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Objectives
Upon completion of this presentation, participants will be able to:• Identify potential challenges in implementing
quality improvement (QI) at a clinic• Discuss reasons and solutions of resistance to
change
So now we know what quality of care is, how to measure it and how to improve. It should be
easy from here right?Not always.
Some components for successful QI at an organization
• A culture of quality and improvement• Strong leadership commitment to
quality/QI• Multidisciplinary teams willing to
work together
What is a “culture of QI”
• Commitment to patient safety, quality and improvement.
• Openness to reviewing a clinic’s performance and discussing reasons for a gap.
• Replacing blame when gaps are found with working towards improvement
How leaders can support QI
• Create and support a vision for quality/QI
• Establish a multidisciplinary QI team• Build staff capacity and motivation for QI• Support effort to measure quality,
discuss gaps and work together to improve
• Support open discussion without blame of both successes and challenges
• Celebrate successesWHO. Operations Manual for Delivery of HIV Prevention, Care and Treatment in High-Prevalence, Resource-Constrained Settings, 2010
QI is a team effort• Teams are stronger and more effective than an
individual “champion”– Different members may provide unique
understanding of a gap based on their role in the process as well as how to improve
• Membership represents range of staff (and ideally patients) involved
• All members are equal• May need coaching in how to move forward
and believe that change can happen
If leadership support and a team are not in place there may be (more) resistance to doing QI
But even with these things in place there still may be resistance in the
beginning
What do you need to move long QI?
• 5 minute discussion
• What resistance to QI do you think there might be at your clinic?
• What is in place to help overcome and what else is needed?
Resistance to change
• The push-back one experiences when trying to change or improve a process or system.
• Can occur from one individual or from an entire team.
Adapted from the National Quality Center and IHI
5 minute exerciseWhy do people resist change?
• Turn to your neighbor and discuss 2-3 reasons that people may resist changing a process in the clinic in order to improve quality
• Be prepared to present back to the group
JSI and HAIVN Training April 2012 16
Why do people resist
Three main factors:• Background – What one has been taught and accepts as true
• Experience– “This is the way I have always done it,”– “change never works”
• Knowledge– Do not have the information and skills needed to
drive the change
Resistance to change• What Does it Look/Feel/Sound Like?– “We don’t have time for this activity”– “The problem is out of our control “– “You can’t tell me what to do”– “My patients are sicker than the other clinic…”– “That’s fine for other clinics, but it won’t work
here – our situation is different”– “We don’t have enough staff”– “It’s not my job”– “It’s up to the clinic chief”
Adapted from the National Quality Center
JSI and HAIVN Training April 2012 18
Reasons people resist change (1)
1. Do not believe there is a problem2. Worry that things may get worse with change3. People have a connection and feel
comfortable with how things have always been done
4. No role models or teachers for the new activity
5. People fear they lack the knowledge and skills to make the change
6. People feel overloaded and overwhelmedAdapted from “Overcoming Resistance to Change: Top Ten reasons for Change Resistance, AJ Schuler
19
Reasons people resist change (2)7. Worry they don’t have the resources8. People want to be sure it is a good idea9. People worry why the people wanting change
are doing this 10.People feel threatened by the proposed change11.Concern about having more work12.Worry leadership will not support13.People really believe the change is a BAD IDEA
Don Berwick’s resistance to changeExample – review of performance data
• Four stages of resistance
–Stage I: “The data are wrong…” –Stage II: “The data are right, but it’s
not a problem…”–Stage III: “The data are right, it’s a
problem, but it’s not my problem…”–Stage IV: “The data are right, it’s a
problem, it’s my problem…”
Adapted from the National Quality Center and IHI
Resistance to change: How to manage (1)
• First - Recognize that resistance to change is normal
• Most people go through stages that should be met with facts, understanding and ongoing discussion.
• Recognize: “People do not resist change, they resist being changed”
Adapted from the National Quality Center
22
Resistance to change: How to manage (2)
• Ask everyone’s opinion• Get everyone on board• Understand what they hope will happen• Understand what they fear• What suggestions do they have • Provide a clear picture of the future and
answer questions-what will the work flow look like
Ref Lisa Hirschhorn
Resistance to change: How to manage(3)
• Listen – both one on one and in groups• Make sure everyone understands the data and the
goals of improvement.• Provide an opportunity for people to express
concerns• Form a team which includes those most affected by a
problem and solution and try to address concerns.• Ensure leadership support• Establish a culture of quality improvement that
encourages identifying and dealing with problems
• Incorporate QI into routine clinic activities
Adapted from the National Quality Center
Group exercise
• Your clinic has found a problem with patients not showing up for appointments and a decision is made to o a QI project
• Split the group in ½-one group are the changers and one are the resistors
• 10 minutes-hold a QI project meeting and the changers work to understand why the resisters do not want to do the QI
• Identify one reason together and start a plan how to help them agree to start to look into change
• Be ready to report back
JSI and HAIVN Training April 2012 25
What if it really seems hopeless?
• No one thinks change is possible• Try making it worse• Take a problem– High rates of loss of pre-ART patients
• Brainstorm how to make it WORSE• Then ask what happens if you do the opposite
Summary (1)
• Four important factors for successful QI implementation:– A culture of QI– Leadership support– Functioning multidisciplinary QI team– Time, training and opportunity to overcome
resistance
Summary (2)
• Resistance may occur because those factors are not in place or at the individual/clinic team level
• Resistance at the individual level is important to address– expected in the beginning – handle with information/knowledge
dissemination, discussion, encouragement and reassurance.