Section 3: Planning for Change

A structured approach to improvement and change is recommended for planning and implementing an abbreviation initiative.

Introduction

The Model for Improvement3 is an example of a structured approach to improvement and change that is used throughout this section. More information about application of the Model for Improvement in healthcare can be found in these resources:

Canadian Patient Safety Institute
“Improvement Frameworks Getting Started Kit”

Institute for Healthcare Improvement
“How to Improve”

Structured Approach

Activities in the Model for Improvement3 are focused on addressing three questions:

  • What are we trying to accomplish?
  • How will we know that a change is an improvement?
  • What changes can we make that will result in improvement?

Two critical elements for success are measurement and a cyclical process of testing and refining different changes to produce the desired improvement.

Figure 1. The Model for Improvement


(from: Associates in Process Improvement, www.apiweb.org)

Specify an Aim

Although a desired outcome or general goal for the project was established in the project proposal stage, the improvement team often needs to develop more specific aims that will guide selection of the changes and measurement activities. In order to set specific project aims and brainstorm potential ideas for change, the team should be informed of:

  • Safety concerns related to abbreviation use, such as information from the literature (Literature Summary).
  • The extent of the local problem. In addition to the initial evidence that helped identify the problem, more information may be needed to help understand not just what is happening but why. Team members should help identify additional questions about the local problem that need to be answered before specific project aims can be developed.

A project aim should:24

  • Be clearly stated.
  • Describe measurable goals to work towards that include a time commitment.
  • Represent a stretch goal that will require a fundamental change in the system.
  • Focus on an outcome that is achievable in the short-term but can be refocused when the initiative needs to spread.
  • Be repeated often to remind the team of what they are committed to achieving.

U for Units: Stating an Aim

The improvement team decided that a feasible interim aim for the project that would allow them to test some change strategies before rolling it out to the entire hospital was: “Increase the use of units in ordering medications to 85 per cent of all applicable orders on the target medical and surgical units within six months.”

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U for Units: Stating an Aim

The improvement team recognized that the initiative needed to target both prescribers and transcribers. The team decided that a feasible interim aim for the project that would allow them to test some change strategies was: “Increase the use of units in ordering and transcribing insulin doses to 85 per cent of orders within six months.”

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Establish Measures

Observation and measurement are an essential part of making a change. It is important to collect data about what is happening before and after a change is made, and analyze the data to learn if the change made a difference and determine what to do next.3 Timely and ongoing collection and analysis of data is needed to determine if a change has resulted in improvement and to monitor how well the change strategies are working.25

Table 1. Tips for effective measurement 3, 25

Measures should relate directly to the aim of the change initiative. Measures can reflect:

  • Outcomes of care for patients – For example, achievement of therapeutic goals, mortality, and morbidity including adverse outcomes related to care.
  • Steps in the processes of care – Develop a process or flow map to help understand all the steps, activities, tasks, and decisions that are needed to achieve a desired outcome.

Define the measures and how data will be collected.

  • Everyone needs to document and interpret the data in a consistent way.

Use different kinds of measures to get a complete picture of the impact of the change.

  • Quantitative measures – something that can be observed and counted or measured using some kind of tool.
  • Qualitative measures – perceptions and feelings of those affected by an issue or change, usually gathered from interviews, surveys, or focus groups.

Collect data at numerous points over time and look for trends and patterns.

  • A run chart is a graph that tracks the data points over time.89
  • Enough data and time points are required to distinguish between expected fluctuations over time and variations that signal change.

Collect just enough data to know whether a change is an improvement.

  • Avoid collecting information that is ‘nice to know’ but not needed.
  • Avoid collecting personally identifying information about individuals (patients or staff).

Use sampling to make efficient use of resources during data collection.

  • Collect data from a representative subset or sample of the total data available.
  • The sample size or number of measurements taken at each time point needs to be adequate to detect a pattern that signals change. The table below shows suggested numbers of measurements to take for different improvement situations.
  • Integrate measurement into the daily routine using a simple data collection form.
Table 2. Suggested sample sizes for tests of change 3
Number of measurements (sample size) Improvement Situation
Fewer than 10 Expensive tests of change, long periods between available data points, large effects expected
15 to 50 Usually adequate to detect moderate to large changes
50 to 100 Effect of change is expected to be relatively small compared to typical variation
More than 100 Change is intended to affect a rare event

Adapted from Langley and Nolan 3

U for Units: Selecting Measures

The project team decided to collect baseline data from medication orders received by the pharmacy from the target units on five randomly selected days over a two week period:

  • Name of medications being ordered by the dose designation U or units. It was anticipated that most would be for heparin or insulin which are both high-alert medications.
  • Dose designation used – either U or unit.
  • Prescriber initials. It was necessary to identify the prescriber during data collection in order to provide feedback to prescribers during the project. A separate list of prescriber names corresponding to the initials was created.

A simple data collection form was developed with columns for medication name (check off heparin, insulin or other), dose designation used (check off U or units), and prescriber initials.

To analyze the data, the total number of orders for each medication category was tallied for each prescriber, and the proportion of each for which units was used was calculated. The team decided it was important to use positive reinforcement by illustrating how often the desired practice, units, was used. A bar graph was prepared that illustrated by prescriber the proportion of orders for heparin, insulin and other medications for which units was used as the dose designation. Prescriber identity was protected by not including initials on the graph.

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U for Units: Selecting Measures

The project team decided to gather additional information to serve as a baseline.
1. The pharmacy collected information about all insulin prescriptions over a 4 week period:

  • Dose designation used – either U or unit
  • Prescriber initials. A separate list of prescriber names corresponding to the initials was created. It was necessary to identify the prescriber during data collection in order to provide feedback to prescribers during the project.
  • Orders transcribed from a verbal prescription were designated with TO.

A simple data collection form was developed with columns for date, dose designation used (check off U or units), prescriber initials, and whether it was a transcribed order.

To analyze the data, the total number of orders for insulin was tallied for each prescriber, and the proportion of each for which units was used was calculated. The team decided it was important to use positive reinforcement by illustrating how often the desired practice, units, was used. A bar graph was prepared that illustrated by prescriber the proportion of written insulin orders for which units was used as the dose designation. Prescriber identity was protected by not including initials on the graph. A separate graph was prepared for verbal prescriptions showing the proportion of transcriptions for which units was used as the dose designation.

2. Over the same 4 week period, the consultant pharmacist reviewed all new and changed insulin orders transcribed at both the facility and the pharmacy. The identity of the transcriber was not collected. A bar graph was prepared that showed the proportion of transcribed verbal orders for insulin at the facility and pharmacy for which units was used as the dose designation.

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Determine Interventions

The team will need to generate ideas for strategies that can be used to influence how abbreviations are used. Consider ideas from other initiatives or from the literature, adapt current processes or technologies, or devise a completely new change idea.

The most important learning from the experience of others is that using a combination of intervention strategies is required in order to change ingrained practice habits like the use of abbreviations. Different interventions and strategies that have been used to curtail abbreviation use are described in Section 4: Making it Happen. The main categories of intervention strategies are summarized below in the order from least to most effective according to the hierarchy of effectiveness:31

  • Policies and guidelines – While policies and guidelines need to be in place for any type of enforcement strategy to be effective, they will be ineffective when used alone.
  • Education and awareness – In order to be effective, educational interventions should be tailored to the needs of the group expected to change their practice.
  • Reminders – Most initiatives use some form of reminder or prompt to reinforce what people learn from educational interventions.
  • Audit and feedback – Measuring how abbreviations are being used and providing feedback to individuals about their performance can be an effective strategy.
  • Standardization of orders – The use of protocols or pre-printed clinical order sets (paper or electronic) that do not use abbreviations can help structure medication ordering and support clear communication.40
  • Computerization – Computerized prescriber order entry (CPOE) and electronic prescribing help to standardize medication prescribing, eliminate illegible orders, and curtail the use of error-prone abbreviations.
  • Forcing functions – A forcing function or constraint is a process or equipment design feature that makes it easy to do the right thing. For example, in an electronic health record system, free text data entry fields can be designed to not accept certain abbreviations (forced correction) or to automatically convert a short form of communication into an acceptable format (auto-correction).

U for Units: Choosing Interventions

The project team determined that the primary change strategy would be education combined with feedback to individual prescribers about their use of units and U. A phased approach to education was proposed beginning with a letter from the chief of medicine and the chief of surgery to their colleagues setting expectations for performance. This would be accompanied by a personalized report for each prescriber showing how their prescribing compares to that of their unnamed colleagues. This would be followed by an inservice education program presented in person and accessible as a podcast through the internal website. Posters were designed for the nursing station to raise awareness of the issue and reinforce key messages from the inservice.
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U for Units: Choosing Interventions

The project team determined that the primary change strategy would be education accompanied by prescriber feedback. The medical advisor sent a letter to all physicians caring for residents of the facility setting expectations for insulin ordering. For prescribers who had ordered insulin during the baseline period, the letter included a bar graph showing how that prescriber’s use of units and U compared to that of their anonymous colleagues. Posters were designed for the nursing stations to raise awareness of the issue and reinforce key messages. A 10 minute inservice suitable for presentation at shift change was developed for nursing and pharmacy staff. It highlighted the problems encountered when U is used as the dose designation for insulin and how this had contributed to medication incidents at the site. It also included information on the use of U in transcribed orders. Expectations for using units instead of U in transcribing orders were established.

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Test and Refine

The model for improvement is based on a trial-and-learning approach to improvement in which small, frequent cycles of change are used to turn ideas into action. This process allows ideas to be discarded if they are not effective, modified when the idea shows promise, and implemented when deemed successful. Each cycle of change has four steps and is commonly referred to as the PDSA cycle.3

PLAN – Design a change, list the actions needed to trial the change, and predict the outcome.

DO – Try the change on a small scale and document the results. Use measures identified above and document problems and unexpected observations.

STUDY – Analyze the data collected, compare to the predicted outcome, and summarize what was learned. Note that a substantial proportion of tests – 25 to 50 per cent – will result in no improvement but can still produce learning that can be applied to redesigning the change.

ACT – Take action based on what was learned. This could include discarding ineffective changes, modifying a change to address problems encountered, trying a successful change on a larger scale, or making a decision to implement a change that seems to be working.

U for Units: Cycles of Change

The project team continued with data collection in the last two weeks of every month to assess the impact of the interventions. The letter to prescribers was followed one month later by the inservice education program and accompanying posters. Each month, feedback was provided to prescribers showing how their use of units in ordering medications compared to their anonymous colleagues, and a graph showing how the proportion of their total orders that used the full word units changed over time (run chart). After three months, a 75 per cent compliance rate with the use of units to order the target medications had been achieved; more than half of the prescribers were consistently using units for all their orders.

After four months, it was noted that three prescribers began to revert to their former practice of consistently using U instead of units. A targeted intervention was designed for this small group which consisted of personal contact by their chief of service to emphasize expectations of performance related to medication ordering and a phone call from the pharmacy to request a correction of any orders in which U was the dose designation. This was successful in changing the ordering practices of this group.

After five months, the use of U began to gradually increase again across the target units. The timeline of the initiative was extended to try some new strategies. It was decided to add to the order form a reminder to avoid using abbreviations. As an interim solution to test this change, a sticky label was affixed to the top of each new order sheet by the unit clerk. After two months, the use of units had climbed to 80 per cent of all applicable orders. However, this was not considered to be sufficient as patients were still at risk of medication errors from this practice. Finally a policy was implemented in which medication was not dispensed until the order was clarified. This reinforced to the pharmacy and nursing staff the importance of not making assumptions about a dose before dispensing or administering a high risk medication like insulin to a patient.

By the end of a nine month project period, 98 per cent of orders for the target medications from the medicine and surgery services used a dose designation of units. The remainder of the orders required follow-up by the pharmacy before the medication was dispensed.

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U for Units: Cycles of Change

The educational intervention took place over a two week period after which the project team resumed data collection on all insulin orders. After each four week period, bar graphs were created showing how the use of units during that period compared to the baseline period. Prescriber feedback was sent out showing each prescriber how their use of units was changing over time compared to that of their anonymous colleagues. Posters were placed in the pharmacy and in staff areas at the facility to show how the use of units by physicians and in transcribed orders was changing over time.

After four months, the nursing and pharmacy staff were consistently using units to transcribe orders for insulin, with a 97 per cent compliance rate. Staff responded quickly to personal requests, usually from their colleagues, to change an order they had transcribed incorrectly. There was a steady increase in the use of units by prescribers, with an overall 75 per cent compliance rate by the end of the fourth month. Compliance ranged from 100 per cent to zero – three prescribers continued to use U to prescribe insulin for all orders. The medical advisor contacted these individuals personally to discuss expectations for ordering insulin. Compliance issues were also noted when new physicians or locums providing vacation relief prescribed insulin. These prescribers were sent a letter from the medical advisor followed by a prescriber feedback letter after four weeks of data collection.

By the end of the six month period the aim of 85 per cent compliance with the insulin ordering policy had been achieved and the ordering practices of all physicians had improved. However the project team decided that this was not sufficient because patients were still at risk of medication errors from misinterpreted orders. It was decided to implement a policy in which insulin doses designated with U would not be dispensed until the order was clarified with the prescriber. This reinforced to the staff the importance of not making assumptions about a dose before administering a high risk medication like insulin to a patient.

Data collection continued for another two months at the end of which the compliance rate for prescribers was 98 per cent. Nursing and pharmacy staff consistently continued to use units when transcribing orders for insulin.

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Implement Changes

Implementation is the permanent change to a new way of working in one area or throughout an entire organization. Using small cycles of change to try out new processes helps with implementation by engaging those who will be affected by the change and demonstrating success with the new process. However, implementation requires permanently altering ingrained habits and processes and can be very challenging. Resistance to change is often greater during implementation than during testing. Careful planning that includes developing strategies to overcome resistance and manage the social aspects of change is critical; early and ongoing communication is key (see Table 3). Use learnings from the testing cycles to anticipate issues that will need to be dealt with during implementation. Develop processes to support individuals in the new way of doing things, such as altering job descriptions, adjusting policies and procedures, and introducing training.

Table 3. Communication strategies to mitigate resistance to change3
  • Share information on why change is needed.
  • Demonstrate support from champions throughout the organization.
  • Inform people about how the change will specifically affect them.
  • Be open to questions, requests for clarification, or ideas about the change.
  • Highlight the collaborative nature of the project, that solutions are developed with the input and support of those who will be affected the most.
  • Publicize the ongoing results of the change process.

Implementation can be accomplished with a series of cycles accompanied by measurement, similar to the testing phase.3 Three main approaches to implementation are:

  • “Just do it” – A date is set on which the new process becomes the expected way of doing things. This is most suitable for a simple change that will have limited impact outside the area where the change is being introduced.
  • Parallel implementation – The new process is phased in while the old system is continued before being phased out.
  • Sequential implementation – The new process replaces the old process gradually in terms of completeness or coverage. This is advisable for complex changes. Learning from continued measurement throughout implementation can be used to adjust the implementation process or tweak the change to respond to new issues that were not detected during testing.

U for Units: Implementation Strategy

The project team concluded that a ‘no fill’ policy was required to reach 100 per cent compliance with the requirement to use the dose designation units. They also concluded that the education and peer comparison feedback process was a valuable strategy to increase compliance with the expected practice standard. A sequential approach to implementation was chosen for other areas using a similar education and peer feedback process, with priority for implementation given to those areas where use of U was common.
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U for Units: Implementation Strategy

The project team concluded that a ‘no fill’ policy was required to reach 100 per cent compliance with the requirement to use the dose designation units. They also concluded that the education and peer comparison feedback process was a valuable strategy to increase compliance with the expected practice standard. No additional implementation strategy was needed because the practice of all prescribers and those who transcribe orders had been addressed during the test and refine stage.

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Spread and Sustain

Spread involves replicating a successful implementation process more broadly throughout an organization or to other organizations.23 It is informed by lessons learned during implementation such as infrastructure issues (space, equipment, staff), sequencing of tasks, managing upstream and downstream impacts, and helping people adapt to a new way of working. Plan-Do-Study-Act cycles can be used to help with the spread and sustainability of the project. They support different areas in adapting the change to unique aspects of their work and demonstrate that change is an improvement. Organizations and individuals are encouraged to share their improvement work so that others may learn from their experience.

U for Units: Sustaining Change

After implementation was completed in each area, the data collection and peer comparison feedback process was repeated two more times at four month intervals as a reminder to prescribers of the expected practice. Key messages from the in-service education program were incorporated into a medication ordering standards online education module that new medical staff were expected to complete. The ‘no fill’ policy was incorporated into existing policies. The order form was changed to include a reminder about the organization’s expected practice regarding the use of abbreviations.

The project team is now assessing whether the initiative needs to be expanded to address the issue of how the abbreviation U is used in charting, or whether there is a need to address other abbreviations that are commonly used in medication ordering.
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U for Units: Sustaining Change

After implementation was completed, the data collection and peer comparison feedback process was repeated two more times at four month intervals as a reminder to prescribers of the expected practice. Transcription of insulin orders was reviewed and reported to staff at the same time. Key messages from the in-service education program were incorporated into a medication ordering standards online education module that new nursing, pharmacy and attending physicians were expected to complete. The ‘no fill’ policy for insulin was incorporated into existing policies. The order form was changed to include a reminder about the organization’s expected practice regarding the use of abbreviations.

The project team is now assessing whether the initiative needs to be expanded to address the issue of how the abbreviation U is used in charting, or whether there is a need to address other abbreviations that are commonly used in medication ordering.

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Summary

Keys to a Successful Abbreviation Initiative
  1. Focus your efforts

    Determine where your challenges exist by evaluating current use of error-prone abbreviations.
  2. Engage leaders/management

    Demonstrate the need for an abbreviation initiative. Find a champion on the executive team. Continue to keep leadership informed of the project’s progress.
  3. Start small

    Consider targeting only one abbreviation or one high risk medication to start with. It could be an abbreviation that has caused a significant patient adverse event in your practice site or one that is used frequently; it could be a high risk medication, such as insulin, where use of abbreviations has been a factor in close calls or errors.
  4. Use teamwork

    Include representation from all healthcare provider groups who will be affected: those who write orders or document in the health record, those who review or transcribe orders, and those who dispense or administer medications. From each group recruit early adopters to test the changes and find champions to help promote the project. Listen to ideas from the frontline.
  5. Work towards an information technology solution

    Computerization is a key strategy to reduce the use of abbreviations. Consider a stand-alone order entry or prescription writing program if a comprehensive electronic health record is not financially feasible.
  6. Develop system supports for the change – structure, process and tools

    Develop a medication order writing policy or documentation guideline to address the use of error-prone abbreviations. Update your medication order forms with a section listing unapproved abbreviations and the preferred options.
  7. Communicate frequently

    Inform prescribers and other staff at the start of the initiative and continue with monthly updates at committee or staff meetings. Use bulletin boards in staff areas to keep staff updated about progress with the initiative.
  8. Make education a priority

    Be creative and use several approaches to increase awareness. Include an educator on the team to assist with planning. On-going education is essential.
  9. Partner with others

    Remember to include those who provide contracted services (e.g., doctors and pharmacists) in the initiative. Consider forming a collaborative with other facilities, clinics, and pharmacies in your community.
  10. Be patient and persistent

    Changing ‘old habits’ takes time and effort.
  11. Take time to celebrate
    
Share ongoing evidence and reward positive actions and results.