Integrating Change in Healthcare

Integrating change in healthcare can be difficult for many reasons including a lack of the following resources to effectively drive change: quality support staff, data, leadership, time, adequate mentoring, knowledge of quality improvement (QI) techniques, and a culture that does not support change. The workplace culture aspect is very influential, because it includes hanging on to old practices because ‘this is the way it’s always been done’, also referred to as sacred cows (Kelly et al, 2018).  That mindset doesn’t reflect the best way of doing something.  

A QI approach can shift always-been-done-this-way mindsets. It includes evaluating if current processes can be done better or if research supports integrating specific changes into practice.  Unfortunately, this is a slow process, with the average length of time to integrate national guidelines into clinical practice being cited as 17 years (Markow & Main, 2019). There are, however, many tools and strategies that can help reduce this time to adoption and bridge the gap to the bedside. 

Tools to help integrate change in healthcare 

There are a variety of ways to incorporate change to the bedside, these include use of evidence based safety bundles, guidelines and protocols, and electronic medical record optimization. The following table defines these tools along with examples.

Tool	Definition	Example(s)
Bundle	Organized way of improving care processes and patient outcomes, derived from evidence based practices. These practices, when used as a whole, have been shown to improve patient outcomes. (IHI, n.d.)	IHI Elective Induction Bundle (Oxytocin), IHI Augmentation Bundle (Oxytocin), and the IHI Vacuum Bundle California Maternal Quality Care Collaborative Obstetric Hemorrhage Safety Bundle: including hemorrhage cart, order sets, risk assessment, quantitative blood loss, teamwork training including simulation and systems learning through debriefings and case reviews (Markow & Main, 2019).
Guidelines	Documents based on literature review, that include recommendations for patient care	AWHONN Nursing Care and Management of the Second Stage of Labor Evidence-Based Clinical Practice Guideline
Protocols	More prescriptive, includes detailed steps to be followed pertaining to select patient populations or diagnoses.	Oxytocin Checklist Protocol. Details assessment parameters prior to initiating oxytocin and in-use. Ensures adequate fetal and maternal well being are assessed and met, the patient is a good candidate for induction/augmentation and adequate safety measures are in place.
Electronic Medical Record (EMR) Optimization: Flowsheets	Rows within the EMR that may include required documentation, assessment parameters, or action items to be completed. Can serve as reminders or visual cues.	Second stage of labor flowsheet row containing pushing technique, maternal position, position aids, maternal response to pushing
EMR Optimization: Clinical Decision Support	Embedded alerts or reminders for correct next steps to be followed, compliance with best practice or documentation requirements	Best practice alerts (BPA’s) for emergency room providers that (a) alert providers when pregnant or postpartum patients have Blood Pressures that reach severe range (b) list next step interventions for treatment/management
EMR Optimization: Order Sets	A group of orders designed for specific patient diagnoses with the goal of standardizing practice	Order sets for management of severe hypertension in pregnant/postpartum patients for emergency room providers that include: medications, lab work, fetal monitoring, obstetric consult, blood pressure monitoring parameters

(Kelly et.al., 2018)

Toolkits

In addition to the above-described tools, a more comprehensive strategy is a toolkit. Toolkits are defined as collections of evidence-based articles, resources, guidelines, protocols, implementation guides, and education slide decks (Markow & Main, 2019). The California Maternal Quality Care Collaborative (CMQCC) has developed several tool kits including (but not limited to) obstetric hemorrhage, hypertensive disorders of pregnancy, sepsis, and cardiovascular disease.

Bringing Change to the Bedside

One critical component to effectively driving change to the bedside is going to the people doing the work. Consider all key stakeholders including frontline staff and those outside the department (ex. Blood bank, Anesthesia, Switchboard, Main OR) in the project team. These folks add key information on barriers and challenges, along with ideas on what will work in their environment. They can also serve as champions and resources for the project work in the day to day. Involving frontline staff in project work helps to build efforts from the ground up, ensuring buy-in and feasibility of efforts. 

Other helpful tips:

• Establish a vision, or call to action for your work

• Regularly communicate that with your team- repetition is the mother of all learning!

• Consider starting with small tests of change (ie one shift, one unit)

• Approach with a study and adjust mindframe- often minor changes are needed based on feedback/audits to make the process work well 

• Use a data driven approach- start with understanding your data to determine root causes of the problem, which then informs action planning. Next, use data to demonstrate change to your team and display it an area that they will see regularly

*If this article interests you, you may also enjoy my book titled: Obstetric and Neonatal Quality and Safety (C-ONQS) Study Guide: A Practical Resource for Perinatal Nurses, available on amazon: Amazon_obneonatalstudyguide

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Copyright by Jeanette Zocco MSN, RNC-OB, C-EFM, C-ONQS

References

California Maternal Quality Care Collaborative (n.d.). What We Do. Retrieved from https://www.

 cmqcc.org/about-cmqcc/what-we-do

Institute for Healthcare Improvement (n.d.). Evidence-Based Care Bundles. Retrieved from 

https:// www.ihi.org/Topics/Bundles/Pages/default.aspx 

Kelly, P., Vottero, B. A., & Christie-McAuliffe, C. A. (2018). Introduction to Quality and Safety 

Education for Nurses: Core Competencies for Nursing Leadership and Management. Springer 

Publishing Company.

Markow C., & Main E. (2019). Creating Change at Scale. Quality improvement strategies used

 by the California Maternal Quality Care Collaborative. Obstet Gynecol Clin N Am 46, 317-328.