1. Challenges to successful quality improvement HAIVN 2012

2. Objectives Upon completion of this presentation, participants will be able to: Identify potential challenges in implementing quality improvement (QI) at a clinic Discuss reasons and solutions of resistance to change

3. So now we know what quality of care is, how to measure it and how to improve. It should be easy from here right? Not always.

4. Challenges in implementing QI Site/Organization level Individual/team level

5. Challenges in implementing QI Site/Organizational level Individual/team level

6. For QI to be successful there needs to be an environment for change

7. Some components for successful QI at an organization A culture of quality and improvement Strong leadership commitment to quality/QI Multidisciplinary teams willing to work together

8. What is a “culture of QI” Commitment to patient safety, quality and improvement. Openness to reviewing a clinic’s performance and discussing reasons for a gap. Replacing blame when gaps are found with working towards improvement

9. How leaders can support QI Create and support a vision for quality/QI Establish a multidisciplinary QI team Build staff capacity and motivation for QI Support effort to measure quality, discuss gaps and work together to improve Support open discussion without blame of both successes and challenges Celebrate successes WHO. Operations Manual for Delivery of HIV Prevention, Care and Treatment in High-Prevalence, Resource-Constrained Settings, 2010

10. QI is a team effort Teams are stronger and more effective than an individual “champion” – Different members may provide unique understanding of a gap based on their role in the process as well as how to improve Membership represents range of staff (and ideally patients) involved All members are equal May need coaching in how to move forward and believe that change can happen

11. If leadership support and a team are not in place there may be (more) resistance to doing QI But even with these things in place there still may be resistance in the beginning

12. What do you need to move long QI? 5 minute discussion What resistance to QI do you think there might be at your clinic? What is in place to help overcome and what else is needed?

13. Challenges in implementing QI Site or Organization level Individual or team level

14. Resistance to change The push-back one experiences when trying to change or improve a process or system. Can occur from one individual or from an entire team. Adapted from the National Quality Center and IHI

15. 5 minute exercise Why do people resist change? Turn to your neighbor and discuss 2-3 reasons that people may resist changing a process in the clinic in order to improve quality Be prepared to present back to the group

16. Why do people resist Three main factors: Background – What one has been taught and accepts as true Experience – “This is the way I have always done it,” – “change never works” Knowledge – Do not have the information and skills needed to drive the change JSI and HAIVN Training April 201216

17. Resistance to change What Does it Look/Feel/Sound Like? – “We don’t have time for this activity” – “The problem is out of our control “ – “You can’t tell me what to do” – “My patients are sicker than the other clinic…” – “That’s fine for other clinics, but it won’t work here – our situation is different” – “We don’t have enough staff” – “It’s not my job” – “It’s up to the clinic chief” Adapted from the National Quality Center

18. Reasons people resist change (1) 1.Do not believe there is a problem 2.Worry that things may get worse with change 3.People have a connection and feel comfortable with how things have always been done 4.No role models or teachers for the new activity 5.People fear they lack the knowledge and skills to make the change 6.People feel overloaded and overwhelmed Adapted from “Overcoming Resistance to Change: Top Ten reasons for Change Resistance, AJ Schuler JSI and HAIVN Training April 201218

19. Reasons people resist change (2) 7.Worry they don’t have the resources 8.People want to be sure it is a good idea 9.People worry why the people wanting change are doing this 10.People feel threatened by the proposed change 11.Concern about having more work 12.Worry leadership will not support 13.People really believe the change is a BAD IDEA 19

20. Don Berwick’s resistance to change Example – review of performance data Four stages of resistance – Stage I: “The data are wrong…” – Stage II: “The data are right, but it’s not a problem…” – Stage III: “The data are right, it’s a problem, but it’s not my problem…” – Stage IV: “The data are right, it’s a problem, it’s my problem…” Adapted from the National Quality Center and IHI

21. Resistance to change: How to manage (1) First - Recognize that resistance to change is normal Most people go through stages that should be met with facts, understanding and ongoing discussion. Recognize: “People do not resist change, they resist being changed” Adapted from the National Quality Center

22. Resistance to change: How to manage (2) Ask everyone’s opinion Get everyone on board Understand what they hope will happen Understand what they fear What suggestions do they have Provide a clear picture of the future and answer questions-what will the work flow look like Ref Lisa Hirschhorn 22

23. Resistance to change: How to manage (3) Listen – both one on one and in groups Make sure everyone understands the data and the goals of improvement. Provide an opportunity for people to express concerns Form a team which includes those most affected by a problem and solution and try to address concerns. Ensure leadership support Establish a culture of quality improvement that encourages identifying and dealing with problems  Incorporate QI into routine clinic activities Adapted from the National Quality Center

24. Group exercise Your clinic has found a problem with patients not showing up for appointments and a decision is made to o a QI project Split the group in ½-one group are the changers and one are the resistors 10 minutes-hold a QI project meeting and the changers work to understand why the resisters do not want to do the QI Identify one reason together and start a plan how to help them agree to start to look into change Be ready to report back

25. What if it really seems hopeless? No one thinks change is possible Try making it worse Take a problem – High rates of loss of pre-ART patients Brainstorm how to make it WORSE Then ask what happens if you do the opposite JSI and HAIVN Training April 201225

26. Summary (1) Four important factors for successful QI implementation: – A culture of QI – Leadership support – Functioning multidisciplinary QI team – Time, training and opportunity to overcome resistance

27. Summary (2) Resistance may occur because those factors are not in place or at the individual/clinic team level Resistance at the individual level is important to address – expected in the beginning – handle with information/knowledge dissemination, discussion, encouragement and reassurance.

28. Thank you! Questions?