Julie Samuelson, RN, MSN, Principal Consultant, Press Ganey Associates
Have you ever gotten to the implementation phase of an important, even mission-critical, change effort only to recognize:
- A lack of clarity about what must actually change, so that those responsible for changing their behaviors aren't aware of what they need to do differently?
- The change effort is adding to an already full plate by those who must change their practices or process – typically the patient-facing employee and middle manager.
- Other priorities may likely defeat or dilute these change efforts because there isn't the required buy-in.
- Your plan has duplicative or contradictory elements to another change effort being planned or implemented by another department or division?
You aren't alone.
Successful execution of change is often where we fail – even when change is highly desirable and evidence-based. Many times, as detailed and as thorough as the plan is, it may be because your team involved hasn't asked and answered these six key questions (I call it Success6
- What do we need to START doing?
Have you clearly identified what it is that needs to be operationalized and integrated into a new standard of practice that isn't being done today? You can help those responsible for designing and delivering the new process/practice by painting a crystal clear picture of the desired outcome to be achieved. Share the rationale – the value and meaning of the change – to the customer served (i.e., the patient, employee or physician). This facilitates the buy-in and often ignites the affective commitment necessary to take personal accountability for the new practice.
- What do we need to STOP doing?
Make sure your new process isn't just piling on to your workforce's already full plate. You need to clarify what has been determined to be ineffective or of little value to the customer being served and stop it. If you omit this important step, confusion and contradiction in standards of practice and waste of time often occur.
- What should we SUSTAIN?
Certainly all change is not a complete disarmament of our past processes and practices. You have succeeded so far for a reason. Change can often be perceived as sending the message that everything done before is wrong. Honoring what has been done right and has contributed to past success by positioning the new process as expanding on that base can be comforting and allow the new practice to feel less threatening.
- What practices should we SPREAD to additional areas or services?
In the spirit of Appreciative Inquiry, you should ensure that you're looking within your own organization for those areas or individuals that currently portray your "best" – achieving the successes you aimed for – while working under the same conditions and constraints as the rest of the organization. Learn what's working and why and the spread best practices to additional areas.
- What practice/process can we SIMPLIFY?
Does a discrepancy in performance occur because of a process that is overly complex? Could you get better outcomes by simplifying it and omitting steps that are of no value? That will allow staff to have success in a timely, efficient and focused effort.
- What opportunity for SYNERGY in practice or change efforts exists?
Is there another process or effort currently in place where alignment of efforts or practice is the key? Are there silos that prevent awareness of common goals?
Consider this example when applying the SUCCESS6
method in your organization:
A Midwest hospital aimed to improve its HCAHPS score in the medication composite – particularly regarding patient perception of having understood medication side effects. The hospital aimed to improve its scores beginning with the total joint patient population – a patient type that had more than an acceptable level of complications and ED visits post-hospitalization.
It was determined that in its current practice of discharge phone calls the hospital needed to START including specific questions regarding the discharge medications – particularly the anticoagulant medications. It needed to STOP asking a variety of opened-ended, yes/no questions regarding a multitude of topics during discharge phone calls and limit its focus to those priority issues that could lead to readmission or a preventable ED visit – including early signs of complications or adverse effects from their medications.
A good question: "I want to be sure I was clear in my instructions while you were here at the hospital, so can you tell me what problems your blood thinner can cause and what you would do if any of those happen?"
The hospital needed to SUSTAIN the practice of discharge phone calls to this often high-risk group (for post-discharge venous thromboembolism) but to replace the content/focus of the call with priority issues such as medication side effects.
When examining the success of peers that had better scores in patients' understanding of medications, the hospital looked at the practices of the certified diabetic educator (CDE) with the diabetic patient population. The CDE consistently utilized the "teach-back" best practice – querying patients in such a way that they were able to demonstrate their understanding of the medication, how to administer it, what complications to watch for and how to manage those complications should they arise. Many of these follow-up conversations were via phone call in addition to being face-to-face. The joint program was able to incorporate (i.e., SPREAD) this type of questioning in which a patient could validate his/her understanding of the medication side effect by describing how he would manage a complication of their anticoagulant during office hours as well as during weekends and evenings. The hospital also SIMPLIFIED its discharge phone call by focusing on what it defined as the first two weeks' "survival skills." Therefore, phone calls were of shorter duration and added value to the patient.
In the process of change the Medication Side Effect/Total Joint Improvement Team discovered that a chronic heart failure team was exploring the introduction of discharge phone calls as well as the teach-back method. The teams were able to create some SYNERGY around the design and introduction of common documentation for the discharge phone call process, thus saving this additional team time and energy in the process.
Change is never easy, and it is in the execution of new practices that failure happens. Try asking the key questions around these six themes; collectively they hold a promise for improved SUCCESS6