The clinical approaches used in any healthcare organization for disease management are otherwise easily understood, but when combined with social systems their management becomes very intricate and complex.
Healthcare worldwide is changing along with the needs, demands and expectations of patients, carers and communities. In Australia ageing population and high prevalence of chronic diseases is providing great challenge for planning, delivery and funding of healthcare services. Better value healthcare initiatives are required for the provision of right resources at the right time and place. This leads to optimization of health resource utility while maintaining high quality patient care. It encompasses strategies and innovations aiming at delivering of better patient outcomes through efficient productivity, appropriate funding, proper identification of core businesses and leveraging private sector. Healthcare organizations are complex due to the diversity of medical professions and administrators with competing interests and perspectives. To address these myriad issues affecting our healthcare systems there is a need for ongoing leadership and strong collaboration between healthcare professionals along with the unified understanding and approach from all the stakeholders towards the change required and its implications.
Health managers are accountable to the communities they serve. In spite of their dependence on the context, health managers play a significant role in influencing the quality of life and services provision. They need to have a greater visibility of the reforms along with professional and educational development.
With current developments in healthcare one key concern in healthcare management is “change management”. Healthcare managers nowadays are obligated to not only acquire the skill and expertise around the change management, but also to develop and maintain them. Change is constant. We may be supportive, indifferent, passive or active to it. Managing change is ability to handle the underlying complexity of the process through evaluation, planning, and implementation of strategies and tactics making sure that the final outcome is relevant. Change in healthcare is mostly unpredictable due to the rapid nature of the change required. For successful organizations managers and executives need to develop framework for change management and key issues accompanying it.
Background
Chronic disease management requires ongoing monitoring and guidance from all health professionals, if addressed at the right time this also motivates clients to actively manage their own health. Provision of regular consultations over the course of time takes up significant amount of clinician’s time. Mostly the patients are discharged from acute facility once their acute condition is resolved and not seen again till another acute episode. This results in significant increase in the rate of chronic health conditions in the community as well as reduced self-management activity. Chronic diseases are responsible for 68% of all death globally. This trend is evident in Australia where 280 Australians develop diabetes every day. The quality of health care services which are offered to people with chronic illnesses is often not up to the standards. Population with chronic health illnesses accounts for higher healthcare expenses than any other ailment. Due to limited resources there is a strong need for efficient methods which would improve quality of care.
AIM Statement:
Provide patients with chronic diseases a coordinated and accessible chronic care through establishment of chronic disease management unit along with development of an efficient chronic diseases model of care.
Organizational setting (Context)
Any effort around improving patient care should be woven into it’s organization’s fabric and aligned with the strategies for quality improvement. In this change management the senior leadership and clinician’s engagement is of vital importance. The importance of chronic care improvement and prevention plans should be translated into their goals and reflected in the organization’s policies and financial planning and budgeting.
The people responsible for implementing and sustaining any change are mostly the ones who get affected by the given change. Hence without the support and buy in of such affected groups, the implementation and success of the initiative is very less. The long-term success of a program depends on clinical staff engagement and willingness. If the staff members have an understanding that the primary goal of the change is to improve patient care they will be more likely to embrace the change due to their beliefs. The communication plan begins with the hospital’s CEO and executive-management teams. The programmes’ goals should be conveyed to the staff on regular intervals through communication channels like meetings, intranet articles, staff cafeteria displays and emails etc. In healthcare organizations change management is very complex and multifaceted, hence a multi-dimensional approach is the best practice
Effective communication to change the culture
Before the programme begins there should be knowledge transfer meeting for sharing experiences and integrate common challenges and roadblocks faced at different levels of the organization. Surveys should be conducted to gauge the overall attitude of staff and any underlying resonant issues. There should be proper timely identification of resistance and barriers most likely to hinder the change.
Communication is very vital in any change management plan implementation and success. The change needs to be aligned with executive leadership and executive sponsorship with accountability for sustained results. Gosford Hospital is a 484 bed state owned metropolitan public hospital in NSW under CCLHD council.
Keeping in mind the organizational structure above, the key ELT (executive leadership team) which should be engaged for this change are as below.
Executive Director Clinical Operations (EDCO)
The Executive Director Clinical Operations will be the Executive Lead for the chronic disease management plan
Executive Director Medical Services (EDMS)
The Executive Director Medical Services is responsible for ensuring senior clinical engagement for the Plan.
Executive Director Workforce and Culture
The Executive Director Workforce and Culture is responsible for ensuring workforce support for the Plan.
Executive Director Finance and Corporate Services
The Executive Director Finance and Corporate Services is responsible for ensuring financial support for the Plan and the support of relevant corporate services teams
Site Director(s) of Nursing and Midwifery (DONM’s)
The Site Directors of Nursing and Midwifery are responsible for facility level patient demand and capacity monitoring and delivery for their facility.
Site Director(s) Clinical Services (DCS’s)
The Site Directors are responsible for facility level liaison between DONM’s and medical workforce with the aim of ensuring effective implementation of the change management.
Divisional Directors (DD’s)
The Divisional Directors are responsible for coordinating planning of patient flow in consultation with specialties and services and staff under their control to the Site DONM’s.
Facility Patient Flow Managers (PFM’s)
Facility Patient Flow Managers have daily operational responsibility for managing patient flow with support from the Directors of the Divisions as well as managers of clinical services and managers of clinical support services. The Patient Flow managers are responsible for reporting escalation and management plans to the site DONMs.
After Hours Nurse Managers (AHNM’s)
Responsible for the overnight and weekend facility level operational management for facility. Liaise with other facilities in the District to ensure continued support for the Site DONMs and Patient Flow Manager.
Operational Nurse Managers (ONM’s)
The Operational Nurse Managers are responsible for ensuring clinical nursing unit support of the Plan.
Nurse Unit Managers (NUM’s)
The Nurse Unit Managers are responsible for ensuring unit level service engagement with the Plan
Director Medical Imaging (DMI)
The Director Medical Imaging is responsible for managing the Imaging service support and engagement for the plan.
Director Pharmacy (DP)
The Director Pharmacy is responsible for managing the Pharmacy service support and engagement for the Plan.
Pathology Liaison Officer (PLO)
The Pathology Liaison Officer is responsible for ensuring Pathology North’s service support and engagement for the Plan.
Director Allied Health (MAH)
The Director Allied Health is responsible for ensuring Allied Health service support and engagement for the Plan.
Need for change
Chronic disease requires ongoing monitoring and guidance from a range of health professionals, which can also motivate clients to actively manage their own health if seen in a timely manner. However, providing regular consultations to chronic disease clients over the long-term can take up a significant amount of the clinicians’ time. This means that clients are often discharged from services once their acute issues have been resolved and may not be seen again until another acute episode occurs. The result is an increased rate of chronic conditions in the community as well as reduced self-management due to a lack of support.
There is often long waiting times for clinic appointments which leads to worsening of symptoms and increased complications. In addition, fragmentation of healthcare particularly for those with multiple chronic diseases makes things worse like high readmission rates and missed appointments. There is adhoc community testing of risk factors at community events but there isn’t enough follow up for the abnormal results or tracking of the progression of the disease. In addition, the clinicians also can’t register the interventions which meant that the activity data couldn’t be collected for our ABF model since the time spent on these activities couldn’t be tracked or recorded.
Due to the complex nature of integrated primary care for patients with chronic illnesses, there is a need for:
- Processes to be in place where there are timely interventions to identify, rapidly asses and link the patient to the right type of care at the right time in their journey of chronic illness.
- Self-management promotion through identification of clearer health goals and action plans which are linked to the patients’ primary and secondary carers.Increasing awareness strategy to educate patients with chronic illnesses to become partners in their own health care process
- Streamlining of patients’ journey after any unplanned admission due to a chronic illness
- Embedded referral lines between acute and community interfaces
- ABF models
- Changing the fragmented care approach into integrated models of care.
- Systematic assessment of quality results
Intended Change
A district wide approach to chronic disease management to:
- Improve patient experience through specialised consultation and enhanced hospital care
- Improve access to hospital specialists
- Reduction in health system dependency (self-management)
- Promote effective models of care (integrated care)
- Increased engagement with GPs and community allied health services
- Enhancement in management and communication between primary and secondary drivers
- Reduction in adverse events
- Reduction in Length of stay
- Reduction in hospital readmissions
Implementation:
- Standardized identification and screening processes for both planned (i.e. surgical) admissions and unplanned (i.e. Emergency Departments).A monthly drop in clinic to be developed and opened to the community for one hour every alternate week.
- Develop and implement referral criteria including risk stratification. Need to develop pathways for timely and appropriate feedback from specialists; and identify strategies for proper communicating channels and linkages to specialist centers within the LHD.
- Develop and implement decision-support tools. Smart phone apps, electronic medication prescriptions etc. for the clinicians on site. Also review and promotion of existing resources and tools.Documentation development which will include doctors referral letter templates, patient data record sheets.
- Develop models of care around safe procedures for transfers of care between different facilities, wards and discharges to community centers
- Develop and implement work processes which would automatically identify patients requiring specialist input. For example, identification of hyperglycemia etc.
- Develop and implement strategies to benchmark chronic disease care KPIs across all the LHD. Work collaboratively with divisional directors and managers to get data on their average length of stay and admission/readmission rates of patients with chronic illnesses.
- Spreading the word and publicity to local media, General Practitioners (GPs) clinics, and chronic disease clinicians in LHD. Brochures to be distributed amongst attendants/relatives and patients who attended the Emergency Department for an exacerbation or issue related to chronic disease, such as COPD, diabetes and heart disease.
- Staffing as per the change management demand. Like chronic disease clinicians, for measuring the general profile like each participant’s weight, Body Mass Index (BMI) blood pressure (BP) and blood glucose levels. Appointment of staff who could educate the patients depending on their results.
- To ensure continuity of care and regular follow ups, work process in place where the test results are being sent to GPs and other specialists.
- Implementation of group education sessions on a wide range of topics relevant to chronic disease management and prevention in view of self-management and care.
Implementation sites
Gosford Hospital (Central Coast Local Health District CCLHD)
Results
The clinic will see some reasonable number of participants every month with some regular monthly visitors while others could be every 2-3 months as “check-in’ patients. Though some changes will be small in terms of weight loss management and other life style changes, yet they are a positive step for chronic disease management.
Data which can be collected from patients include:
- average weight loss, for management of patients with obesity
- average BMI reduction, for obese patients
- systolic BP reduced, to monitor patients with cardiovascular problems
- diastolic BP reduced, to monitor patients with cardiovascular problems
There are several changes and steps involved to bring desirable level of change in any organization. There are many challenges involved and to become a change management vanguard a multipronged approach is required.
Evaluation
One of the key steps of any change management plan is evaluation. There should be processes and mechanisms in place to identify if the change is having the intended impact. This ensures continuous quality improvement informs ongoing implementation of the change. Plan-Do-Study-Act (PDSA) cycle should be used to implement and spread the desired change. By using PDSA cycle the change can be tested by planning, trying, observing the results and hence acting on what was the outcome and if the change implementation needs a broader implementation scale or not.
Managing and monitoring the change process:
The purpose of monitoring this change will be:
- To ensure the desired change will result in an improvement.
- To decide on one proposed change methodology which could bring about improvement.
- To decide if the proposed change will work in the actual environment.
- To evaluate costs along with social impacts of the change.
- To evaluate the level of resistance and how could it be minimized.
- Tracking the progress of change against the main objectives.
- Regular meetings with key stake holders to discuss and make decisions, develop referral pathways within and across different divisions, foster working relationships and have common agreements.
- Strengthening inter-organization networks. Better understanding of the roles, values and impacts of cross-divisional engagement for prevention and integrated care.
- Rigorous evaluation of prevention initiatives thorough research models.
- Build processes which would increase focus on primary prevention, invest in primary prevention schemes. Provision of funding to include healthy lifestyle activities particularly for children. Actively encourage the healthcare facilities through legislation that promotes healthy living through regulations of food products reformulation.
- Adoption and promotion of national health risk assessment systems which would attribute health value and cost to specific activities and habits which would then be used to communicate health risk.
Barriers/Resistance
| Barriers to the Change and Potential Solutions | |
| Factors Inhibiting Change | Solutions |
| Lack of Leadership Support | Active communication and facilitation with peer groups who have been successful in deploying change methodologies.
Compulsory training around “change management” for the groups who can be key stake holders for this and any change in the organization. |
| Resistance from Staff | Stakeholder analysis. Have regular team meetings and use a team-based problem-solving approach. |
| Hesitancy to Invest Time and Money | Collect sound data based on costs associated with re-admissions of patients with chronic conditions and cost the hospital incurs with increased length of stays, increased sources etc. Create a business case around the data to give a clearer picture. |
| Workforce shortage for leading the change initiative | Active recruitment around different project requirements. Mentoring of the skilled staff for immediate outcomes. |
| Lack of communication | Develop a proper communication plan. Use intranet and other channels to increase awareness amongst the staff. |
| Lack of Accountability | Organizational structures and position descriptions should link the projects and performances with overall performance reviews and strategies. |
Sustainability and Innovation:
For reinforcement of management systems health care systems usually struggle to understand the initial basic steps in standardizing work processes at different levels. There is always a need to start with the existing work standards, testing small level tests at unit level and then setting the grounds for broader changes which eventually leads to a sustained improvement.
Goals alignment: Managers and clinical leaders of all the divisions should be aware of the expectations from them and how can they benefit the organization and sustain the change through their work.
Management “hygiene.” Ensure that the areas where change management has to take place should have good management practices already in place. A division who is already under chaotic environment and has unstable staff schedules etc., will have difficulty in implementing the changes required for promotion of sustainability and standard work practices.
Engagement: To sustain the change, the division should have a leader or management which can build staff confidence and can buy in staff’s confidence and excitement, a leader who can encourage his team’s participation through proper coaching. The unit should have a respected local champion who can build excitement for change, encourage participation, coach the team, and celebrate success
For successful management and sustain change, the organization should build the required change in its standardized work processes. In absence of clearly defined and standardized work practices in the daily operations of the front line leaders either the system will revert to the original process or the administrators feel obliged to get into the routine supervision of the unit. Such cases of micromanagement cause resentment of the required change which diminishes the possibility that it will sustain.
Use of early wins to build and boost momentum: Monitoring of short term goals with simple metrics will help motivate the staff and boost their motivation. For sustainability of any change management initial simple set targets with guaranteed positive outcomes will help build the momentum of the team. If in early stages the pilot units are asked to achieve complex goals may demoralize the staff and could even set them up for negative results or failures. Early wins definitely build team’s momentum and boost their energy to aim for better.
Motivation of frontline clinical managers: For standardizing work for managers the key is to motivate the managers themselves. No matter how well the role of each manager is defined if managers haven’t themselves bought into the change, the system can’t work.
Clinical managers always welcome clinical improvements, especially the ones which would benefit their patients. For sustainability of the change, the issues which create daily hassles need to be eliminated first. This will reduce daily chaos and improve the confusion by streamlining the operations and workflows. This will increase the frontline managers’ confidence in the desired change and belief in the improvement strategies. From there the managers will have built momentum to tackle many other problems.
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