Making QI Stick & Stay

Making QI Stick & StayJune 2015

1EXTRA TeamJos Pereira, Lynda Weaver, Dionne Sinclair, Isabelle Boss, Armand Boudreau (Coach)JOSEThis is the EXTRA team at Bruyere Continuing Care in Ottawa.Jose Pereira, Medical Chief for the Palliative Care DivisionLynda Weaver, Coordinator with the Quality, Patient Safety and Risk Management deptDionne Sinclair, Director, Complex Continuing CareIsabelle Boss, Director, Learning and Development deptAnd with them is Armand Boudreau, their EXTRA Coach1Bruyre Continuing Care, OttawaNon-acute care teaching hospital2Inpatient ProgramsPalliative Care Care of the Elderly and RehabilitationComplex Continuing CareLong Term Care 731 beds and 3000+ staff

Outpatient programs Family Health TeamsDiagnostic ImagingPhotodermatologyDermatologyAmbulatory StrokePalliative RehabPalliative Consultation

+ The Village: Independent Living, Assisted Living, LTC

JOSEBruyre Continuing Care is a non-acute care teaching hospital in Ottawa, with 3000+ staff and physicians. The inpatient programs include Palliative Care, Care of the Elderly and Rehabilitation, Complex Continuing Care, and Long Term Care, with a total of 731 beds. Our outpatient programs include two Family Health Teams, Diagnostic Imaging, Photodermatology, Dermatology, Ambulatory Stroke services, and Palliative Rehabilitation, with thousands of annual therapeutic encounters. We are the only such hospital in the Champlain region of Ontario.

2Problem = Opportunity3Making QI Stick and Stay

Emanates from organizational CULTURE

(problem statement and why improvement was needed, including an anecdote to illustrate the problem)

JOSE One day on the palliative care unit, Dr. Jos Pereira walked into the room of a patient who had been on the unit for about two weeks. Hello, Mrs. Bee, Im Dr. Pereira and Ill be your physician for the next few weeks. Mrs. Bee, shook her head and said Another new person? I cant keep track of all of you! I never know which nurse or doctor is supposed to be looking after me. This seems awfully unorganized. Dr. Pereira started to explain that the nurses and doctors names are on the white board near her bed. However, when he looked, the white board was completely blank. The quality improvement project on the unit to update the white board on every shift had not been sustained after just a few months. Dr. Pereira apologized for the lack of information and promised it would be corrected. He then picked up the small folding chair that is available for clinicians to sit beside their patients to be at their eye level. He realized that this quality improvement project had been sustained for over seven years. The question is: Why do we let Mrs. Bee and other patients down at times? Why was one of the quality improvement project still in place after seven years and another dropped after only a few months? What makes QI stick and stay?

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March 2014EXTRAJOSEIn March 2014, Bruyre Continuing Care rolled out a new Quality Framework for anchoring quality improvement in the organization with a structure and processes. As seen here, the Structure connects the three levels of responsibility (corporate, programs, units) through a system of planning, communication, and actions. Senior leaders focus on strategic quality issues, and create the corporate quality plan with information from managers, patient safety reports, MOH data, and feedback surveys from patients, families and employees. Programs focus on program-specific quality plans that are integrated with the corporate plans and unit-specific needs. Unit-based Quality Teams focus on unit-based quality needs, and interact with the program quality committee to ensure their change ideas are consistent with or complementary to the program and corporate quality plans. At this point in time, only clinical operations were included in this diagram, leaving our corporate services for the next implementation phase. The EXTRA team reports to the Senior Quality of Care committee.

4By June 2015, 80% of full-time frontline staff (nursing, medicine, allied health, and support staff) on the two intervention units, will have the basic QI knowledge and attitudes that facilitate the integration of QI in daily practice, as assessed by the Bruyre QI Surveyand the active participationin specific QI activities. AIM Statement August 20145JOSEEXTRAs Aim statement was written in August last year, in Mont Tremblant: By June 2015, 80% of frontline staff (nursing, medical, allied health, and support staff) on the two selected intervention units, will have the basic QI knowledge and attitudes that facilitate the integration of QI in daily practice, as assessed by the Bruyere QI Survey and the active participation in specific QI activities.

Education was going to be our biggest push. Now, we would probably rewrite the Aim statement to include all the things we have found in the evidence and by engaging with our colleagues at Bruyre, such as the corporate and program aspects that must be in place to support the unit-based transformations.

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Needs AssessmentsPilot unitsSenior leadership

QI expert

6Literature SourcesChange managementQI SustainabilityOrganizational CultureSystematic reviews (HSE)Residencies144 articles

FindingsPrinciples and Essentials for changeGap analysisTools, ResourcesFishboneContributing factorsBurning platform for changeAim statement

(Evidence review critically summarize the improvement-related evidence (including sources) )

JOSETo address our aim statement, the EXTRA team conducted a fishbone exercise which helped depict the overall picture of the problem in the local context of making QI stick and stay. The exercise also helped to categorize the many small problems into large domains or essentials for sustainability (Rubenstein et al., 2013). We will discuss these later.

We then searched for evidence from those who have tackled this problem before us. The Health Sciences Evidence database gave us literature reviews, which led us to other articles from the domains of change management, organizational culture, and sustaining quality improvement in healthcare. There are limitations to our search, as we did not go outside the field of healthcare (with a few exceptions), nor did we undertake an exhaustive search.In addition to the literature, we went to the staff to hear what they wanted from QI educational materials. We also had a session with the Senior Leadership Team to hear some of their needs and wants.Lastly, we consulted with an internal QI expert to get his take on our thoughts (DR. Jay Mercer in family health).

I wont go into the details about our findings here, as they constitute the rest of our presentation. I will hand it over to Dionne now.

6Models changed from7

NHS Sustainability Model DIONNEWe want to show you what we have learned over the last year, and how it has affected our project.Recently, we changed the models to help us from the Kotter model of change and the NHS sustainability model to..(next slide)78To 1. HQO QI Framework

http://www.hqontario.ca/quality-improvement/quality-improvement-framework2. Principles and Essentials for ChangeReferences+++DIONNEThe HQO QI Framework, which is much more detailed and it was what our staff were taught last year. And, we devised our own Principles and Essentials for Change based on the evidence we had collected. I will explain these now.8Making QI Stick and Stay9PrinciplesSustainability requires good change management

Two levels of sustainability:Corporate, SystemProject

(brief description of theory of change and change management framework)

DIONNE We have used 2 Principles all along in shaping our project. 1) Sustainability requires good change management techniques right from the beginning of the transformation. Without following the principles of change management, there can be no sustainability. Changes management includes those principles such as being relevant to the employees, empowering them to decide on and conduct the changes, removing barriers, and having managements blessings.

The second principle was our AHA moment: we discovered that there are 2 levels of sustainability. One at the corporate level, where there must be an infrastructure to support change and quality improvement, and the other at the unit-level to foster the actual changes. These require different focii, stakeholders, and pertinent questions to ensure sustainability. Isabelle will be talking about these 2 areas of sustainability later.9Making QI Stick and Stay10EXTRA QI Sustainability Essentials for Change(brief description of theory of change and change management framework )

DIONNEHere are our Essentials for sustainability. These five areas constitute the model we used to organize our literature review and our findings in the Gap Analysis. For example, when we go back to the Senior Quality of Committee in the fall, we will organize our recommendations along these Essentials. Isabelle will 10Implementation Model:HOW will we achieve a QI Culture?QI Culture across BruyreImproved patient, family, staff, physician experienceBRUYERE QUALITY STRUCTUREJUNE 2014QI Culture on 2 unitsPhased ImplementationProcess IndicatorsOutcome IndicatorsUnit-based Quality TeamsProgram Quality TeamsSenior Quality CommitteeQuality CoachesQuality Improvement Training

QI Culture in clinical and non-clinical teamsBRUYERE SUSTAINABILITY ESSENTIALS11ACCOUNTABILITYEDUCATIONCOMMUNICATIONEVALUATION & REPORTINGPROCESSES, STRUCTUREEvidence-basedJUNE 2016DIONNE To make QI stick and stay at Bruyere, we realize that changing culture takes time and effort (Baker & Denis, 2011), thus a phased-in approach is needed. Below is an implementation logic model that outlines the major plan activities over time. The phased in approach will look like this. The existing Bruyere Quality Framework will be augmented by the EXTRA teams development of Bruyeres Quality Toolkit, which includes our five ESSENTIALS I just rexplained (Education, Accountability, Communication, Evaluation and Reporting, and Policies, Processes and Structures). These tools emerged from the literature on change management and sustainability, so they are evidence-based. The phases are outlined here, going from the 2 pilot or intervention units, to the next group of Quality Teams to be established, which will expand QI across all of Bruyere. Our hypothesis is that patient, family, staff and physician experience surveys will show improvements as quality improvement becomes a way of life, or culture.

11Evidence: Gap AnalysisEssentialsSUSTAINABILITY FACTORSWHAT BRUYERE DOESWHAT EXTRA ADDEDRECOMMENDATIONSACCOUNTABILITY8 factorsEDUCATION2COMMUNICATION5MONITORING, REPORTING2STRUCTURE, PROCESSES1012

Consider these144 refs = 33 used hereISABELLEOur gap analysis helped us situate the tools and resources that were needed. From the 144 references, there were 33 that were pertinent. We organized the findings under our Essentials. We called those findings Sustainability Factors, as in Column 2. There were 8 factors under Accountability, 2 under Education, 5 under Communication, 2 in Monitoring and Reporting, and 10 under Structure & Process. CLICK FOR ANIMATIONThen we compared what Bruyere is already doing against those sustainability factors, which is column 3. CLICK FOR ANIMATIONIn the 4th column, we put the tools and resources that EXTRA developed. CLICK FOR ANIMATIONAnd the last column is for recommendations for continuing to move forward. Let me give you an example. Under Education, one of the sustainability factors is that the organization must have the capacity to conduct QI by ensuring the right people have the appropriate QI knowledge and skills. Bruyere has already provided almost all the managers and some key staff with QI education with the help from HQO and their QI model. EXTRA has added resources by:Conducting educational needs assessment with pilot unitsIncorporating QI into General Orientation for new staffGetting ready to incorporate QI into Orientation for new physicians (work in progress)Developing Staff training Doodles we have done 3, and will work with the Learning Dept for moreDeveloping a draft Corporate QI Training Program that outlines which positions in the organization need what QI knowledge and skills and a way to educate them.

The recommendation is that the SQC committee reviews the corporate education program that the EXTRA team helped draft, and gets it moving along.

1213Interventions:Sustainability Tools, Resources, ChangesISABELLEEvidence and engagement were central to our project. It shaped our understanding of QI sustainability and everything we created was based on the literature, our engaging of senior leaders, pilot units and an internal expert in QI. These tools and resources fit into the various QI Essentials categories, I just havent shown it here. I only have time to talk about a few of these items, so I chose three that you will hear more about from Mr. Blais later on. They are the Framework for Spread, the corporate Educational program, the evaluation plan for the Quality Structure that was implemented in 2014. I will tell you about the Corporate QI Sustainability Checklist, the QI Project Sustainability Checklist, the web resources, and the Educational Doodles. 1314

Subscales:Organizational culture8 itemsQI capacity and competency10 itemsAlignment and spread15 items

(33 items)Corporate QI Sustainability Checklist - ExcerptISABELLEHere is the front page of our Corporate QI Sustainability Checklist. It comes from Joly et al, 2012 where they called it the QI Maturity Tool. We took the questions word for word and just added the Dont Know category for response options. (click for animation). CLICK FOR ANIMATIONIt contains 33 items that are organized into 3 subscales: Organizational Culture; QI Capacity and Competency, and Alignment and Spread. These are the CORPORATE focii for senior leadership. They focus on the infrastructure and support necessary for staff to carry our QI projects. They are the high level aspects of culture needed to ensure QI sticks and stays.1415

QI Project Sustainbility Checklist - ExcerptSubscales (4-7 items each; 37 items) Engage Leaders Involve and support front-line staffCommunicate benefits of improved processEnsure change is ready to be implemented and sustainedEmbed improved processBuild ongoing measurementISABELLEHere is one page of the QI PROJECT SUSTAINABILITY CHECKLIST. The questions are taken verbatim from Health Quality Ontarios QI Sustainability Planner and Checklist. We modified to for use by the unit-based QI Teams at several intervals during their project trajectory. We want them to consider the 37 items as they are planning, and 1,3 and 6 months after the QI project has been launched. CLICK FOR ANIMATIONThe 6 subscales examine everything necessary for good change management and sustainability: Engaging Leaders Involving and supporting front-line staffCommunicating benefits of improved processEnsuring change is ready to be implemented and sustainedEmbedding improved processBuilding ongoing measurement

1516Frame of doodle What is QI?

ISABELLEWe developed 3 very short learning modules that we are still in the process of disseminating. This is a screen shot of the basics of What is QI?. We show this video first to set up the rest of the series.1617

ISABELLEThis screen shot is the one for how to do FISHBONES.1718

ISABELLEHere is the screen shot of the third video, on Teamwork. This topic emerged from a focus group with our 2 pilot units. They wanted to hear more about how to work together, more than they wanted QI techniques.1819

ISABELLEHere is the proposed first page of our web-based resources for staff. They would click on a QI Acorn on the main web page, and then click on an acorn here to delve further into videos or text about the topics. The Quality Coaches made suggestions, such as having one or two acorns that changed to depict news and short term items. This web page is in addition to articles written about individual QI success stories, as part of our Communication Plan.19Timing of the EXTRA intervention roll-out coincided with the roll-out of EPR, Accreditation, hiring of several new managers, a major recovery plan to reduce costs, and a very large transformation QI experience. Literature depicts how important funding stability is for sustaining change (Center for Public Health Systems Science et al., 2013), as well as social stability (Buchanan et al., 2005). There was a black out period in April 2015 at which time all meetings and education were cancelled, thus not allowing us access to the pilot units.QI Framework was unfolding regardless of the EXTRA project, so it was difficult to stay ahead of the progress already being initiated by the QI Teams. We will not be able to say whether or not it was the EXTRA education or checklists that had impact on the pre/post test analysis, as there were many QI activities going on.It has been difficult to say what is EXTRA work and what was our normal work related to QI. For example, the Framework for Spread and the Education would have occurred even without EXTRA. However, our contribution was definitely guided by our new knowledge of the QI sustainability literature.

QI Framework was unfolding regardless of the EXTRA project, so it was difficult to stay ahead of the progress already being initiated by the QI Teams. We will not be able to say whether or not it was the EXTRA education or checklists that had impact on the pre/post test analysis, as there were many QI activities going on.It has been difficult to say what is EXTRA work and what was our normal work related to QI. For example, the Framework for Spread and the Education would have occurred even without EXTRA. However, our contribution was definitely guided by our new knowledge of the QI sustainability literature.We should have made more effort to meet with senior leadership to keep them informed of our ideas and progress throughout the year. Our intervention is about sustainability, and most QI projects are just getting to that stage now. Because of the upcoming EPR, we cannot ask pilot units to conduct audits to verify their change sustainability. This will happen in May-June 2015.Much of what we are recommending is attitudinal, which is difficult to measure.Our Pre/Post-tests are not validated.

Implementation Facilitators & ChallengesLiterature Bruyres QI Framework & Structure Leaders fully on boardSenior Quality of Care CommitteeCheck-in with leadership, QI expertQI teams QI techniques = Good change managementInterprofessional EXTRA team20Competing priorities EPR implementation, AccreditationRequired advanced planning, lots of flexibilityQI activities at implementation stageOur project = sustainabilityRequired communication, engaging stakeholdersDeveloped measurement tools and interventions in parallelNot completely in syncChanging culture takes timeISABELLECreating these resources that we portrayed in that coloured wheel had some facilitators and challenges.Facilitators were:Literature Bruyres QI Framework & Structure Leaders fully on boardSenior Quality of Care CommitteeCheck-in with leadership, QI expertQI teams QI techniques = Good change managementInterprofessional EXTRA teamCLICK FOR ANIMATION 1 (small font) - Challenges were many!CLICK AGAIN FOR ANIMATIONBut seriously, here were are largest challenges and how we dealt with them.Concurrent PrioritiesEPR implementation, AccreditationRequired advanced planning to know when the staff and senior management would be out of out reachSometimes lasts longer than expected!Organization at implementation stage; Our project = sustainabilityRequired communication, engaging stakeholders to get them to focus on sustainability when most people were up to their elbows in implementation. Our impact wont be seen for a while longer. In retrospect, we would try to engage the senior stakeholders more often despite the competing priorities perhaps with more one-on-one discussions. Developed measurement tools and interventions in parallelNot completely in sync but we did our best to measure what we wanted to change, and now will continue to create resources to make that change happen. It is a messy process. Ideally it is linear with everything lining up, but this is reality.Changing culture takes time, so the full effect of our efforts will be seen in another year or more.I WILL HAND IT OVER TO LYNDA TO TELL YOU THE RESULTS OF OUR EDUCATIONAL EFFORTS20Results Pre/Post Tests21Bruyre QI Knowledge and Attitudes QuizPre testsDecember - March 2015N= 47 from 2 units, i.e. ~50% Education6 short modulesDoodles x 3, powerpoint, game, videoMay 18-June 19 Post testsJune 15-19POSTPONED(results supported by data report on data on outcomes, and plans for monitoring and reporting results over the longer term)

LYNDAIf you recall, our Aim Statement was to improve the knowledge and attitudes of the staff on the 2 pilot units. We developed a pre/post test questionnaire and about 50% of the unit staff filled out the pretest. We tried valiantly to provide very short educational sessions using our little doodles and other resources CLICK FOR ANIMATION but the staff were too committed to learning the EPR to be able to focus on QI techniques. 21Results - Knowledge22QI Items:Pre (n=47)%Post (n=xx)%EXTRA educationQuality Improvement7.5Quality Charter65.0Aim Statement52.5Fishbone exercise53.85 Whys exercise61.5Quality indicators48.7Process mapping55.0P.A.C.E. chart82.9PDSA cycle71.8Quality Huddles61.5"LEAN"62.5Spread64.1+ Teamwork----Table 1: For each QI item, % of respondents from two pilot units selecting thelowest rating: UNFAMILIAR: I do not know what it isDraft(results supported by data report on data on outcomes, and plans for monitoring and reporting results over the longer term)LYNDABruyre QI Knowledge and Attitudes QuizThis table is showing you the percent of respondents from our 2 pilot units who rated themselves as UNFAMILIAR with the QI items. Pre tests done December - March 2015N= 47 from 2 units, i.e. ~50%

We used the 6-point rating scale from the Health Quality Ontario education evaluation form: it goes from Unfamiliar all the way up to WISDOM where respondents believe they can teach the topic.

As you can see, a very small percent of people were Unfamiliar with Quality Improvement in general (top row)For the specific QI techniques, the majority of respondents rated themselves as Unfamiliar. So there is good potential for improving knowledge.

Our Education that we gave in May and June hit 6 topics: Quality Improvement, Fishbone, 5 Whys, PACE chart, PDSA cycles, and Teamwork.

Post tests, June 15-19

22Results Knowledge (Pre)On QI team? 26% In QI projects? 41%Current state of knowledge?0% ExpertDesired state of knowledge?34% Expert

23LYNDA ONLY IF THERE IS TIME.23Results Attitudes (Pre)19 questions8 with over 80% agreement Good attitudes towards QI11 under 80%Areas for improvement .

24LYNDA only if there is time.2425Attitudes under 80% agreement:Agree, Completely AgreePRE % POST %On the unit, all the staff are INVOLVED in quality improvement activities37I am PROUD OF THE QUALITY IMPROVEMENT WORK we are doing now on the unit52I feel CAN SPEAK UP about quality improvement ideas in front on everyone on my unit58On my unit, quality improvement projects we have started ARE STILL IN PLACE59I have OPPORTUNITIES TO PROVIDE IDEAS on how we could be doing things better on the unit60My involvement with the units quality improvement work has given me an OPPORTUNITY TO LEARN61Quality improvement work can be FUN62I believe our quality improvement work on our unit has resulted in BETTER PATIENT CARE63When I take ideas about doing things better on the unit to my manager, she/he TAKES THEM SERIOUSLY72On the unit, we are ALWAYS LOOKING FOR WAYS to improve the care we provide72I am PROUD OF WORKING ON THIS UNIT76DraftLYNDA Here are the 11 attitude questions that have most potential for seeing improvement. Our educational and communication efforts will be aimed at doing so. If you recall, one of our challenges was creating educational resources and the pre-test at the same time, so we did not have this pre-test data. Now we know where to focus our next educational efforts. 25Results - QI Project Checklist26From HQO Sustainability PlannerGood tool to identify areas for improvement E.g. Geriatric Rehab Unit:Nurses team up to go to each patients room first thing in the morning to introduce themselves and proactively address any emergencies until after morning report. 1.5 Leaders have removed barriers or threats to facilitate this QI project.3.3 Stories, updates at staff meetings and a visual display of data have been shared.

(results supported by data report on data on outcomes, and plans for monitoring and reporting results over the longer term)LYNDAThe QI Project Sustainability Checklist is proving to be very useful. We have trialed it on one pilot unit, and others. For example, the QI team leader on the Geriatric Rehab unit realized that she had not removed all the barriers to facilitating their project that had been going on for several months. She realized she had lost her champion and needed one to keep the momentum going after the morning routine had changed with the implementation of our EPR system. And, she realized that she needed to keep talking it up at every opportunity to ensure ongoing successful change management and therefore QI sustainability. 26Results - Corporate QI Checklist:27From QI Maturity Tool (Joly et al, 2012)N = 7 / 11, Senior Quality of Care CommitteeSelected areas for improvement: 15. Programs and services are continuously evaluated to see if they are working as intended and are effective.

24. We allocate sufficient time for staff to participate in quality improvement efforts.

(results supported by data report on data on outcomes, and plans for monitoring and reporting results over the longer term)LYNDAThe Corporate QI Sustainability Checklist has also proven to be useful for the Senior Quality of Care Committee. For example, two of the items that had low agreement were 15 24. These are actionable items that they can begin to address now that they know they are problems. There were others, but most of the 33 items were being addressed adequately, according to the respondents. By bringing this checklist to the quality committee on an annual basis, they can see if they are making progress and fully supporting QI within the organization.Mr. Blais will tell you about the SQC action plans.(We presented the results of the checklist administration back to the Senior Quality of Care committee and they have requested we combine these findings with a full report from the EXTRA team in September. From that, they will come up with an action plan to address the priorities on an ongoing basis.)

27From the CEO Organizational ImpactEXTRATook existing QI work to the next level, with evidence-based foundationsAccelerated existing QI workEmbedding sustainability into fabric of BruyreTalent Management and Succession PlanningHRCompetenciesLearning program28

(Comments on organizational impact (not context): How has the improvement project changed the organization, and if not why not. Would the change have taken place in the absence of the EXTRA program?)MR. BLAISRead from slide.

28Making QI Stick and Stay Moving ForwardSenior Quality of Care Committee:May 5, 2015Presented Corporate QI Sustainability Checklist resultsTo present full EXTRA report and recommendations in September 2015Action plan will emerge from that discussion

29MR. BLAISRead from slide.

2930Making QI Stick and Stay Moving ForwardSenior Quality of Care CommitteeStanding item at monthly meetingsSeptember 2015:Present report and recommendationsIdentify prioritiesQ3 2015Review and adopt corporate education planQPR & Learning to implementQPR to continue online communication Q3 2015Establish QI formal communication planQPR to continue reporting corporate indicators to unitsQ2 2015Review and adopt QI Structure Evaluation PlanQPR to implementQ3 2015Review and adopt Framework for Spread to non-clinical servicesDraftMR. BLAISYou remember this slide with the QI Sustainability Essentials? There are items from the Gap Analysis and the Corporate QI Sustainability Checklist that need to attention in order to move QI sustainability forward. Let me give you just some of the highlights of the PROPOSED plan.

CLICK FOR ANIMATIONAccountability: QI Sustainability is a standing item on the SQC agenda now. And they will develop a plan based on the EXTRA teams recommendationsCLICK FOR ANIMATIONStructure and Processes: We are starting to evaluate the Quality structure now, and we need the Lynda to help carry this outCLICK FOR ANIMATIONEducation: We will develop a corporate education plan to keep up the skills of managers and staff, and to nurture more QI Coaches. We need Isabelle to help here.CLICK FOR ANIMATIONCommunication: We will continue to promote the good work at the unit level as we are doing now, and the SQC needs to develop a formal plan to ensure this continuesCLICK FOR ANIMATIONMonitoring and Reporting: We will continue getting data to the units, and we may augment this based on the recommendations from EXTRA in September.30

Support for EBDMCorporate LevelGap analysis and Corporate QI Sustainability Checklist Decisions made accordingly to support QI

Unit or QI Project levelQI Project Sustainability Checklist Fosters good change management and sustainabilityPre-post tests to examine success

New resources and toolsQI Coaches and EXTRA fellows will assist with assessing ongoing evidenceBruyre Better Evidence Research Group (BBERG)31MR. BLAISSupport structures for evidence-informed decision-making: Here are the ways that will build on the results achieved thus far and to advance evidence-informed decision-making.

31EXTRA Fellows - Leadership DevelopmentInoculated and infectious Tools and know-howWays to innovate Confidence and competenceSee bigger picture, system and complex interactions Greater connections to senior leadersLike-minded colleagues from across CanadaNo one is greater than all of us - teamwork32

(Leadership development: How has the EXTRA program influenced the team members and the senior executive team?)MR. BLAISThe EXTRA team are now inoculated and still very infectious.CLICK FOR ANIMATIONTools and know-how to make evidence-based decisions regarding QI sustainabilityWays to innovate as Directors, Quality Coordinator, and Chief of Palliative Care Confidence and competence, enhancing our influence in organization CLICK FOR ANIMATIONSee bigger picture", system and complex interactions between its partsThey have better connections with senior leadership at Bruyre now.Opportunities to engage with and learn from like-minded colleagues from across CanadaNo one of us is greater than all of us

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Other leadership developments

MR. BLAISThere have been a few other changes among the EXTRA Fellows;CLICK FOR ANIMATIONJos shaved off his goatee; CLICK FOR ANIMATIONLynda grew their hair; CLICK FOR ANIMATIONDionne bought a new dress; CLICK FOR ANIMATIONand Isabelle cut her hair!The next 4 slides depict some of the most influential references the team used from the literature. CLICK THROUGH THEM QUICKLY TO GET TO LAST SLIDE.

33References 1Baker, G. R. & Denis, J.-L. (2011). A Comparative Study of Three Transformative Healthcare Systems: Lessons for Canada Canadian Health Services Research Foundation (now Canadian Foundation for Healthcare Improvement).Brennan., S. E., Bosch, Heather Buchan, & Green, S. E. (2012). Measuring organizational and individual factors thought to influence the success of quality improvement in primary care: a systematic review of instruments . Implementation Science, 121-140.Brennan., S. E., Bosch, M., Buchan, H., & Green, S. E. (2013). Measuring team factors thought to influence the success of quality improvement in primary care: a systematic review of instruments. Implementation Science 2013, 20-37.Brown, M. G. (10-3-2011). How to measure a company's most elusive element: culture. Buchanan, D., Fitzgerald, L., Ketley, D., Gollop, R., Jones, J. L., Saint Lamont, S. et al. (2005). No going back: A review of the literature on sustaining organizational change. International Journal of Management Reviews, 7, 189-205.Center for Public Health Systems Science, George Warren Brown School of Social Work, & Washington University St. Louis MO. (2013). Program Sustainability Assessment Tool.

34MR. BLAIS34References 2Compas, C., Hopkins, K. A., & Townsley, E. (2008). Best Practices in Implementing and Sustaining Quality of Care A Review of the Quality Improvement Literature. Research in Gerontological Nursing, 1, 209-216.Hayes, C. W., Batalden, P. B., & Goldmann, D. (2015). A 'work smarter, not harder' approach to improving healthcare quality. BMJ Quality & Safety Online First, 0, 1-3.Health Quality Ontario (HQO). (2015). Sustainability Planner - Advanced Access and Efficiency for Primary Care. Institute of Healthcare Improvement. (2015). Joly, B. M., Booth, M., MIttal, P., & Shaler, G. (2012). Measuring quality in improvement in public health: the development and psychometric testing of a QI maturity tool. Evaluation & the Health Professions, 35, 119-147.Lin, M. L., Marsteller, J. A., Shortell, S. M., Mendel, P., Pearson, M., Rosen, M. et al. (2005). Motivation to Change Chronic Illness Care: Results from a National Evaluation of Quality Improvement Collaboratives. Health Care Manage, 30, 139-156.Maher, L., Gustafson, D., & Evans, A. (2007). NHS Sustainability Guide and Model National Health Systems (UK), Institute for Innovation and Improvement.

35MR. BLAIS

35References 3Massoud, M. R., Nielson, G. A., Nolan, K., Schall, M. W., & Sevin, C. (2006). A Framework for Spread: From local improvements to system-wide change Institute for Healthcare Improvement (IHI).Morgenthaler, T. I., Lovely, J. K., Cima, R. R., Berardinelli, C. F., Fedraw, L. A., Wallerich, T. J. et al. (2012). Using a framework for spread of best practices to implement successful venous thromboembolism prophylaxis throughout a large hospital system. Americal Journal of Medical Quality, 27, 30-38.Parker, V. A., Wubbenhorst, W. H., Young, G. J., Desai, K. R., & Charns, M. P. (1999). Implementing Quality Improvement in Hospitals: The Role of Leadership and Culture. Americal Journal of Medical Quality, 14, 064-069.Ploeg, J., Markle-Reid, M., Davies, B., Hihguchi, K., Gifford, W., Bajnok, I. et al. (2014). Spreading and sustaining best practices for home care of older adults: a grounded theory study. Implementation Science, 9, 162-180.Rubenstein, L. V., Stockdale, S. E., Sapir, N., Altman, L., Dresselhaus, T., Salem-Schatz, S. et al. (2013). A patient-centered primary care practice approach using evidence-based quality improvement: rationale, methods, and early assessment of implementation. Journal of General Internal Medicine, 28, S589-S597.36MR. BLAIS

36References 4Slaghuis, S. S., Strating M.M.H., Bal, R. A., & Nieboer, A. P. (2011). A framework and a measurement instrument for sustainability of work practices in long-term care. BMC Health Services Research, 11, 314-325.Slaghuis, S. S., Strating M.M.H., Bal, R. A., & Nieboer, A. P. (2013). A measurement instrument for spread of quality improvement in healthcare. International Journal of Quality in Health Care 2013, 25, 125-131.Studer, Q. (2014). Making Process Improvement Stick. Healthcare Financial Management, 90-96.

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use the power of our QI culture to make transformation stick and stay

Bruyre EXTRA Team, 2015QI is everybodys business

What ifMR. BLAISThats our work to date. We are aiming at a culture change at Bruyere that sees the adoption of QI in a manner that makes it stick and stay. We want our management and staff to adopt the two concepts: QI is everybodys business and What if..THANK YOU!38