Before putting quality and safety work into practice, it’s important to plan for the challenges brought on by implementation and sustainability. Challenges include lack of upper-level support/commitment and personnel, project fatigue, and competing priorities. These represent an organizational commitment to quality and safety, adequate support, and use of an organized approach with careful consideration to the current state of project work and what is being asked of all staff involved. This article will explore these concepts in greater detail, along with strategies for quality improvement sustainment and change.
Upper Level Support
Hospital leadership — the board of directors and senior leadership — establishes the hospital’s vision and mission and ensures they prioritize quality and safety. They emphasize safety by developing a safety culture, supporting quality and safety work, and monitoring progress toward safety goals. Literature supports the positive influence boards have on quality in high-performing hospitals, through the organized use of data, goal-setting, and regular tracking of performance (Agency for Healthcare Leadership and Quality, n.d.).
Here are a few examples of what upper level support looks like for quality and safety work:
Supporting and providing resources for obtaining and analyzing data including development of dashboards
Project management support
Funding approval for various quality and safety initiatives (i.e. electronic record optimization, technology to enhance safety, training/education)
Leadership walkrounds- when executive leaders regularly visiting units and discuss safety concerns with frontline staff.
In contrast, a lack of hospital leadership support can lead to insufficient support for the previously stated elements, along with a disconnect between frontline staff and executive leadership around safety concerns, barriers, and the day-to-day reality.
Challenges in quality improvement work
Project fatigue describes a state in which there are multiple simultaneous ongoing projects being conducted. For example, a clinical unit may be striving to improve hand hygiene, improve perinatal care core measures, and increase patient experience. The additional work brought about as a result can be overwhelming for frontline staff and leadership involved, especially if they are already being stretched thin (Pronovost, 2015).
Competing priorities describes a state in which there are many “asks” being requested and different project work will need to be prioritized. For example, if a serious safety event occurs while other safety initiatives are in progress, priority would shift away from the existing initiatives toward new QI changes to prevent a similar safety event — at least initially.
Lack of personnel to conduct quality and safety work poses a significant barrier to implementation. This may be a result of not having adequate quality support staff in place to lead the work and monitor progress, along with a lack of frontline staff available due to staffing shortages and turnover. Project fatigue contributes here: multiple competing projects can lead to lack of personnel, and those left may be overburdened by their tasks.
Leading change
While there are many tools for leading change, the following section provides a few key considerations including establishing a vision, adequately communicating the vision, and project team makeup.
“Vision refers to a picture of the future with some implicit or explicit commentary on why people should strive to create that future” (Kotter, 2012, p. 71). It provides the direction for change, inspires forward moving action steps, and efficiently brings together the different people required to make that change . Providing direction helps to ensure everyone is on the same page and understands why the effort is important. An effective vision motivates individuals to make the necessary changes that may initially be painful or uncomfortable. It connects these pain points, or sacrifices, to the end benefits. Lastly, autonomy and reduced conflict result from better coordinated work (Kotter, 2012).
Once a clear vision is established, it must be adequately communicated. It is not uncommon to see failed efforts from a vision getting lost in other tasks and priorities due to undercommunication. Here are a few examples of effective communication strategies:
Keep it simple
Use examples (pictures help)
Use multiple methods (newsletters, meetings, emails, huddles, etc.)
Create muscle memory with repetition
Role model the vision
Address inconsistencies
Allow for dialogue and feedback among all staff involved (Kotter, 2012).
Lastly, when creating change, it’s important that all the right people are involved. Ideally a QI project team will consist of multidisciplinary members, which draws from a greater staff resource pool and ensures multiple perspectives are captured. In addition, utilizing staff in various areas and levels of expertise enables more resources. This may include quality, data analytics, informatics, project management, frontline staff, novice and experienced staff, and any other pertinent focus areas.
It is critical to include all key stakeholders including team members who are doing the work (ie frontline staff) in the project team. These folks add key information on barriers and challenges, along with ideas on what will work in their environment. Involving frontline staff in project work helps to build efforts from the ground up, ensuring buy-in and feasibility of efforts.
*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
Copyright by Jeanette Zocco RNC-OB, C-EFM, C-ONQS
References
Agency for Healthcare Leadership and Quality. (n.d.). Leadership Role in Improving Safety. Retrieved from https://psnet.ahrq.gov/primer/leadership-role-improving-safety
Kotter, J. (2012). Leading Change. Harvard Business Review Press.
Pronovost, P. (2015, June 10). A cure for ‘initiative fatigue’?. Retrieved from https://armstronginstitute. blogs.hopkinsmedicine.org/2014/03/11/a-cure-for-initiative-fatigue/