper and lower control limits) in the specific metric Scatter diagram Provides a graphical representation of the relationship between two variables to determine cause-and-effect relationships The specific variables to be graphed can be selected by those identified in the Cause-and-Effect Diagram or the Failure Modes and Effects Analysis These tools are available at http://www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx complexity of the questions being asked and the presence of preexisting tensions or biases among team members Recent methodologic studies suggest that having eight participants per group is the most frequently recommended size and that 90% of identified themes and ideas occur by the sixth session.26 Tools to Implement Change While these tools play key roles in planning change and outlining specific steps, implementing change requires keen focus on communication, education, and transparency about the impact on meaningful outcomes These aspects are crucial when considering 34 S E C T I O N I Pediatric Critical Care: The Discipline the second half of Kotter’s eight-step model and the process and inner setting domains of the CFIR model The NHS Change Day offers an example By including three social media and communication experts in the core team, the leaders ensured frequent and consistent communication to its large workforce during the initiative Social media platforms, community outreach initiatives, and public release of a Change Day video and website met the NHS’s goals of educating the public and garnering support at the national, local, and individual levels.1 However, communication cannot be limited to advertising that a change initiative is about to occur In leading and managing change, communication becomes an educational initiative that provides the rationale for why change is needed and offers the evidence supporting the effectiveness of the proposed clinical practice change Summaries of the work accomplished using the CFIR model and IHI QI tools can be used to communicate the rationale behind, urgency for, and process of change Communicating the impact of change on meaningful outcomes allows discussion of short-term successes and becomes part of the education process By committing to transparent discussion of the performance measures and outcomes following the change in clinical practice, frontline staff gain trust in the process and can see for themselves how the work is improving patient care Debriefing events and open results review can be quite impactful on communication and education during a change initiative These sessions provide an opportunity to discuss outcomes in a transparent fashion that acknowledges successes, highlights lessons learned, and outlines opportunities for improvement The ICU-Resuscitation (ICU-RESUSC) study provides an example in the PICU setting This 10-site US collaborative introduces postarrest interprofessional debriefing as part of an ongoing, unitwide initiative to improve cardiopulmonary resuscitation (CPR) quality In a single center, these debriefing events have both sustained the CPR training efforts and correlated with improved post-arrest neurologic outcomes.27 By debriefing all personnel from in-unit cardiac arrests within weeks of the CPR event, the authors created a forum open to all PICU staff that allowed honest dialogue about a stressful event, displayed CPR quality metrics, and reviewed relevant literature.27,28 The inclusion of open discussions of ongoing CPR training interventions and patient outcomes following CPR made the CPR QI efforts transparent This provided a way to discuss short-term results openly and identify opportunities for improvement Since then, this comprehensive CPR training and debriefing program is being implemented in 10 US PICUs as part of the ICU-RESUSC study evaluating post-arrest neurologic outcomes.29 As described in Kotter’s eightstep model, not only have these investigators anchored the change in their own unit, they are also introducing similar change in other tertiary care PICUs across the country Successful change leadership and management requires a blend of educational approaches in addition to debriefing events or reporting results Computer-based learning (CBL) has become a common component of many healthcare initiatives Advantages of this educational platform include cost-effectiveness by decreasing the number of instructors needed to reach the target audience, increased accessibility by eliminating the time and location restrictions of traditional classroom teaching, flexibility in allowing learners to complete or review the material at their own pace or as just-in-time training, and automated tracking of completion rates among required staff Disadvantages include inability to answer questions not covered in the material, inability to interact in real time with other students, and lack of spontaneous discussions that promote deeper understanding Unfortunately, the superiority of CBL compared with in-person education in achieving sustained knowledge retention has not been demonstrated in a rigorous fashion, and the best method and format of CBL modules has not been proven.30 Nevertheless, CBL has demonstrated effectiveness in discrete tasks such as arterial blood gas interpretation among ICU nurses31 and for more broad-based education in postgraduate nursing critical care courses.32 Pediatric residents working on an in-patient oncology rotation also had favorable reaction to use of CBL modules as a supplement to traditional didactic education when used in a just-in-time format during their 4-week rotation.33 Peer coaching has also been an effective component of education initiatives that helps bridge the gap between didactic or independent learning and bedside practice As a nonevaluative partnership between colleagues, peer coaching has also been described as having identified “super-users” available during patient care to serve as a real-time resource These super-users often undergo additional interactive education regarding the new change in practice and typically are recognized as informal leaders or individuals with particular expertise Waddell and Dunn named the essential components of peer coaching in nursing staff development to be (1) recognizing the time-sensitive need for education or information transfer, (2) hands-on training of the new practice, (3) demonstration of competency in the new skill, (4) nonevaluative feedback, (5) opportunity for questioning and clarification, and (6) self-assessment.34 Examples of peer coaching success in inpatient and ICU settings include increased use of ceiling lifts for patient transfers35 and improved recognition of delirium in ICU patients.36 Sustaining Change The ability to sustain gains following change implementation also requires specific attention Without intentional planning on how to anchor the new clinical practice as part of standard behavior, old habits and practices are likely to creep back For example, a multiprofessional team of physicians, nurses, and pharmacists from one tertiary care PICU spent months developing a nursedriven sedation protocol Upon completion of the protocol, an extensive education program reached all PICU staff These 1-hour, small-group training sessions included a review of PICU sedation literature, pharmacology review, and specific direction on use of the sedation protocol and its interface with computerized order entry and electronic medical record documentation Peer coaching by a nurse educator with bedside nursing occurred as part of just-in-time training in order to answer questions and evaluate for appropriate protocol application Pharmacy staff took responsibility for reviewing accuracy of medication ordering and titration and performed daily audits of protocol compliance In a subsequent analysis of consecutive PICU admissions requiring invasive mechanical ventilation year before and year after sedation protocol implementation, the group observed a significant decrease in duration of lorazepam and morphine exposure with a trend toward decreased duration of mechanical ventilation and length of PICU stay.37 However, within years of this observed success, resources dedicated to protocol education, monitoring, and communication were redistributed to other initiatives Consequently, all of the observed improvements in the year following protocol implementation had completely reverted back to preimplementation ranges for duration of sedation exposure, duration of mechanical ventilation, and length of PICU stay.38 The ... domains.18 Intervention: This do- main refers to the characteristics of the planned intervention A key element of this domain relates to how well the intervention fits within the current team dynamics... open-access 10-item quality improvement (QI) toolkit to guide healthcare teams in this work (Table 5.2).25 With this toolkit, the guiding coalition and bedside PICU team members can work with implementation... initiative fit within the CFIR model and provided a “lessons learned” summary of points to consider during ICU Liberation implementation.20 By applying the CFIR to their work, this multiprofessional