Prescription for Change: Barriers To Change In Health Care
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Barriers to Change in Health Care (with detailed speakers notes)
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Prescription for Change: Barriers To Change In Health Care
- 1. Barriers To Change in Health Cate Gayle A. Mitchell, PMP
- 2. Medication Errors Educate Before You Medicate • • • • • • • • Dose Omission Overdose/multiple dose Under Dose Wrong Product Strength Expired Order Incorrect Documentation Wrong Product Wrong Rate of Administration • • • • • • • • • Wrong Time Wrong Patient Wrong Duration Monitoring Error Wrong Form of Product Expired Product Incorrect Route Nocsomial Infections Improper Labeling
- 3. A Prescription for Change • Identify the organizational change • Articulate the case for organizational transformation in health care
- 4. A Prescription for Change • Detect organizational/individual barriers • Recognize influencing factors • Address motivational theories to assist change
- 5. A Prescription for Change Motivational Theories to Assist Change • Machiavelli’s Commentary on Change • Motivation Theories – – – – – – Need Motivation – Maslow Two-Factor Theory - Herzberg ERG Theory - Alderfer Acquired Needs Theory - McClellan Reinforcement Theory- B.F. Skinner Expectancy Theory – Vroom and Tolman
- 6. A Prescription for Change • Technology is not the sole panacea • The human factors of change – Culture – Alignment – Controls – Accountability
- 7. A Prescription for Change • Common Barriers to Change – Fear of the Unknown – Lack of Knowledge and Understanding – Lack of Strategic Vision, Leadership and Communications – Absent Engagement of Stakeholders – No Roadmap – Idiosyncrasies of Individual Participants – No Progress Measurements – Failure to Recognize Successes
- 8. A Prescription for Change • Overcoming Resistance to Change – Reasonable Initial Hypotheses – Organizational Readiness – Clear vision – Sense of urgency – Committed leadership – Transparent Communications – Conflict Resolution Strategies – Reinforcement
- 9. A Prescription For Change Six Sigma • What is Six Sigma? – Overview – DMAIC – Kaizen
- 10. A Prescription For Change Six Sigma • Why Six Sigma for this change effort? – Disruptive innovation drivers – Alignment with complex systems management – Targets 99.99975% error-free conditions – Standardizes critical incident reporting – Documented previous success
- 11. A Prescription for Change Conclusion
- 12. References Buck, C. (2001). Application of six sigma to reduce medical errors. Quality Congress.ASQ's ...Annual Quality Congress Proceedings, , 739-242. Retrieved from http://search.proquest.com/docview/214394036?accountid=458 Cherry, K. (n.d.). Theories of Motivation - Major Theories of Motivation. Psychology - Complete Guide to Psychology for Students, Educators & Enthusiasts. Retrieved September 21, 2013, from http://psychology.about.com/od/psychologytopics/tp/theories-of-motivation.htm Frey, B., Buettiker, V., Hug, M. I., Waldvogel, K., Gessler, P., Ghelfi, D., . . . Baenziger, O. (2002). Does critical incident reporting contribute to medication error prevention? European Journal of Pediatrics, 161(11), 594-9. doi:http://dx.doi.org/10.1007/s00431-002-1055-0 Groen, P., Mahootian, F., & Goldstein, D. (2008, April 19). Medical Informatics: Emerging Technologies, ‘Open’ EHR Systems, and Ethics in the 21st Century. Shepherd University. Retrieved September 21, 2013, from www.shepherd.edu/surc/cosi/Me...s%2004 Jordan, S. (2011). Signposting the causes of medication errors. International Nursing Review, 58(1), 45-46. doi:10.1111/j.1466-7657.2010.00867.x
- 13. References Kellert, S. H. (1993). In the wake of chaos: Unpredictable Order in Dynamical Systems. Chicago: University of Chicago Press. Machiavelli, N., & Donno, D. J. (2003). IV. The Prince (Bantam Classic reissue. ed., p. 21). New York: Bantam Dell. Steel, P., & König, C. J. (2006). Integrating Theories of Motivation. Academy Of Management Review, 31(4), 889-913. doi:10.5465/AMR.2006.22527462 Study: Errors continue as leading cause of death in hospitals. (2006). OR Manager, 22(5), 32. Retrieved from http://search.proquest.com/docview/213088793?accountid=458
Notes de l'éditeur
- This slide highlights the numerous types of medication errors that may occur within a hospital setting. A substantial body of evidence advises that medical errors continue to be a leading cause of death and injury in the United States. Institutes of Medicine (IOM) and the Centers for Disease Control statistics conclude that medical error is the sixth leading cause of death in America.Groen, Mahootian, and Goldstein refer to resources indicating that 44,000 to 200,000 inpatients expire from causes linkedto preventable medical errors. These statistics are compounded by accompanying financial repercussions estimated between $17 billion and $29 billion per year nationwide.They also note that the National Council for Patient Information and Education(NCPIE) reports an additional 125,000 deaths annually due to adverse reactions to drugs that should not have been prescribed. The mortality toll attributed to correctly and incorrectly prescribed synthetic prescription medications totals approximately 231,000 deaths annually. Analogously, these ominous statistics equate to the World Trade Center disaster occurring every week for 1.5 years, or the downfall of two fully occupied 747 aircraft every day for 365 days. The Institute of Medicine states that “medication-related error has been studied extensively because it is one of the most common types of errors, substantial numbers of individuals are affected and it accounts for a sizable increase in health care costs.”These overwhelmingly graphic illustrations are designed to heighten awareness, impose a sense of urgency, and dramatize the need for change to reduce medication errors.
- This health care organization identifies medical errors as a noteworthy problem bearing significant consequence to the organization and to the patient population. Our organization will pursue the introduction of Six Sigma process improvement methodologies to reduce medication errors at our facilities. The Pareto Principle, also referred to as the 80/20 rule, proves that 20% of input errors cause 80% of the defects. Our organizational change mandate is to proactively introduce processes to reduce medication errors.The case for organizational transformation in health care regarding medication errors is expressly detailed in the previous slide the content of which culminates in need to address the imperative governing topic of patient safety and quality concerns. Medication administration is an error prone, high risk, complex system within health care.
- Barriers to the proposed organizational change include demographics, operational issues, rapidly changing technologies, formularies, treatments, digital transitions, workforce issues, financial constraints, and leadership challenges.Among the proximate external factors influencing this specific change are economics, particularly the revised payment standards enacted by the Centers for Medicare and Medicaid Services (CMS). CMS now declines to reimburse hospitals for mistake-ladentreatment and services and subsequent additional resources and services required to correct those errors.Internal factors that may affect this change are knowledge of risk factors or lack thereof, attitudes, beliefs and core values associated with the status quo, and self-efficacy. Employee perception of the change is also a prominent factor.Practical theories identified to assist this change effort are Six Sigma/Kaizen.
- "It must be considered that there is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle, than to initiate a new order of things. For the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order, this lukewarmness arising partly from fear of their adversaries, who have the laws in their favour; and partly from the incredulity of mankind, who do not truly believe in anything new until they have had actual experience of it.” - MachiavelliThere are many substantive theories for facilitating, managing, promoting change, and encouraging participant motivation. Given the diverse nature of the hospital workforce, selecting the proper motivational tools for our audiences is a critical step in our change process. We shall examine the following:Maslow’s Hierarchy of needs is a classical depiction of human motivation escalating from physiological to safety to social to esteem and finally to self-actualization.Herzberg’s Two-Factor theory or motivator-hygiene theory focuses on job factors that result in satisfaction or the prevention of dissatisfaction.Alderfer’s ERG theory bears many characteristics of Maslow’s theory emphasizing existence needs, relatedness needs, and growth needs.McClellan’ Acquired needs theory proposes that specific needs, classified by achievement, affiliation and power, are shaped by life experience and acquired over time.Skinner’s Reinforcement theory is rooted in behaviorism and parallels Pavlov’s theory surmising that motivation is driven by rewards and punishment.Vroom and Tolman explain that Expectancy Theory examines motivational forces from perceptions of expectancy, instrumentality and valance. Motivational force is the produce of these perceptions.Motivation theories may also be more generically categorized as instinctive, inventive, drive, arousal, and humanistic.
- Simply layering 21st century technologies atop 20th century workflows will not yield the desired quality of outcomes and efficiencies. Hospitals must redesign processes to address the human characteristics affectingchange processes. This includes the shaping of common goals, overcoming resistance to change, ensuring a pure correlation between improvement initiatives, performance, and strategic goals supported by consistent management processes and monitoring controls to ensure sustainability.Transformation cannot occur in the absence of transparency. Transparency will not materialize in the absence of culture change. Culture change will not occur in the absence of a common vision, a universal toolset, and management and stakeholder commitment and support. Accountability and controls insure sustainability and momentum.
- Apprehension and fear of the unknown are the most frequently encountered barriers to change. Apprehension is bred through a lack of knowledge and understanding of what is forthcoming. Apprehension may be easily avoided through communications of the strategic vision and roadmap by credible leadership along with engagement of stakeholders.Individual idiosyncrasies are also barriers to change. One may overcome these obstacles through outreach and engagement; determining and communicating how those with distinguishing characteristics will contribute to the change.If something cannot be measured, it cannot be effectively improved. Progress measurements and metrics are essential to all change processes. Lessons learned arise from these metrics and should be documented and incorporated into the organization’s knowledge base.Acknowledgement of successes is very important as well. Celebration of successes speeds the pace of change, communicates value of individual contributions, and garners additionalcommitment to the efforts.
- Overcoming the many obstacles to change is imperative for the success of any change initiative. Steps to navigating the minefield of obstacles that accompany change include:Beginning with a reasonable hypothesis and recognition of circumstances driving changeEnsuring organizational readinessDefining a clear vision of the change and desired outcomesEstablishing a sense of urgencyEngaging leadership committed to execution and ongoing support of the changeEffective communicationsReinforcement of the change through monitoring and training
- Six Sigma, developed by Motorola in the 1980s, is a qualityimprovement methodology that applies foundational statistics to deliver precise measurements and reduce variations in processes and products. It combines a standardized approach to problem solving and process optimization and management discipline. Proven success of this methodology hasled to global adoption and deployments across multiple industries including health care. Six Sigma also incorporates a comprehensive, flexible management support systemfor achieving, sustaining, and maximizing optimizations.The core of Six Sigma is the DMAIC process: Define, Measure, Analyze, Improve, and Control. The definition stage delineates problems and identifies opportunities for improvement. The measure stage includes benchmarking. The analysis stage focuses on root cause analysis and possibleredesign considerations. Improvement period activities attack the root cause of problems. The control period insures the sustainability of the improved processes.A widely-recognized translation of the Japanese word Kaizen is “good change”. Kaizen represents a Japanese business philosophy of continuous improvement and is frequently linked to a modular approach to implementing Six Sigma in which control period activities institutionalize the Kaizen or the “good change”.
- The influencing factors driving this change support the need for disruptive innovation, the management of which necessitates a structured analytical approach. Medication errors often stem from inadequately designed complex systems that are frequently associated with Complexity/Chaos Theory “a qualitative study of unstable aperiodic behavior in deterministic nonlinear dynamical systems (Kellert).”In recent years, studies note a decrease in the number of errors attributable to the pharmacy/pharmacist and increases in the administrative process errors. The ultimate Six Sigma objective is to design processes that effectively satisfy methodology specifications ensuring 99.99975% error-free conditions; less than 3.4 defects per million opportunities in any process, product or service. This is highly desirable goal for the reduction of medication errors. The Six Sigma approach to process improvement also standardizes the critical incident reporting process. Buck cites success in the employment of “Six Sigma methodology to reduce medication and laboratory errors and improve patient safety in a tertiary care hospital affiliated with an academic medical center”. The medical center assembled a multidisciplinary team of physicians, nurses, pharmacists, laboratory personnel, and administrators to conduct a systematic examination of medication delivery processes, identify weaknesses, and to remediate those weaknesses using the Six Sigma methodology. Their efforts revealed significant variability in the ordering and processing of medications and a general lack of standardization, all of which posed risks for system failure. The multidisciplinary task force developed standards to reduce variations and introduced interventions including uniform physician ordering sheets, revised policies, and the use of color-coded labels. Within thirty days measurable progress was evident with discrepancies falling from 47.4% to 14%.
- This hospital strives to be an adaptive learning organization demonstrating a willingness to embrace change, identify problems, and to implement solutions. This institution acknowledges that there is no universal remedy for all medication error issues, but advocates the implementation of the proven Six Sigma methodology for process improvement.This organization is committed to understanding the psychological aspects of change and applying tactical and strategic approaches to motivate participants in circumscribing root causes and embracing the changes that will remedy those issues.