Section 3: Planning for Change
A structured approach to improvement and change is recommended for planning and implementing an abbreviation initiative.
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”
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.
- Strategies that have been used to curtail abbreviation use, typically gathered from the literature (Section 4: Intervention Strategies).
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.
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
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).
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 PDSAcycle.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.
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.
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.
KEYS TO A SUCCESSFUL ABBREVIATION INITIATIVE
- Focus your efforts
Determine where your challenges exist by evaluating current use of error-prone abbreviations.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Be patient and persistent
Changing ‘old habits’ takes time and effort.
- Take time to celebrate
Share ongoing evidence and reward positive actions and results.