1. Disclaimer information here… Click to edit Master title style WHA’s Learning Series: QI 100 for Health Care Clinicians Unit 3: Holding the Gains Aligning Forces for Quality is supported by the Robert Wood Johnson Foundation, through a grant to the Wisconsin Collaborative for Healthcare Quality. In Wisconsin, Aligning Forces for Quality is a joint project by the Wisconsin Collaborative for Healthcare Quality, the Wisconsin Hospital Association, and other organizations.

2. Disclaimer information here… Click to edit Master title styleQI 100 Rules of Engagement 2 1.This powerpoint must be in “Slide Show” mode in order for all links to be active (see the Slide Show menu at the top of your screen). 2.You must complete this unit in one sitting. You will not be able to exit and re-enter from where you left off. 3.This unit has three exercises and a five question quiz at the end. You must complete the quiz to get credit for Unit 3. You will be asked to enter your name. 4.CEU’s will be awarded after you have taken all five units and completed the Capstone Quiz – a link to this quiz is given in Unit 5. 5.The content provided in this unit is for educational purposes only and is not to be interpreted as an endorsement by WHA or any of it’s member or partner organizations. 6.This learning series is supported by the Aligning Forces for Quality grant. Aligning Forces for Quality is supported by the Robert Wood Johnson Foundation, through a grant to the Wisconsin Collaborative for Healthcare Quality. In Wisconsin, Aligning Forces for Quality is a joint project by the Wisconsin Collaborative for Healthcare Quality, the Wisconsin Hospital Association, and other organizations. 7.If you have questions or problems please e-mail: ssobczak@wha.orgssobczak@wha.org Please read carefully:

3. Disclaimer information here… Click to edit Master title styleQI Unit Progression 3 Why Quality Matters Unit 1 Participating in Improvement Unit 2 Holding the Gains Unit 3 Health Care Change Systems Unit 4 Capstone & Credit Unit 5

4. Disclaimer information here… Click to edit Master title styleIntroduction to Unit 3 You are about to participate in the QI 100 Unit 3 Holding the Gains After completing this unit, you will be able to: Understand the dynamics of change. Learn why some change efforts don’t “stick”. Understand the components of work in health care impacted by change. Understand the importance of trend in process measurement. Learn about control charts to track variation. Understand how to help others that may be struggling with change. 4

5. Disclaimer information here… Click to edit Master title styleGetting Credit for Unit 3 5 When you see a light bulb icon, you can access a brief exercise to reinforce the concept. Simply click on the light bulb. When you see a screen icon, you should access a quiz to test your knowledge. Simply click on the question mark. When you are done with an exercise simply close the page by clicking the or at the top of the page. In order to officially participate in this unit, and receive continuing education credit, you need to complete the Unit 3 quiz. X

6. Disclaimer information here… Click to edit Master title styleContinuous change in health care Have you noticed frequent change at your workplace? New technology Software Updates Changing procedures Changing requirements “More with less” Cost reductions Zero adverse events Reporting requirements 6

7. Disclaimer information here… Click to edit Master title styleThe impact of change on work Change ProceduresProcessesBudgets Documen- tation Patient Experience Job Descriptions Job Roles Reports & Data IT Systems 7 When considering a change, it is a good idea to systematically consider all the components of work that may be impacted by the change. Each of these must be addressed to reduce the potential for things to “go back” to they way they used to be once a change is implemented.

8. Disclaimer information here… Click to edit Master title styleWhy people may resist change 1.The risk of change is seen as greater than the risk of not changing. 2.People feel connected to other people who are identified with the old way. 3.People have no role models for the new process. 4.People fear they lack the competence to change. 5.People feel overloaded and overwhelmed. 6.People really feel the change is a bad idea. Disclaimer information here… 8 These are some examples about how someone may, unconsciously or consciously, react to a change. Have you seen any of these in others?

9. Disclaimer information here… Click to edit Master title style Your decision – how to react to change? Which decision-making style best describes you? Analytical Style Technical, logical, careful, methodical, needs much data, likes order, enjoys problem- solving, enjoys structure, enjoys scientific study, and enjoys working alone. Conceptual Style Creative and artistic, future oriented, likes to brainstorm, wants independence, uses judgment, optimistic, uses ideas vs. data, looks at the big picture, rebellious and opinionated, and committed to principles or a vision. Behavioral Style Supportive of others, empathetic, wants affiliation, nurtures others, communicates easily, uses instinct, avoids stress, avoids conflict, relies on feelings instead of data, and enjoys team/group efforts. Directive Style Assertive, acts rapidly, takes charge, persuasive and/or is manipulative, uses rules, needs power/status, impatient, productive, single-minded, and enjoys individual achievements. Disclaimer information here… 9 Identify your reaction to change. How you react is your decision.

10. Disclaimer information here… Click to edit Master title styleCoping strategies for change Disclaimer information here… 10 Strategies to help you with change if your decision-making style is: Analytical - You see change as a challenging puzzle to be solved. You need plenty of time to gather information, analyze data, and draw conclusions. You will resist change if you are not given enough time to think it through. Conceptual - You are interested in how change fits into the big picture. You want to be involved in defining what needs to change and why. You will resist change if you feel excluded from participating in the change process. Behavioral - You want to know how everyone feels about the changes ahead. You work best when you know that the whole group is supportive of each other and that everyone champions the change process. If the change adversely affects someone in the group, you will perceive change as a crisis. Directive - You want specifics on how the change will affect you and what your own role will be during the change process. If you know the rules of the change process and the desired outcome, you will act rapidly and aggressively to achieve change goals. You resist change if the rules or anticipated results are not clearly defined.

11. Disclaimer information here… Click to edit Master title style Understanding the dynamics of change Exercise #1: This is a True/False exercise to help you consider the dynamics of change – more information may be provided based upon your answer. Just click on the light bulb  11 X When you are done, simply close out by clicking the or at the top.

12. Disclaimer information here… Click to edit Master title style Why some change efforts don’t ‘stick’ Did you know that in US businesses, some 70% of change efforts don’t result in lasting change, or fail altogether. In Wisconsin, the WHA survey found that only 30% of QI Managers could say their hospital’s change efforts were successful at least 80% of the time. Reasons for this are varied, but significant keys to change that ‘sticks’ are communication about the change, early involvement by those affected by the change, and measurement that shows definite improvement. 12

13. Disclaimer information here… Click to edit Master title styleHelping change “stick” Studies have show that change efforts are likely to succeed when several factors are in place. (These success factors are gleaned from a 3 year international study of 500 organizations’ successful projects.)* Leadership supports and encourages QI efforts. Internal champions of improvement efforts are identified and involved. Successful improvement efforts are widely recognized in the organization. All employees are encouraged to be involved in improvement efforts. Managers ensure that the work of improvement efforts is shared by many. Widespread communication about improvement efforts occurs at least monthly. There are specific strategies used to ensure that the change “sticks”. Every project uses data so that actual improvement can be measured. 13 * see reference slide

14. Disclaimer information here… Click to edit Master title style Measurement & Change Management In addition to having a solid plan, obtaining buy-in among staff, and providing consistent communication about the change, the importance of measurement is sometimes forgotten. Sometimes short term measures used to implement a process don’t evolve into measures that monitor a process over the long term. This is one reason a change may not stick. 14

15. Disclaimer information here… Click to edit Master title styleUnderstanding Trend One key to ensuring long lasting change is to incorporate ongoing measurement into the process to track data trends Measuring processes over a period of time provides a good indication that the change made results in improvement, and that the improvement will last. 15

16. Disclaimer information here… Click to edit Master title styleWhat trending tells us 16 An Increasing Trend A Decreasing Trend Trend cannot be determined because at least 3 points in succession are needed to determine a trend. When a data series trends in the wrong direction, it may be time for another cycle of improvement.

17. Disclaimer information here… Click to edit Master title styleWhen Change Comes Around As we have seen, there are very good data driven methods for determining when a change is needed, and how to monitor a change over time. Great reasons to change don’t necessarily make the actual change easier on a personal level. 17

18. Disclaimer information here… Click to edit Master title style Helping Those Struggling with Change Here is a strategy to consider when you encounter a negative or strong reaction: Pause: A quick “off the cuff” response can have unintended effects, such as keeping others from expressing their feelings Listen: The next step is to listen carefully not only to what they are saying but also to how they are saying it. Listen for any hidden messages. You can also ask good questions to ensure you really understand their point of view. Empathize: Make your initial response one that empathizes with their position. First show that you understand (even though you may not agree) and respect their right to voice an honest opinion. Think: Before you respond, think carefully about what you are going to say and how you are going to say it. This is a moment of choice on your part to respond positively or negatively. Respond: Respond in a way that offers the other person a dignified way out. Seek a win- win. Reframe their position to allow them to see and consider a bigger picture. 18

19. Disclaimer information here… Click to edit Master title styleDifferent thinking about change A frame, or 'frame of reference' is our set of unquestioned beliefs, and values that we use when inferring meaning. If any part of that frame is changed (hence 'reframing'), then the meaning that is inferred may change. Here are some examples of reframing: A problem as an opportunity A weakness as a strength An impossibility as a potential possibility Oppression ('against me') as neutral (‘wait & see') Abruptness as a lack of caring or understanding Disclaimer information here… 19

20. Disclaimer information here… Click to edit Master title styleRe-framing change Exercise #2 Match the feeling about change with a statement re-frames that feeling into something more positive. Just click on the light bulb  20 X When you are done, simply close out by clicking the or at the top.

21. Disclaimer information here… Click to edit Master title styleUnit 3 Summary Quiz Congratulations! You have completed Unit 3: Holding the Gains You can now test what you have learned by taking a short assessment: Just click on the screen icon  **You must take the assessment to get full credit for Unit 3 21 X When you are done, simply close out by clicking the or at the top.

22. Disclaimer information here… Click to edit Master title styleUnit Resources Quality Improvement Implementation and Hospital Performance on Quality Indicators. Bryan J Weiner, et al. Health Services Research 2006 41:2, 307. Ten reasons people resist change. Copyright (c) 2003 A. J. Schuler, Psy. D.. A. J. Schuler is an expert in leadership and organizational change. To find out more about his programs and services, visit www.SchulerSolutions.com Develop a coping strategy based on who you are. http://ezinearticles.com/?Coping-with-Change:- Develop-Your-Personal-Strategy&id=51313http://ezinearticles.com/?Coping-with-Change:- Develop-Your-Personal-Strategy&id=51313 New Ways of Working in Hospitals. American Hospital Association publication 2008. Price Waterhouse Cooper study reference:http://www.aha.org/aha/issues/Workforce/nww/nww-resources-toc2.pdfhttp://www.aha.org/aha/issues/Workforce/nww/nww-resources-toc2.pdf http://www.cdc.gov/nchs/data/misc/healthcare.pdf for Trend Chart Examples http://www.cdc.gov/nchs/data/misc/healthcare.pdf Qual Saf Health Care 2007;16:387-399 doi:10.1136/qshc.2006.022194 Phillips, B. (1999). Reformulating Dispute Narratives Through Active Listening, Mediation Quarterly,17(2), 161-180 http://changingminds.org/techniques/general/reframing.htm 22