Module 2: How To Manage Change
Slide 1: How To Manage Change
ADD Hospital Name
Slide 2: QI Change Process
- Change process strategies can be applied to other quality improvement (QI) efforts:
- Hospital falls.
- Catheter-associated urinary tract infections.
- Deep vein thrombosis or pulmonary embolism after knee and hip replacement.
- Blood incompatibility.
Image: Puzzle pieces are labeled “assess readiness,” “manage change,” “implement practices,” “best practices,” “measure,” “sustain,” and “tools.” The piece labeled "manage change" is highlighted in blue.
Slide 3: Module 2 Goals
- Identify actions needed to improve organizational readiness.
- Maximize the possibility of successful implementation by addressing these questions:
- How can you set up the Implementation Team for success?
- What needs to change, and how do you redesign practice?
- How should goals and plans for change be developed?
- How do you bring staff into the process?
Slide 4: Expected Outcomes
- Finalize Implementation Team members and assign roles. (Tool 2A)
- Present the completed process analysis on one patient care unit. (Tool 2C)
- Present the assessment of current pressure injury prevention policies and procedures. (Tools 2D, 2E, and 2F)
- Team Leader or designee completed assessment and folds recommendations into the action plan.
Slide 5: Expected Outcomes
Begin to write a draft Pressure Injury Prevention Action Plan, tailored to this hospital (see Tool 2I).
Image: Photograph shows medical providers and staff team members meeting at a table.
- How often will you meet?
- What are the ground rules for managing meeting time and communication?
- How will you communicate with each other?
- How will you communicate successes?
- How will the Team do its work?
- Small group work.
- Working meetings.
Slide 7: Finalize Team Members
The first goal is to finalize the Implementation Team members and assign roles.
Image: Photograph shows medical providers gathered for a meeting.
Slide 8: Successful Implementation Team
- A strong link to hospital leadership.
- Members with the necessary expertise (Tool 2A).
- Access to resources needed to accomplish the aim.
- Links to quality improvement expertise.
- Members who influence the areas involved in pressure injury prevention.
- Includes Pilot Unit Manager.
Slide 9: Multidisciplinary Team (2A)
Images: A table captioned "Multidisciplinary Team" charts Discipline, Names of Possible Implementation Team Members From Each Area, and Area of Expertise for potential team members. An icon of a magnifying glass in front of open book identifies the table as Tool 2A.
Slide 10: QI Process
- Link the Pressure Injury Prevention Program with quality improvement.
- This information helps you define resources this hospital has for quality improvement.
- Plan, Do, Study, Act is one systematic approach to analysis and implementation.
Images: Photograph shows medical providers looking at laptop together. An icon of a magnifying glass in front of open book refers to Tool 2B. An icon of a magnifying glass in front of open book refers to Page 27.
Slide 11: QI Process
- Your Implementation Team Leader filled out many assessment forms already.
- We’ll be working to find solutions for positive change.
- Let’s hear from your Implementation Team Leader about this hospital’s QI program and how to link with QI.
Image: Photograph shows a medical provider holding papers.
Slide 12: Collaboration
- Pressure Injury Implementation Team.
- Wound Care Team.
- Unit Team.
Image: Photograph shows a team leader speaking to medical providers.
Slide 13: Collaborative Relationships
Image: A Venn Diagram consists of three overlapping circles captioned:
- Implementation Team: Interdisciplinary team charged with designing and implementing pressure ulcer change project.
- Wound Care Team: Interdisciplinary group of experts who provide day-to-day care of skin and wound needs and are a resource for staff and patient/family.
- Unit-Based Team: Staff on the unit who provide daily care to patients, which includes skin and pressure ulcer assessment and care planning.
Slide 14: Assess Current Pressure Injury Processes
- Understand current processes in patient care units.
- Use process mapping to examine key processes (Tool 2C).
- Assess current practices on a representative sample of units; do process mapping.
- Which practices need changing? Determine how to build in new practices.
- Do the care processes follow best practices?
Slide 15: Practice Insight
Use of Shadowing To Assess Current Practices
Image: Photograph shows medical providers holding a meeting in a hallway. Icon of binoculars.
Slide 16: Current Process Analysis (2C)
Images: Two screenshots show the Current Process Analysis. An icon of a magnifying glass in front of open book identifies this as Tool 2C.
Slide 17: Current Process Analysis (2C)
- Let’s hear from the team member(s) who completed the process analysis.
- Share process mapping from the unit.
- Point out key processes being used.
Image: Two photogaphs show a medical provider holding clipboard in front of laptop, and a medical provider holding clipboard and pen.
Slide 18: Assess Current Policies (2D)
Images: A screenshot shows the Pressure Ulcer Policy Assessment form. An icon of a magnifying glass in front of open book identifies this form as Tool 2D.
Slide 19: Assess Current Policies
- The Implementation Team Leader identified the policies in place and areas for improvement.
- You’ll want to address these areas in the Action Plan.
- In Module 3, we’ll compare this assessment with best practices.
- A group you designate may opt to do further fine tuning at a later time.
- Let’s look at completed Tool 2D now.
Slide 20: Assess Pressure Injury Screening Practices
Images: A screenshot shows the Assessment of Screening for Pressure Ulcer Risk form. An icon of a magnifying glass in front of open book identifies this form as Tool 2E.
Slide 21: Assess Pressure Injury Care Planning Practices
Images: A screenshot shows the Assessment of Pressure Ulcer Care Plan form. An icon of a magnifying glass in front of open book identifies this form as Tool 2F.
Slide 22: Implementation Action Plan
- The Implementation Action Plan for change should address the following:
- Membership and operation of the Implementation Team.
- Standards of care and practices to be met.
- How gaps in staff education and competency will be addressed.
Slide 23: Implementation Action Plan
- The Implementation Plan also addresses:
- Plans for rolling out new standards and practices, where needed.
- Staff accountability for monitoring implementation.
- How changes in performance will be assessed.
- How this effort will be sustained.
Slide 24: Sample Action Plan
Images: Two screenshots show an example of a Pressure Ulcer Prevention Action Plan. An icon of a magnifying glass in front of open book identifies this as Tool 2I.
Slide 25: Practice Insight
Image: A screenshot shows a table titled "Pressure Ulcer Prevention Program Action Plan: June 2015-January 2016"; the first section, Key Intervention/Task 1, "Analyze Current State of Pressure Ulcer Prevention Practices," is circled in red. Icon of binoculars.
Slide 26: Action Plan
- Let’s go over Tool 2I together.
- Let’s discuss action steps for Key Intervention 1.
- Then we can determine who is responsible for this task and when it tentatively will be completed.
Images: A sample Action Plan is shown with Key Intervention 1 circled in red. An icon of a magnifying glass in front of open book sits above the text "Refer to your Action Plan template."
Slide 27: Summary
- Completed assessment of current policies and practices:
- Pressure Injury Policies.
- Risk Screening Assessment.
- Care Planning Assessment.
- Current Process Analysis.
- Set up the Implementation Team.
- Developed a draft Action Plan for Key Intervention 1.
- Working document that can be revised.