1. Challenges to successful quality improvement HAIVN 2013

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. Does this make you excited or nervous? 3 Image from wwww.diabetesmine.com

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 Multidisciplinary teams willing to work together Strong leadership commitment to quality/QI

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. When gaps are found: Replacing blame with discussion and working towards improvement

9. QI is a team effort Teams are stronger and more effective than an individual “champion” 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

10. Leaders are essential for 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 Celebrate successes WHO. Operations Manual for Delivery of HIV Prevention, Care and Treatment in High-Prevalence, Resource-Constrained Settings, 2010

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

13. Change DriversResisters/Barriers 13

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 reflection Write down one time when you have tried to get change but encountered resistance Write down one time when you resisted a change someone else was trying to make Be ready to share

16. 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

17. Why do people resist Three main factors: Background Experience Knowledge JSI and HAIVN Training April 201217

18. Reasons people resist change (1) Background What one has been taught and accepts as true 1.Do not believe there is a problem 2.Worry that things may get worse with change 3.Based on what they know, people really believe the change is a BAD IDEA 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) Experience 1.People feel comfortable with how things have always been done 2.People worry why the people wanting change are doing this 3.Worry leadership will not support 19

20. Reasons people resist change (3) Knowledge 1.People fear they lack the knowledge and skills to make the change 2.Do not understand what you are trying to do 3.No role models or teachers for the new activity

21. Other reasons Doubt-have tried to make changes in the past and nothing worked Fear-lose position, status or quality of working life Overwhelmed, overloaded, no time No incentive It will take more resources and they really do not have them Conflict: resistance to person asking for change

22. Group discussion Look back at the personal resistance examples you shared. What were some of the possible reasons for resistance? 15 minute – pair up

23. We can work to solve resistance…. 23 Increase the drivers

24. We can work to solve resistance…. 24 Increase the drivers Decrease the resistance

25. Strategies to manage resistance to change

26. http://www.elca.org/Who-We-Are/Our-Three- Expressions/Churchwide-Organization/Global- Mission/Where-We-Work/Asia/Vietnam.aspx http://www.plasticsurgery.org/for-medical- professionals/resources-and-education/foundation/psf- newsletter/september-2010-foundation.html Strategies to manage resistance to change

27. Overcoming Resistance to change (1) Need to know what change you want people to make Need to understand WHY people are resisting change – What are the drivers which could move change? – What are the barriers? By understanding can effectively work to overcome 27

28. Overcoming resistance to change (2): Resistance is normal Recognize that resistance to change is normal Should be met with facts, understanding and ongoing discussion. Adapted from the National Quality Center

29. Overcoming resistance to change: Provide knowledge (3) Make sure everyone understands: the data why it matters the goals of improvement Understand what new knowledge/training may be needed Ref Lisa Hirschhorn29

30. Overcoming resistance (4): Engage people in the change Recognize: “People do not resist change, they resist being changed” Provide an opportunity for people to express concerns – Understand what they hope will happen – Understand what they fear – What suggestions do they have? Ref Lisa Hirschhorn 30

31. Resistance to change (5): Engage all members in the change Make sure everyone understands and agrees with moving forward and the goals for QI – Not one person’s “job” Ask everyone on the team to give possible reasons for the gap. 31

32. Overcoming resistance (6): Answer questions and discuss fears Provide a clear picture of the future – Answer questions about what work flow will look like Listen to the concerns of those most affected by a problem and solution and try to address. Adapted from the National Quality Center

33. Overcoming resistance (7): Encourage leadership Work closely with management to get their support and agreement and encourage their involvement (more on day 3) Adapted from the National Quality Center

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

35. Summary (2) Resistance may occur because those factors are not in place or may exist even with those things in place 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.

36. References JSI National Quality Center WHO. Operations Manual for Delivery of HIV Prevention, Care and Treatment in High- Prevalence, Resource-Constrained Settings, 2010 “Overcoming Resistance to Change: Top Ten reasons for Change Resistance, AJ Schuler

37. Homework (1) Go back to the list of your personal resistance to change examples and possible reasons Start to think of approaches to address them. Write down and be ready to discuss tomorrow. 37

38. Homework (2) What do you think are the goals of a successful QI coach? Write down 2-3 goals

39. Thank you! Questions?