Where Do Models for Change Management, Improvement and Implementation Meet? A Systematic Review of the Applications of Change Management Models in Healthcare

Nurse managers' managerial innovation and it's relation to proactivity behavior and locus of control among intensive care nurses

BACKGROUND

The nursing profession is undergoing rapid transformation, requiring innovation in management approaches and proactive behaviors among staff. Nurse Managers play a vital role through managerial innovation, but its impacts on intensive care nurses' proactivity and locus of control remain underexplored.

OBJECTIVES

This study aimed to assess the levels of Nurse Managers' managerial innovation and relate it to proactivity behaviors and locus of control orientations among intensive care nurses.

METHODS

A cross-sectional correlational design was adopted, recruiting 242 intensive care nurses from Tanta University Hospital, Egypt. Participants completed standardized questionnaires measuring perceived managerial innovation, proactivity behavior, and locus of control.

RESULTS

Nurse Managers demonstrated moderately high innovation across all dimensions, especially in continuous learning and development (mean = 4.65) and advanced technology use (mean = 4.56). Nurses exhibited sound proactivity levels, particularly in adaptability (mean = 4.40) and planning (mean = 4.35). The majority of nurses showed an internal locus of control (64.5%). Managerial innovation had significant positive correlations with nurses' proactivity (r = 0.45, p < 0.001) and internal locus of control (r = 0.42, p < 0.001). Regression analysis revealed age, gender, experience, education, and ICU type as significant predictors of proactivity and locus of control.

CONCLUSION

Innovative nursing leadership positively influences staff's proactivity levels and perceived control over their practice. This underscores the vital role of nurse managers in creating empowering environments in intensive care.

Clinicians' perspectives on remote patient management: A qualitative exploration of physiotherapists using the DiAL (Direct Access Line) programme

BACKGROUND

In response to the COVID-19 pandemic, face-to-face consultations within healthcare settings were suspended. Remote consultations became crucial for managing musculoskeletal conditions alongside Patient Initiated Follow-ups, leading to the development of the DiAL programme at a large National Health Service Community Trust. Previous research has focused on quantitative data, little is known about staff experiences with this programme.

OBJECTIVES

To explore the perceptions and opinions of physiotherapy staff using DiAL, in order to highlight the benefits and challenges of this service with identification of areas for future development.

DESIGN

Qualitative focus groups.

METHODS

Two virtual focus groups were conducted via Microsoft Teams, involving a purposive sample of physiotherapy staff in the musculoskeletal services known to have used DiAL. Thematic analysis was conducted.

RESULTS

Ten clinicians participated in the study, generating two main themes: Clinician Autonomy and Institutional Needs. These themes encompassed several subthemes.

CONCLUSIONS

Clinicians reported higher job satisfaction and improved accessibility for patients, attributing these positive outcomes to the autonomy and flexibility provided by the platform. While the programme met National Health Service targets for Patient Initiated Follow-ups, there was a desire for ongoing improvements and a recognition that previous audits failed to capture all the benefits. DiAL serves as a treatment choice, supporting evidence on the advantages of remote consultations and contributing to the National Health Services' goal of reducing its carbon footprint. There is a collective desire for the platform to continue with future recommendations including expanding its use and exploring additional audit metrics.

Shedding new light for nurses: Enhancing pressure injury prevention across skin tones with sub-epidermal moisture assessment technology

AIM(S)

To assess the effectiveness of sub-epidermal moisture (SEM) assessment technology in the detection of early-stage pressure damage in a critical care unit (CCU) and dark skin tone patients and its impact on hospital-acquired pressure injury (HAPI) incidence.

DESIGN

Quality improvement study employing Kurt Lewin's change model emphasizing planning, implementation, evaluation and sustainable change.

METHODS

The study evaluated 140 adult patients admitted to the CCU over a 24-week period, from July to December 2022. Retrospective analysis of standard PI care pathways was performed in 90 patients admitted during a 12-week pre-implementation period. Fifty patients were admitted through the subsequent 12-week implementation period. SEM assessments were performed daily at the sacrum and heels and interventions were applied based on SEM assessments; SEM delta ≥0.6 indicating localized oedema or persistent focal oedema. Statistical analyses were performed on anonymized data.

RESULTS

Pre-implementation HAPI incidence was 8.9% (N = 8/90). All eight patients were African American with varying skin tones. A 100% reduction in HAPI incidence was achieved in the implementation period which included 35 African American patients. The relative risk of HAPI incidence was 1.6 times higher in the pre-implementation group.

CONCLUSION

Implementing SEM assessment technology enabled equitable PI care for all population types and resulted in a 100% reduction of PIs in our CCU. Objective SEM assessments detected early-stage PIs, regardless of skin tone and enabled providing interventions to specific anatomies developing tissue damage as opposed to universal preventive interventions.

IMPLICATIONS

PI care pathways relying on visual and tactile skin assessments are inherently biased in providing equitable care for dark skin tone patients. Implementing SEM assessments empowers healthcare practitioners in driving objective clinical interventions, eliminates bias and enables positive PI health outcomes.

IMPACT

Implementing SEM assessment technology had three main effects: it detected early tissue damage regardless of skin tone (detection effect), enabled anatomy-specific interventions (treatment effect) and prevented PIs across all population types (prevention effect). The authors have adhered to the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. What does this paper contribute to the wider global clinical community? Addressing health inequities in pressure injury prevention; Demonstrated effectiveness across patient populations; Resource optimization and enhanced patient safety.

Long-Term Adoption of Televisits in Nursing Homes During the COVID-19 Crisis and Following Up Into the Postpandemic Setting: Mixed Methods Study

BACKGROUND

There is growing evidence that telemedicine can improve the access to and quality of health care for nursing home residents. However, it is still unclear how to best manage and guide the implementation process to ensure long-term adoption, especially in the context of a decline in telemedicine use after the COVID-19 crisis.

OBJECTIVE

This study aims to identify and address major challenges for the implementation of televisits among residents in a nursing home, their caring nurses, and their treating general practitioners (GPs). It also evaluated the impact of televisits on the nurses' workload and their nursing practice.

METHODS

A telemedical system with integrated medical devices was introduced in 2 nursing homes and their cooperating GP offices in rural Germany. The implementation process was closely monitored from the initial decision to introduce telemedicine in November 2019 to its long-term routine use until March 2023. Regular evaluation was based on a mixed methods approach combining rigorous qualitative approaches with quantitative measurements.

RESULTS

In the first phase during the COVID-19 pandemic, both nursing homes achieved short-term adoption. In the postpandemic phase, an action-oriented approach made it possible to identify barriers and take control actions for long-term adoption. The implementation of asynchronous visits, strong leadership, and sustained training of the nurses were critical elements in achieving long-term implementation in 1 nursing home. The implementation led to enhanced clinical skills, higher professional recognition, and less psychological distress among the nursing staff. Televisits resulted in a modest increase in time demands for the nursing staff compared to organizing in-person home visits with the GPs.

CONCLUSIONS

Focusing on health care workflow and change management aspects depending on the individual setting is of utmost importance to achieve successful long-term implementation of telemedicine.

Power and politics of leading change in emergency departments: A qualitative study of Australasian emergency physicians

OBJECTIVE

The ability to lead change is well recognised as a core leadership competency for clinicians, including emergency physicians. However, little is known about how emergency physicians' think about change leadership. The present study explores Australasian emergency physicians' beliefs about the factors that help and hinder efforts to lead change in Australasian EDs.

METHODS

An online modified Delphi study was conducted with 19 Fellows of the Australasian College for Emergency Medicine. To structure the process, participants were sorted into four panels. Using a three-phase Delphi process, participants were guided through a process of brainstorming, narrowing down and ranking the factors that help and hinder attempts to lead change. Reflexive thematic analysis was used to code and interpret the qualitative data set emerging from participants' responses through the final ranking phase.

RESULTS

A wide array of self-, ED- and hospital-related enablers and barriers of leading change were identified, the relative importance of which varied as a function of panel. Five core themes characterised emergency physicians' conceptions of change leadership in hospitals: challenging environments of competing interests and tribalism; need for trust and psychological safety to sustain collaboration; challenges of navigating complex hierarchies; need to garner executive leadership support and; need to maintain a growth mindset and motivation to practice change leadership.

CONCLUSION

The findings of our study provide new insight into emergency physicians' conceptions of the nature, barriers to and enablers of change and point to new directions in leadership development to support emergency physicians' aspirations in the context of quality, organisation and health systems improvement.

Artificial intelligence (AI) implementation within the National Health Service (NHS): the South West London AI Working Group experience

In the rapidly evolving field of artificial intelligence (AI) for radiology, with a plethora of vendor options and use-cases and evidence claims to sift through, the pressing question is how to effectively implement the right tool for enhanced patient care? This article presents a structured approach to AI deployment, drawing from a comprehensive case study in South West London. We underscore the necessity of forming a dedicated AI team with a clear vision and assertive leadership to navigate such complexities. Central to our discussion is the significance of crafting an AI implementation plan, with an overarching aim to augment patient care, promote operational efficiency, and lay down standardized protocols for seamless AI adoption. By presenting a blueprint for AI implementation within the National Health Service (NHS), we intend to demystify the process for radiology departments across the UK, enabling them to make informed decisions and empowering their staff to embrace and leverage AI responsibly ensuring that patient welfare remains at the heart of innovation. Thus, having a framework to follow when implementing an AI solution that addresses a vision for scalable adoption, core team members with diversity of skillset, staff engagement and education, plan for vendor selection, and change management is crucial for success.

Nurse Manager's Responsibilities in Creating Supportive Working Conditions Post Implementation of Everyday Coping: A Hermeneutic Research Study of District Nurses' Experiences

Aim

To gain knowledge about how district nurses experience changes in working conditions and discuss nursing manager's responsibility in facilitating working conditions for district nurses following the implementation of everyday coping.

Background

To overcome the challenges related to the sustainability of the healthcare sector, everyday coping was implemented in district nursing. The implementation was set by the government and implemented by the municipality. The nursing manager has an overall responsibility to facilitate working conditions so that everyday coping can be applied into district nursing practice.

Method

This descriptive and interpretative study involved 19 interviews and 19 observations on 10 nurses. Kvale and Brinkmann's three levels of understanding were employed in the analysis.

Results

Three categories were established based on the results of the data analyses: (i) time and space are not considered, (ii) crossfire of conflicting expectations, and (iii) nursing manager's commitment to everyday coping.

Conclusion

The working conditions of district nurses are not adapted for them to work according to the everyday coping mindset. The nursing manager has a key role in supporting nurses and addressing challenges the nurses meet in their daily work, where everyday coping is implemented. The study highlights the importance for healthcare managers, at various levels in the healthcare sector, to be conscious of the district nursing practice, its complexity, and quality of health services when implementing change. This knowledge is important when planning future healthcare and nursing practice.

Riding the wave of change: Providing solid ground to support nursing with patient transitions to novel haemophilia therapies

INTRODUCTION

Haemophilia nursing practice has experienced a shift in the past decade, as the historic chief focus on factor infusions shifted to extended half-life products, bispecific antibody therapies and other non-replacement therapies. This evolution has driven a need for changes in nursing practice in many haemophilia treatment centres.

AIM

This article intends to provide insights to the haemophilia nurse to champion practice changes at their haemophilia treatment centres.

METHODS

Two popular change theories, Lewin's three-step change model and Kotter's eight-step change model are discussed as a framework for haemophilia nurses to think, structure and be leaders in change.

CONCLUSION

Examples of these models in practice could give guidance and examples to reflect on for haemophilia nurses needing to make changes in their practice settings. These models of change, alongside existing haemophilia nurse competencies and tools such as the shared decision-making tool from the World Federation of Hemophilia, can assist the nurse to be a capable change agent to usher in these new innovations.

Strategies to implement evidence-informed decision making at the organizational level: a rapid systematic review

BACKGROUND

Achievement of evidence-informed decision making (EIDM) requires the integration of evidence into all practice decisions by identifying and synthesizing evidence, then developing and executing plans to implement and evaluate changes to practice. This rapid systematic review synthesizes evidence for strategies for the implementation of EIDM across organizations, mapping facilitators and barriers to the COM-B (capability, opportunity, motivation, behaviour) model for behaviour change. The review was conducted to support leadership at organizations delivering public health services (health promotion, communicable disease prevention) to drive change toward evidence-informed public health.

METHODS

A systematic search was conducted in multiple databases and by reviewing publications of key authors. Articles that describe interventions to drive EIDM within teams, departments, or organizations were eligible for inclusion. For each included article, quality was assessed, and details of the intervention, setting, outcomes, facilitators and barriers were extracted. A convergent integrated approach was undertaken to analyze both quantitative and qualitative findings.

RESULTS

Thirty-seven articles are included. Studies were conducted in primary care, public health, social services, and occupational health settings. Strategies to implement EIDM included the establishment of Knowledge Broker-type roles, building the EIDM capacity of staff, and research or academic partnerships. Facilitators and barriers align with the COM-B model for behaviour change. Facilitators for capability include the development of staff knowledge and skill, establishing specialized roles, and knowledge sharing across the organization, though staff turnover and subsequent knowledge loss was a barrier to capability. For opportunity, facilitators include the development of processes or mechanisms to support new practices, forums for learning and skill development, and protected time, and barriers include competing priorities. Facilitators identified for motivation include supportive organizational culture, expectations for new practices to occur, recognition and positive reinforcement, and strong leadership support. Barriers include negative attitudes toward new practices, and lack of understanding and support from management.

CONCLUSION

This review provides a comprehensive analysis of facilitators and barriers for the implementation of EIDM in organizations for public health, mapped to the COM-B model for behaviour change. The existing literature for strategies to support EIDM in public health illustrates several facilitators and barriers linked to realizing EIDM. Knowledge of these factors will help senior leadership develop and implement EIDM strategies tailored to their organization, leading to increased likelihood of implementation success.

REVIEW REGISTRATION

PROSPERO CRD42022318994.

A novel framework for human factors analysis and classification system for medical errors (HFACS-MES)-A Delphi study and causality analysis

The healthcare system (HCS) is one of the most crucial and essential systems for humanity. Currently, supplying the patients' safety and preventing the medical adverse events (MAEs) in HCS is a global issue. Human and organizational factors (HOFs) are the primary causes of MAEs. However, there are limited analytical methods to investigate the role of these factors in medical errors (MEs). The aim of present study was to introduce a new and applicable framework for the causation of MAEs based on the original HFACS. In this descriptive-analytical study, HOFs related to MEs were initially extracted through a comprehensive literature review. Subsequently, a Delphi study was employed to develop a new human factors analysis and classification system for medical errors (HFACS-MEs) framework. To validate this framework in the causation and analysis of MEs, 180 MAEs were analyzed by using HFACS-MEs. The results showed that the new HFACS-MEs model comprised 5 causal levels and 25 causal categories. The most significant changes in HFACS-MEs compared to the original HFACS included adding a fifth causal level, named "extra-organizational issues", adding the causal categories "management of change" (MOC) and "patient safety culture" (PSC) to fourth causal level", adding "patient-related factors (PRF)" and "task elements" to second causal level and finally, appending "situational violations" to first causal level. Causality analyses among categories in the HFACS-MEs framework showed that the new added causal level (extra-organizational issues) have statistically significant relationships with causal factors of lower levels (Φc≤0.41, p-value≤0.038). Other new causal category including MOC, PSC, PRF and situational violations significantly influenced by the causal categories of higher levels and had an statistically significant effect on the lower-level causal categories (Φc>0.2, p-value<0.05). The framework developed in this study serves as a valuable tool in identifying the causes and causal pathways of MAEs, facilitating a comprehensive analysis of the human factors that significantly impact patient safety within HCS.

Anticoagulation Stewardship to Bridge the Implementation Gap in Perioperative Anticoagulation Management

Lack of alignment of care protocols among providers in health care is a driver of increased costs and suboptimal patient outcomes. Perioperative anticoagulation management is a good example of a complex area where protocol creation is a clinical challenge that demands input from multiple experts. Questions regarding the need for anticoagulation interruptions are frequent. Yet, due to layers of complexity involving analysis of anticoagulation indication, surgical risk, and anesthesia-associated bleeding risk as well as institutional practices, there is heterogeneity in how these interruptions are approached. The recent perioperative anticoagulation guidelines from the American College of Chest Physicians summarize extensive evidence for the management of anticoagulant and antiplatelet medications in patients who undergo elective interventions. However, implementation of these guidelines by individual clinicians is highly varied and often does not follow the best available clinical evidence. Against this background, anticoagulation stewardship units, which exist to improve safety and quality monitoring for the anticoagulated patient, are of growing interest. These units provide a bridge for the implementation of value-based, high-quality guidelines for patients who need perioperative anticoagulation interruption. We use a case to pragmatically illustrate the problem and tactics for change management and implementation science that may facilitate the adoption of perioperative anticoagulation guidelines.

New Zealand Pae Ora Healthcare Reforms 2022: Viable by Design? A Qualitative Study Using the Viable System Model

BACKGROUND

The New Zealand (NZ) Pae Ora (Healthy Futures) health reforms came into effect in July 2022 with the establishment of Health New Zealand (HNZ) (Te Whatu Ora) and the Māori Health Authority (MHA) (Te Aka Whai Ora) - the organisations charged for healthcare provision and delivery. Given these changes represent major health system reform, we aimed to conduct an early evaluation of the design of the reforms to determine if they can deliver a viable and sustainable NZ health system going forward.

METHODS

The evaluation was informed by Beer's viable system model (VSM). A qualitative exploratory design with semi-structured interviews and documents analysis using thematic analysis was used. We conducted 28 interviews with senior healthcare managers and reviewed over 300 official documents and news analyses.

RESULTS

The VSM posits that for a system to be viable, all its five sub-systems (operations; co-ordination; operational control; development and governance) need to be strong. Our analysis suggests that the health reforms, despite their strengths, do not satisfy this requirement. The reforms do appreciate the complexity of the healthcare environment: multiple stakeholders, social inequalities, interdependencies. However, our analysis suggests a severe lack of detail regarding the implementation and operationalisation of the reforms. Furthermore, resourcing and coordination within the reformed system is also unclear.

CONCLUSION

The health system reforms may not lead to a viable future NZ health system. Poor communication of the reform implementation and operationalisation will likely result in system failure and inhibit the ability of frontline health organisations to deliver care.

A collaborative primary health care model for children and young people in rural Australia: explorations of cross-sectoral leader action

BACKGROUND

Cross-sectoral collaborations are considered necessary to address detrimental health, social, educational and economic outcomes that impact marginalised and disadvantaged populations. There is a strong relationship between the health of children and their educational attainment; good health promotes positive learning. This paper reports cross-sectoral executive and senior management level systems changes required to enable the design of a collaborative primary healthcare service model for children and young people in rural Australia.

METHODS

A descriptive qualitative design was used. Data were collected from executive and senior managers from three organisations (Education, Health and a University Department of Rural Health [n =6]) through individual semi-structured interviews. Data were analysed using an inductive, thematic approach. The study draws on Lewin's Model of Change.

RESULTS

Three overarching themes were generated from the data: an embedded challenge and experimental solutions; building a shared language and understanding; and the role of relationships and trust. Despite the unique geographical and social context of the study area, strategies emerged from the data on how a solution to an embedded challenge, through design of a primary healthcare model, was established and how the strategies described could be transferred and scaled to other rural and remote communities.

CONCLUSION

Contextual differences make each rural and remote area unique. In this study, strategies that are described in the managing change literature were evident. The authors conclude that drawing on strong management of change principles could mean that a service model designed for one remote community might be transferrable to other communities.

Tailored implementation of the FICUS multicomponent family support intervention in adult intensive care units: findings from a mixed methods contextual analysis

BACKGROUND

The Family in Intensive Care UnitS (FICUS) trial investigates the clinical effectiveness of a multicomponent, nurse-led interprofessional family support intervention (FSI) and explores its implementation in intensive care units (ICUs). The local context of each ICU strongly influences intervention performance in practice. To promote FSI uptake and to reduce variation in intervention delivery, we aimed to develop tailored implementation strategies.

METHODS

A mixed method contextual analysis guided by the Consolidated Framework for Implementation Research (CFIR) was performed from March to June 2022 on eight ICUs assigned to the intervention group. ICU key clinical partners were asked to complete a questionnaire on CFIR inner setting measures (i.e., organizational culture, resources, learning climate and leadership engagement) and the Organizational Readiness for Implementing Change (ORIC) scale prior to group interviews, which were held to discuss barriers and facilitators to FSI implementation. Descriptive analysis and pragmatic rapid thematic analysis were used. Then, tailored implementation strategies were developed for each ICU.

RESULTS

In total, 33 key clinical partners returned the questionnaire and 40 attended eight group interviews. Results showed a supportive environment, with CFIR inner setting and ORIC measures each rated above 3 (scale: 1 low-5 high value), with leadership engagement scoring highest (median 4.00, IQR 0.38). Interview data showed that the ICU teams were highly motivated and committed to implementing the FSI. They reported limited resources, new interprofessional information exchange, and role adoption of nurses as challenging.

CONCLUSION

We found that important pre-conditions for FSI implementation, such as leadership support, a supportive team culture, and a good learning climate were present. Some aspects, such as available resources, interprofessional collaboration and family nurses' role adoption were of concern and needed attention. An initial set of implementation strategies were relevant to all ICUs, but some additions and adaptation to local needs were required. Multi-component interventions are challenging to implement within complex systems, such as ICUs. This pragmatic, theory-guided, mixed methods contextual analysis demonstrated high readiness and commitment to FSI implementation in the context of a clinical trial and enabled the specification of a tailored, multifaceted implementation strategy.

Change Management and Health Care Culture

Change management in health care is the process of implementing new policies, procedures, and practices in order to improve the quality of patient care. It involves understanding the need for change, identifying the stakeholders involved, and developing a plan to implement and manage the change. Change management in health care requires a comprehensive and collaborative approach to ensure that changes are properly implemented, communicated, and monitored. It is essential for health care providers to be aware of the current trends in health care and to stay up to date with the latest technology in order to provide the best care possible.

Perspectives on research needs in healthcare epidemiology and antimicrobial stewardship: what's on the horizon - Part I

In this overview, we articulate research needs and opportunities in the field of infection prevention that have been identified from insights gained during operative infection prevention work, our own research in healthcare epidemiology, and from reviewing the literature. The 10 areas of research need are: 1) transmissions and interruptions, 2) personal protective equipment and other safety issues in occupational health, 3) climate change and other crises, 4) device, diagnostic, and antimicrobial stewardship, 5) implementation and de-implementation, 6) health care outside the acute care hospital, 7) low- and middle-income countries, 8) networking with the "neighbors", 9) novel research methodologies, and 10) the future state of surveillance. An introduction and chapters 1-5 are presented in part I of the article, and chapters 6-10 and the discussion in part II. There are many barriers to advancing the field, such as finding and motivating the future IP workforce including professionals interested in conducting research, a constant confrontation with challenges and crises, the difficulty of performing studies in a complex environment, the relative lack of adequate incentives and funding streams, and how to disseminate and validate the often very local quality improvement projects. Addressing research gaps now (i.e., in the postpandemic phase) will make healthcare systems more resilient when facing future crises.

Using In Situ Simulation to Identify Latent Safety Threats in Emergency Medicine: A Systematic Review

SUMMARY STATEMENT

This review aimed to explore existing literature on the use of in situ simulation to identify latent safety threats in emergency medicine. Studies were required to take place in a clinically active emergency department and have either a primary or secondary aim of identifying latent safety threats. A total of 2921 articles were retrieved through database searches and a total of 15 were deemed to meet the inclusion criteria.Latent safety threats were detected by a variety of methods including documentation during debrief/discussion (66%), during the simulation itself (33%), participant surveys (20%), and video analysis (20%). Using a multimodality approach with input from observers and participants from different professional backgrounds yielded the highest number of threats per simulation case (43 per case). Equipment was the most commonly reported threat (83%), followed by teamwork/communication (67%). Some studies did not report on mitigation of identified risks; formal processes should be implemented for the management of latent safety threats identified by in situ simulation. Future research should focus on translational outcomes to further strengthen the position of in situ simulation in emergency medicine.

A survey to explore the psychological and professional impact of change imposed by COVID-19

Aim

Staff of a department underwent a change following the COVID-19 pandemic. The objective of this study was to assess the psychological and professional impact of this change.

Materials & methods

This is cross-sectional study, including all department staff conducted from 15 July 2021 to 15 August 2021.

Results

All the staff concerned (n = 36) participated. Only 9.37% declared that they understood the change. The main problem encountered by participants was poor communication (86.2%). More than 75% among participants had a demotivation and 54.5% had resisted. The main cause of resistance was quality of organization (42.4%).

Conclusion

Our study illustrates the difficulties encountered by actors involved in organizational change and the high risk of their resistance.

'How to' Guide for Pharmacist-led Implementation of Beta-Lactam Therapeutic Drug Monitoring in the Critically Ill

Beta-lactam therapeutic drug monitoring (TDM) can improve precision dosing and clinical outcomes in critically ill patients, but has not been implemented widely in the United States. Mayo Clinic recently implemented a beta-lactam TDM program. This single-center experience forms the basis of the manuscript which outlines practical considerations involved with implementation, including the pharmacist's role as a leader. Our implementation effort focused on three primary domains. First, we aimed to ensure a supportive organizational infrastructure. Early leadership engagement by the pharmacist-led core team facilitated advocacy for the clinical need, allocation of resources, and assay development. Second, core clinical workflows were developed that addressed the preferred patient population for use, desirable pharmacokinetic and pharmacodynamic targets, and the preferred sampling strategy. Clinical tools to guide pharmacists in interpreting the results (e.g., pharmacokinetics calculator) and documenting decisions were developed. Third, stakeholders were offered repeated exposure to evidence and expertise to facilitate understanding and application of the new practice. This act of 'individual internalization' seems to be uniquely important to beta-lactam TDM implementation compared with implementation of other antimicrobial TDM programs. Educational strategies and supportive materials that were developed were focused on providing substantive and varied information tailored to the stakeholders' role in the process. For pharmacists, this included both clinical and operational considerations. A continuous improvement plan to support management of the process was instituted to address necessary updates and changes that inevitably emerged. In summary, the described approach to implementation of a pharmacist led beta-lactam TDM program could be used as a roadmap to aid other institutions that aim to develop such a program.

Looking Back, Looking Forward: A Study Protocol for a Mixed-Methods Multiple-Case Study to Examine Improvement Sustainability of Large-Scale Initiatives in Tertiary Hospitals

Background Hospitals invest extensive resources in large-scale initiatives to improve patient safety and quality at an organizational level. However, initial success, if any, does not guarantee longer-term improvement. Empirical and theoretical knowledge that informs hospitals on how to attain sustained improvement from large-scale change is lacking. Aim The proposed study aims to examine improvement sustainability of two large-scale initiatives in an Australian tertiary hospital and translate the lessons into strategies for achieving sustained improvement from large-scale change in hospital settings. Design and Methods The study employs a single-site, multiple-case study design to evaluate the initiatives separately and comparatively using mixed methods. Semi-structured staff interviews will be conducted in stratified cohorts across the organizational hierarchy to capture different perspectives from various staff roles involved in the initiatives. The output and impact of the initiatives will be examined through organizational documents and relevant routinely collected organizational indicators. The obtained data will be analyzed thematically and statistically before being integrated for a synergic interpretation. Implications Capturing a comprehensive organizational view of large-scale change, the findings will have the potential to guide the practice and contribute to the theoretical understandings for achieving meaningful and longer-term organizational improvement in patient safety and quality.

Systematic review on the involvement and engagement of patients as advisers for the organisation of organ transplantation services

OBJECTIVES

This systematic review aims to derive practical lessons from publications on patient involvement and engagement in the organisation of organ transplantation services.

DESIGN

This systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses. Inclusion criteria for the analysis of publications in English cited in the databases PubMed and Web of Science until 6 December 2022 required that patients participated as advisers in the organisation of organ transplantation services. Quality assessment was performed using the Guidance for Reporting Involvement of Patients and the Public (GRIPP) 2 small form and the Critical Appraisal Skills Programme (CASP) tool for the assessment of the risks of bias.

RESULTS

Deployed search strings identified 2263 records resulting in a total of 11 articles. The aims and strategies, deployed methods, observed effects, observed barriers and proposed improvements for the future varied vastly. All reported that well-developed programmes involving and engaging patients at an organisational level provide additional benefits for patients and foster patient-centred care. Lessons learnt include: (1) to empower patients, the information provided to them should be individualised to prioritise their needs; (2) financial as well as organisational resources are important to successfully implement patient involvement and engagement; (3) systematic feedback from patients in organisational structures to health providers is required to improve clinical workflows and (4) the consideration of ethical issues and the relationship between investigators and participating patients should be clarified and reported.

CONCLUSIONS

Actionable management recommendations could be derived. The quantitative impact on clinical outcome and economic clinical process improvements remains to be investigated. Study quality can be improved using the GRIPP 2 guidance and the CASP tool.

PROSPERO REGISTRATION NUMBER

CRD42022186467.

Embracing relational competencies in applying the LEADS framework for health-care leaders in transformational change and the COVID-19 pandemic

PURPOSE

The purpose of this paper is to assess the extent to which the LEADS Framework guided health-care leaders through organizational change and the COVID-19 pandemic in a western Canadian province.

DESIGN/METHODOLOGY/APPROACH

A qualitative exploratory inquiry assessed the extent to which health leaders applied competencies that aligned with the LEADS Framework. A purposeful sample of 22 health-care leaders participated in the study representing senior, mid-level and front-line health-care leaders in various health-care organizations to ensure diverse representation of leader competencies. The authors conducted semi-structured interviews to collect the data and used Braun and Clarke's (2006) six-phase approach to guide data analysis.

FINDINGS

The analysis suggests that health-care leaders found Engaging with Others and Developing Coalitions were the most critical themes of the LEADS Framework for change management and for navigating the COVID-19 pandemic. Findings reveal that during transformational change and a crisis context, leaders embrace relational approaches to adapt and improve performance in dynamic organizations.

PRACTICAL IMPLICATIONS

These findings have implications for a relational approach to improve teamwork and decrease emotional strain; a focus on mobilizing and sharing power with nurses; and educational programs to advance relational and self-management skills, shared leadership, communication, change management, human resource and talent development as critical learning components for current and future health-care leaders.

ORIGINALITY/VALUE

The LEADS Framework is used to examine how health-care leaders responded to transformational change in the organization while situated in a pandemic context.

A Gateway Framework to Guide Major Health System Changes Comment on "'Attending to History' in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration"

Recent events - on both a global scale and within individual countries - including the lockdowns associated with COVID-19 pandemic, inflation concerns, and political tensions, have increased pressure to reconfigure social services for ongoing sustainability. Healthcare services across the world are undergoing major system change (MSC). Given the complexity and different contextual drivers across healthcare systems, there is a need to use a variety of perspectives to improve our understanding of the processes for MSC. To expand the knowledge base and develop strategies for MSC requires analysing change projects from different perspectives to distil the elements that drove the success. We offer the Gateway Framework as a collaborative transformational system tool to assess and reorganise operations, services, and systems of healthcare organisations. This framework and guiding questions, accounts for past events whilst being proactive, future orientated, and derived from externally defined and a standardised requirements to promote safe, high-quality care.

Mapping quality improvement education initiatives to Standards for QUality Improvement Reporting Excellence (SQUIRE) guidelines

AIMS AND OBJECTIVES

To explore the rigour of nurse-led quality improvement projects involving education, training or continuing professional development, and examine evaluation frameworks contained within.

BACKGROUND

Healthcare organisations invest significantly in quality improvement in the pursuit of cost-effective, safe, evidence-based and person-centred care. Consequently, efforts to examine the success of investment in quality improvement activities are prominent, against a backdrop of rising healthcare expenditure, reforms, consumer expectations and feedback.

DESIGN

A qualitative document analysis of quality improvement projects located in a local health district repository was undertaken.

METHODS

N = 3004 projects were screened against inclusion criteria, with n = 160 projects remaining for analysis. Projects were mapped to an adapted version of the Standards for QUality Improvement Reporting Excellence (SQUIRE), specifically the education extension (SQUIRE-EDU). Additionally, project evaluation frameworks were positioned within Kirkpatrick's four levels of training evaluation model. The SQUIRE checklist was also applied in line with EQUATOR guidelines.

RESULTS

Of n = 60 completed projects assessed against four broad SQUIRE-EDU categories and relevant criteria, n = 36 were assessed not to have met any categories, n = 14 projects met one category, n = 8 projects met two categories, and n = 2 projects met three categories. None of the completed projects met all four SQUIRE-EDU categories. There was insufficient documentation relating to evaluation frameworks in n = 133 projects to position within Kirkpatrick's four levels of training evaluation.

CONCLUSIONS

Scientific rigour should underpin all quality improvement efforts. We recommend that SQUIRE international consensus guidelines (full or abridged) should guide both the design and reporting of all local quality improvement efforts.

RELEVANCE TO CLINICAL PRACTICE

To be of value to the expansion of evidence-based practice, quality improvement platforms should be designed to reflect the structural logic, rigour and reporting recommendations being advocated in consensus reporting guidelines. This may require investment in training and development programs, and identification of governance and support systems. No Patient or Public Contribution, as the study was retrospective in nature and involved a health service repository of quality improvement projects accessible to health service staff only.

Sustaining improvement of hospital-wide initiative for patient safety and quality: a systematic scoping review

BACKGROUND

Long-term sustained improvement following implementation of hospital-wide quality and safety initiatives is not easily achieved. Comprehensive theoretical and practical understanding of how gained improvements can be sustained to benefit safe and high-quality care is needed. This review aimed to identify enabling and hindering factors and their contributions to improvement sustainability from hospital-wide change to enhance patient safety and quality.

METHODS

A systematic scoping review method was used. Searched were peer-reviewed published records on PubMed, Scopus, World of Science, CINAHL, Health Business Elite, Health Policy Reference Centre and Cochrane Library and grey literature. Review inclusion criteria included contemporary (2010 and onwards), empirical factors to improvement sustainability evaluated after the active implementation, hospital(s) based in the western Organisation for Economic Co-operation and Development countries. Numerical and thematic analyses were undertaken.

RESULTS

17 peer-reviewed papers were reviewed. Improvement and implementation approaches were predominantly adopted to guide change. Less than 6 in 10 (53%) of reviewed papers included a guiding framework/model, none with a demonstrated focus on improvement sustainability. With an evaluation time point of 4.3 years on average, 62 factors to improvement sustainability were identified and emerged into three overarching themes: People, Process and Organisational Environment. These entailed, as subthemes, actors and their roles; planning, execution and maintenance of change; and internal contexts that enabled sustainability. Well-coordinated change delivery, customised local integration and continued change effort were three most critical elements. Mechanisms between identified factors emerged in the forms of Influence and Action towards sustained improvement.

CONCLUSIONS

The findings map contemporary empirical factors and their mechanisms towards change sustainability from a hospital-wide initiative to improve patient safety and quality. The identified factors and mechanisms extend current theoretical and empirical knowledgebases of sustaining improvement particularly with those beyond the active implementation. The provided conceptual framework offers an empirically evidenced and actionable guide to assist sustainable organisational change in hospital settings.

Transformational Performance Improvement: Why Is Progress so Slow?

In this chapter, we identify three distinct transformational performance improvement (TPI) approaches commonly used to redesign work processes in health care organizations. We describe the unique components or tools that each approach uses to improve the delivery of health services. We also summarize what is empirically known about the effectiveness of each TPI approach according to systematic reviews and recent studies published in the peer-reviewed literature. Based on examination of this research, we discuss what knowledge is still needed to strengthen the evidence for whole system transformation. This involves the use of conceptual frameworks to assess and guide implementation efforts, and facilitators and barriers to change as revealed in a recent evaluation of one major initiative, the Lean Enterprise Transformation (LET) at the Veterans Health Administration. The analysis suggests ways in which TPI facilitators can be developed and barriers reduced to improve the effectiveness and sustainability of quality initiatives. Finally, we discuss appropriate study designs to evaluate TPI interventions that may strengthen the evidence for their effectiveness in real world practice settings.

Creating a Practical Transformational Change Management Model for Novel Artificial Intelligence-Enabled Technology Implementation in the Operating Room

Objective

To identify change management (CM) strategies for implementing novel artificial intelligence and similar novel technologies in operating rooms and create a new CM model for future trials and applications inspired by the abovementioned strategies and established models.

Methods

Key phases of technology implementation were defined, and strategies for transformational CM were created and applied in a recent CM experience at our institution between October 15, 2020 and October 15, 2021. We appraised existing CM models and propose the newly created model.

Results

The key phases of the technology implementation were as follows: (1) team assembly; (2) committee approvals; (3) CM; and (4) system installation and go-live. Key strategies were (1) assemble team with necessary expertise; (2) anticipate potential institutional cultural and regulatory hurdles; (3) add agility to project planning and execution; (4) accommodate institutional culture and regulations; (5) early clinical partner buy-in and stakeholder engagement; and (6) consistent communication, all of which contributed to the new CM model creation.

Conclusion

Key CM strategies and a new CM model addressing the unique needs and characteristics of operating room novel technology implementation were identified and created. The new model may be customized and tested for individual institution and project’s needs and characteristics.

Virtual care post-pandemic: Why user engagement is critical to create and optimise future models of care

Health systems are shifting from the use of virtual models of care reactively in response to the conditions of the pandemic, to deliberate planning for the integration of virtual models to enhance and extend current service provision. Use of virtual care in recent years has highlighted the critical role of clinician and consumer behaviour and mindsets in realising the opportunities of virtual care for improved health care and outcomes. Yet, the rapid and changing circumstances of the pandemic period provided limited opportunities for effective involvement of both clinicians and consumers in health system decision-making about when, how and which virtual services and associated technologies should be deployed. We explore the opportunity for enhanced engagement with these primary stakeholder groups to create quality healthcare as we emerge from the pandemic and enter a new phase of integrated virtual services.

Achieving change readiness for health service innovations

Continual innovation to address emerging population needs necessitates health service ongoing redesign and transformation worldwide. Recent examples include service transformations in response to Covid-19, many of which were led and managed by nurses. Ensuring change readiness is central to delivering these transformative changes yet has been identified as a central challenge impacting nurse leaders and managers. Recent evidence indicates that affective commitment to change among healthcare staff may be an important contributor to gaining support for change implementation but understudied in healthcare. A cross-sectional survey study was used to examine the association between affective commitment to change and change readiness among 30 healthcare staff across four projects in one state-wide health system in Australia. Our findings indicate that affective commitment to change; healthcare worker's emotional and personal perception of the value of the proposed change is independently associated with individual and collective change readiness. Given that achieving change readiness is a central goal of change management strategies, this pilot work provides valuable insight to inform the change management practices of nurse leaders and managers.

A systematic review of the use of positive deviance approaches in primary care

BACKGROUND

The Positive Deviance (PD) approach focuses on identifying and learning from those who demonstrate exceptional performance despite facing similar resource constraints to others. Recently, it has been embraced to improve the quality of patient care in a variety of healthcare domains. PD may offer one means of enacting effective quality improvement in primary care.

OBJECTIVE(S)

This review aimed to synthesize the extant research on applications of the PD approach in primary care.

METHODS

Seven electronic databases were searched; MEDLINE, CINAHL, Embase, PsycINFO, Academic Search Complete, Psychology and Behavioral Sciences Collection, and Web of Science. Studies reporting original data on applications of the PD approach, as described by the PD framework, in primary care were included, and data extracted. Thematic analysis was used to classify positively deviant factors and to develop a conceptual framework. Methodological quality was appraised using the Quality Assessment with Diverse Studies (QuADS).

RESULTS

In total, 27 studies were included in the review. Studies most frequently addressed Stages 1 and 2 of the PD framework, and targeted 5 core features of primary care; effectiveness, chronic disease management, preventative care, prescribing behaviour, and health promotion. In total, 268 factors characteristic of exceptional care were identified and synthesized into a framework of 37 themes across 7 system levels.

CONCLUSION

Several useful factors associated with exceptional care were described in the literature. The proposed framework has implications for understanding and disseminating best care practice in primary care. Further refinement of the framework is required before its widespread recommendation.

EUnetHTA relative effectiveness assessments: efforts to increase usability, transparency and inclusiveness

OBJECTIVES

The objective of the European Network for Health Technology Assessment (EUnetHTA) Joint Action 3 (JA3) was to develop a sustainable European model for future collaboration on HTA, by reducing duplication in HTA production and increasing patient access to health technologies. Compared to the previous JA2, several procedural changes were made aiming to increase usability, transparency, and inclusiveness of relative effectiveness assessments (REAs). This article presents and highlights these changes, explains their rationale as well as their influence on HTA production.

METHODS

Feedback from REA teams and project managers was collected. At the end of JA3, all lessons learned were mapped, resulting in a set of recommendations for a future REA production process.

RESULTS

In JA3, forty-three EUnetHTA REAs have been produced. Efforts to increase the usability of the REAs were made by focussing on the needs of REA producers and users (HTA agencies) and by increasing stakeholder involvement. Huge steps were taken with regard to transparency, which was achieved through publication of guidances, templates, and up-to-date information on the EUnetHTA website. In an attempt to improve inclusiveness, (stakeholder) interaction and involvement as well as feedback procedures were enhanced and streamlined. The fine-tuned project management brought all aspects together and facilitated a consistent and reliable workflow.

CONCLUSIONS

Despite that HTA agencies have different national requirements, the procedural changes made in JA3 proved to counteract some of these challenges. Nevertheless, it is of utmost importance that further perceived methodological differences are being resolved to ensure a strong base for future European collaboration on REA production.

A blueprint for building an emergency department quality improvement and patient safety committee

The field of quality improvement and patient safety (QIPS) has matured significantly in emergency medicine over the past decade. From standalone, strategically misaligned, and incoherently designed QIPS projects years ago, emergency department (ED) leaders have now recognized that developing a more robust QIPS infrastructure helps prioritize and organize projects for a greater likelihood of success and impact for patients and the system. This process includes the development of a well-defined, accountable, and supported departmental QIPS committee. This can be achieved effectively using a deliberate and structured approach, such as the one described by Harvard Business School Professor John Kotter in his seminal work, “Leading Change.” Herein, we present a blueprint using this framework and include practical examples from our experience developing a robust and successful ED QIPS committee and infrastructure. The steps include how to develop a “burning platform,” select a guiding coalition of leaders, develop a strategic vision and initiatives, recruit a volunteer army of members, enable actions for the committee, generate short-term successes, sustain the pace of change, and, finally, enable the infrastructure to support ongoing improvements. This road map can be replicated by ED teams of variable sizes and settings to structure, prioritize, and operationalize their QIPS activities and ultimately improve the outcomes of their patients.

Is Gaining Affective Commitment the Missing Strategy for Successful Change Management in Healthcare?

Despite the requirement for continual change and development, change failure is omnipresent in health care, ranging from small technical errors within new systems, processes or technologies, through to breakdowns and large-scale disaster. Despite decades of research investment, consultancy and initiatives, creating a healthcare context that promotes clinician engagement with change remains elusive, with limited demonstrated progress. Affective commitment to change refers to commitment that is driven by a desire to support change based on its perceived benefits or value, as opposed to commitment that is based on a sense of obligation or the minimization of costs. Recent evidence from health-care contexts indicates that affective commitment to change drives change readiness more so than the individual’s self-efficacy for dealing with the change. Considering evidence regarding the effect of affective commitment to change on individual and collective change readiness among health-care staff, we may need to reorient our current strategies for managing change. We explore the opportunities to enhance affective commitment to change and, in turn, change readiness through adopting values-based approaches to designing and executing change proposals with clinicians and service users.

Utilization of Kotter's Stages and Statistical Process Control to Implement and Sustain Delirium Screening in PICU

Supplemental Digital Content is available in the text.

Delirium is a preventable cause of ICU morbidity and mortality. Prior unstructured efforts to implement delirium screening in our hospital were unsuccessful. This project aimed to improve the delirium screening compliance from baseline 0% to more than 80% within 12 months (07/2019–06/2020).