Homework answers / question archive / Week Four Session One Lecture – Chapters 8, 3 We spent our third week in review of CQI from several different angles: its effect on the accreditation process and the transformation taking place in public health; and its value in the work being done to improve the health of populations in low- and middle-income countries

Week Four Session One Lecture – Chapters 8, 3 We spent our third week in review of CQI from several different angles: its effect on the accreditation process and the transformation taking place in public health; and its value in the work being done to improve the health of populations in low- and middle-income countries

Health Science

Share With

Week Four Session One Lecture – Chapters 8, 3 We spent our third week in review of CQI from several different angles: its effect on the accreditation process and the transformation taking place in public health; and its value in the work being done to improve the health of populations in low- and middle-income countries. The last week of our course, we will review the challenges of implementation for CQI, and some tools and concepts available to use to address implementation challenges. And, lastly, we will reflect on future trends in CQI and how you, as a future leader, can make a difference. Chapter 8 – A Social Marketing Approach to Increasing Adoption of CQI Initiatives The aim of marketing is to know and understand the customer so well that the product or service fits him or her and sells itself. — Peter Drucker Introduction The first implementation strategy that we will learn about is Social Marketing. As we will learn, this is not social media, it is a different concept altogether. This concept teaches us to “sell” CQI and the solutions it identifies through the CQI process. Let’s look at an example. So, we have completed a successful CQI Team process to reduce hospital-acquired infections. The team has a created a great plan of action. One of their primary actions is to increase handwashing compliance by 10% in the first month of implementation. The CDC tell us that: • • on average, healthcare providers clean their hands less than half of the times they should; and on any given day, about one in 25 hospital patients has at least one healthcare-associated infection. How do you get people on board?! Background and Definitions The concept of social marketing emerged in the 1970s and it is defined as: the principles and techniques to change target audience behavior to benefit society as well as the individual. The focus is less about “buying a product” and more about “buying good behavior”. Back to our opening example, good hand washing practices benefit not only the patients by reducing unwanted infections, but also the staff who are protecting themselves against infections! Hallmarks of Social Marketing By the use of the fundamental concepts from commercial marketing, social marketing focuses on positive behavior change that is perceived by the target individuals to bring benefit, by removing barriers to the desired outcome. In our handwashing example, a barrier may be that the sink is down the hallway from the patient rooms; by making the sinks available in every room, the likelihood of success is greater. To best understand the concept of social marketing think about these campaigns which we have all been exposed to: “Click It or Ticket” to get folks to wear their seatbelts; and numerous ads and billboards to encourage people to quit smoking (and soon to quit vaping). In health care, we have all experienced social marketing campaigns about handwashing; and for those of you whose organizations may have participated the IHI’s One Million Lives and Five Million Lives Campaigns, these are also great examples. Using traditional marketing principles such as: 1) know you audience; 2) focus on actions – like stop smoking; 3) an “exchange” – changing the old behavior for the new; and 4) competition – people who smoke are addicted to its benefits, social marketing can help create a strategy for positive change. Again, it is important to remember that this is not the same as social media, which is a communication strategy. Social marketing promotes voluntary behavioral changes that encourage healthy behaviors, better health outcomes and a better society. Overview of Social Marketing Applications to CQI in Health Care. We have learned that “continuous quality improvement” is about continuously reviewing and improving everything we do. Both CQI and social marketing focus on building a framework for change and positive outcomes. There is great opportunity for synergy between the two concepts. I would like to share a real-world example of how this can work. As a Chief Quality Officer, many of the improvements that needed to be implemented in my organization had to be implemented at the unit level, if they were to be successful. To assure that this happened, we created a program at Palomar Health called the Staff on Safety Program – designed to identify Patient Safety Champions throughout the organization. We requested recommendations of a staff person from every patient care unit or department and my staff and I did the following: • • • Bi-monthly meetings were held with all of the patient safety champions in attendance which addressed: o A topic that need to be implemented or “sold” at the unit level was identified and a program was presented with an overview of the topic, the motivations for change (data!) and the benefits of the change; o A tool kit was provided to each champion that included the slides of the program for their use, data collection tools for data collection efforts before and after their work with staff on their unit, posters and handouts and other “selling tools”; and a guide on how to use them; Once the initial data was collected, the champions presented the results at their department meeting along with the presentation provided and utilized all of the posters etc. in their unit; and They then championed the change on a daily basis and after 6 weeks did another data collection to gather their result. They then shared the results with their department and in most cases celebrated their successful change. The champions participated in the program for a year and were showcased at the leadership and Board meetings. They became the champions for these important quality and patient safety changes on their units going forward. Their efforts did not end when new champions were identified for the next year – indeed, a little army was being created! This is an example of creating positive behavior changes based on CQI using a social market strategy – incidentally – the program doubled in size over a three-year period – people were learning and having fun and making changes stick! Creating a Social marketing Strategy and Plan There are key steps used to create a social marketing plan and strategy which include: 1) Collecting information to identify your goal and focus (see slides 15-16 for a sample question set to facilitate these efforts); 2) describe the plan in detail – issues, background, purpose, and focus; 3) conduct a situational analysis (SWOT); 4) select target markets;5) set objectives and goals; 6) identify competition, barriers and motivators; 7) develop a positioning statement; 8) develop a strategic marketing mix (4 P’s); 9) outline a plan for monitoring and evaluation; 10) establish budgets and identify funding sources; and 11) complete the plan for implementation. Then - implement your social marketing plan! Recent Developments in Social marketing: Journey Mapping. There are a number of tools that can be used for the implementation of a social marketing plan, one such tool is journey mapping. It is a great CQI – social marketing crossover tool – it is a flow diagram which also illustrates the “pain points or barriers” in a process. A Scenario for How to Apply Social Marketing to a Healthcare CQI Initiative We have talked throughout the course about how checklists are being used to make improvements in quality and patient safety. Dr. Pronovost talked about the checklist that was used to make improvements to care following the death of Josie King. And, Dr. Gawande, in last week’s exercise, shared the work being done with surgical checklists around the globe. The last part of Chapter 8 presents a scenario related to the use of the surgical checklist and efforts to create further adoption of its use. It is important to note that when implemented and used appropriately, the surgical checklist has produced remarkable results such as: • University of Connecticut reported statistically significant decreases in 30-day morbidity in overall adverse events from 23.6% to 8.2% in cases with checklist use. So, how do we broaden its use? Table 8.1 presents an example of how these social marketing principles and tools can be used to broaden the use of the checklist. It provides a great example how CQI and social marketing can enhance and complement one another. Conclusion Using a scenario based on the use of the surgical safety checklist, a simple CQI method is given strength and accountability through proven social marketing methods to change behavior for the betterment of the common good of both internal and external customers—a safer surgical environment not only for patients but also for the team members performing the surgery. This social marketing example represents the potential for a powerful approach for the enhancement of the implementation strategies for CQI. Chapter 3 – Integrating Implementation Science into Continuous Quality Improvement The measure of success is not whether you have a tough problem to deal with, but whether it is the same problem that you had last year.” - John Foster Dulles In Chapter 8, we learned a particular approach for enhancing and encouraging the adoption of CQI recommendations into the culture of an organzation. In Chapter 3, we will present an emerging approach based on research and scientific methods, for ensuring implementation is successful. Introduction Given that this field is new and emerging in conjunction with CQI, we will look at the definitions of implementation science; review the integration model with current CQI practices, and be exposed to a few different models for application in the CQI context. As we have learned, CQI is both a management model and a set of concepts and tools for continuously reviewing and improving our key care and service processes. There is a tremendous amount of work that goes into the creation of a team; identification of the problem set for improvement; the use of the team process and tools to analyze the problem and create solutions to the problem; and lastly, to create an action plan for implementation of the solutions. Without a successful implementation of the improvement identified, the aforementioned work may be wasted. The CQI methods that we have been learning have excellent methods and tools, but do not actively call out implementation strategies. This emerging discipline, implementation science, is working toward improving the improvement process! Implementation Science Defined Implementation is defined as: “(A) specified set of activities designed to put into practice, an activity, or program” (NIRN, 2018); Implementation science is defined as: The “scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and hence, to improve the quality and effectiveness of health services and care … (this) field includes the study of influences on health care professional and organizational behavior.” CQI Methods – The Challenge CQI Methods such as Six Sigma and the Model for Improvement do not provide specific implementation steps to insure a successful adoption of the solutions that they identify. As we stated in the introduction – implementation is the key to long term success of the adoption and the integration of the solutions into the daily lives and practices of an organization. Key Ingredients for Successfully Achieving Outcomes We learn from implementation science that there are key ingredients for successfully achieving the outcomes we are looking to implement: Effective interventions; Effective implementation; and Enabling contexts.* *Enabling contexts refer to what is currently happening in the environment, both internally and externally, that could affect implementation. Integrating Improvement and Implementation Implementation science is seeking to integrate their framework(s) and model with CQI models and methods. The Model for Improvement and Implementation (MFII), incorporates the implantation science question set with that of the Model for Improvement to assure implementation is taken into consideration as solutions are proposed. These Implementation question set includes: 1) what implementation outcomes are critical to implementing the changes? 2) what factors impede the achievement of these outcomes? and 3) what implementation strategies are most important to address these factors. (See Slide 42) Implementation Outcomes The first question in the MFII model calls for implementation outcomes: “which outcomes are critical to successfully implementing our solutions/changes?” The implementation outcomes include: acceptability, adoption, appropriateness, costs, feasibility, fidelity, penetration and sustainability. In the model, implementation science has integrated the use of their definitions with that of the components of quality that we have learned: efficiency, safety, effectiveness, equity, patient -centered, and timely to assure continuity with the CQI process. Implementation Outcomes and Definitions Table 3.1 provide definitions for the outcomes to help us understand their context. A few of the definitions offered are: acceptability – perception that an intervention is satisfactory; and appropriateness – fit of an intervention to a particular setting. Review of these outcomes and definitions increases a team’s ability to expand their awareness of what can and will work in a particular unit or department. Just because the team has identified the best solution based on their work and the evidence available, does not mean it will work automatically in that setting. What comes to mind is the implementation of the surgical checklist in an OR at the same time that a new electronic health record is being implemented. The surgical checklist is the ideal solution – but with too much change all at once, delaying its implementation may help assure that it will be accepted and truly adopted by the staff and physicians. You would be surprised how often this kind of scenario occurs within organizations! Integrating the Implementation management concepts and frameworks with CQI, allows for a better chance of success. It is important to take into consideration how implementation outcomes will be measured, just as we measure in the CQI process. Implementation Determinants Implementation science also helps teams consider the kinds of specific activities that will either deter or facilitate the success of the implementation process. Implementation Frameworks A number of frameworks are presented that help teams (led by a CQI expert) plan for implementation in a strategic way. We will review a few of these from a high-level overview. The Consolidated Framework for Implementation provides a framework to consider key factors in the implementation process. Five frameworks created by the National Implementation Research Network (NIRN) are: Usable interventions; Implementation stages; Implementation drivers; Implementation teams; and Improvement cycles. Implementation Drivers A number of drivers are identified and can be linked to key framework components. (See Slides 52, 53) The framework presented in slide 54 reminds us again of the importance of leadership, a supportive culture and the components of a culture of excellence, as drivers of the process. Implementation Strategies Implementation sciences identifies implementation strategies as: methods or techniques used to enhance the adoption, implementation of the adoption, implementation, and sustainability; different strategies may need to be combined depending on the context in which the QI initiative is implemented. See Slides 55- 56 for an excellent mapping of the strategic categories to key activities/outcomes – just walking through this table and brainstorming can help teams think through how to match these strategies to activities for their project solutions. Stages of Implementation Lastly, implementation sciences identifies four stages of implementation: Exploration, Installation, Initial implementation, and Full implementation. Although presented in a linear progression, this is a nonlinear process, and as the timeline reflect in slide 59, true adoption and acceptance may take time. These framework and strategies provide us with an overview of how implementation management is enhancing our existing CQI models and we will likely see it integrated into future CQI models. Conclusions The purpose of the chapter was to present an introduction of some of the key concepts, principles and tools of implementation science. Use of these tools and frameworks can address the critically important step of implementation. All the work done well by CQI teams is lost if the solution is not implemented well and in a lasting way. As the old adage says “What is worth doing is worth doing well!”