Using the head, heart, and hands to manage change in clinical quality improvement in the time of COVID-19
Year: 2021
Type: article
Abstract: There are numerous challenges to implementing successful and sustainable quality improvement (QI) interventions that enhance healthcare outcomes [1]. A widely used approach is the Model for Improvement’s three steps: (i) the aim of the intervention, (ii) measurement methods used, and (iii) how changes are implemented [2]. While all three considerations are important, the success and sustainability of QI interventions often come down to implementation strategies and the human aspects of managing change. In this time of unprecedented challenge in healthcare with the coronavirus disease 2019 (COVID-19) pandemic, implementation strategies that integrate technical approaches to QI with attention to the human aspects of change are especially relevant. The case of Ignaz Semmelweis highlights lessons in managing implementation of QI interventions, even if the terminology of QI had not yet been developed then. Semmelweis (1818–1865), a Hungarian physician, noted a high incidence of maternal deaths due to postpartum sepsis in Vienna in the 1840s [3]. He collected and analyzed data at two maternity wards in his hospital—one staffed by medical students and the other staffed by midwives—and discovered that maternal mortality from postpartum sepsis in the ward staffed by medical students was three times higher than that in the ward staffed by midwives [3]. Since medical students dissected cadavers and midwives did not, he concluded that the causative factor was a substance in cadavers transmitted on students’ hands [3]. Semmelweis instructed students to wash their hands and surgical instruments with a chlorinated lime solution and demonstrated a significant decline in deaths from maternal postpartum sepsis from 18% to 2% in a 2-month period [4, 5]. Although the correlation between Semmelweis’ intervention and its outcome was undeniable, handwashing was not adopted as standard practice. Physicians perceived his messaging as blaming them for being the root cause of sepsis. Semmelweis was ridiculed by his colleagues, dismissed from his job, and died in a mental hospital at the age of 47 years, ironically of sepsis [3]. Handwashing with chlorinated lime was discontinued and rates of postpartum sepsis increased [4, 5]. Semmelweis’ experience provides lessons to QI practitioners as they implement policies and programs, including those with strong evidence, today. Managing change requires paying attention to three factors: The Head, Heart, and Hands (Figure 1). The ‘Head’ refers to rational aspects of human behavior—promoting evidence-based clinical care, providing high-quality data, anticipating and planning for resistance, and adapting implementation strategies on new learning and insights [1, 6]. Strategies to engage the Head involve communicating the need and urgency for change and the consequences of not changing, demonstrating ways to solve the problem, and making a clear evidence-based link between the improvement intervention and organizational success [2]. Listening to those on the frontlines of clinical care to understand problems and processes and forming a QI team that includes frontline clinicians and individuals with skills in data analysis and communication is critical [6–8]. Three strategies to manage change in clinical QI. The ‘Heart’ refers to human and emotional aspects of change. This involves invoking intrinsic motivation, personal goals, and clinicians’ values of altruism and humanism [9]. It is critical to accurately understand the root cause of objections. For example, although people may voice publicly acceptable reasons such as cost or lack of time, their real concern may be fear of loss of autonomy or of influence. Engaging the Heart involves building trust and developing a climate of psychological safety where dissenters are not intimidated, derided, or silenced [10]. Communication strategies to engage the Heart are bold, aspirational, and urgent messages and use patient and clinician stories to demonstrate the benefits of the innovation and the consequences of not changing. Public recognition and celebration of accomplishments and providing positive and ongoing feedback, especially to early adopters, maintains the momentum as do addressing the concerns of dissenters and promoting structural and institutional culture that facilitates uptake of new policies. The ‘Hands’ refers to employing rigorous QI methodology, identifying clinical champions, and gathering a critical mass of supporters [2]. Communication strategies include clarifying how the future state is better than the current state, conveying a clear link between proposed interventions and the future state, tracking progress, making early wins visible, and frequently communicating results through easy-to-understand data visualization. Sustainability plans should include continuing efforts to hardwire behavior and track outcomes and involve a multidisciplinary QI team with frontline clinicians [6, 8, 9]. Including clinicians and patients meaningfully on QI teams and providing them with training, support, and time help harness knowledge from the frontlines that may otherwise have been lost [7, 9]. Semmelweis’ case highlights several issues with the implementation of his QI intervention [1, 3–5]. Regarding the ‘Head’, Semmelweis was unable to provide scientific evidence to counter the thinking that illness was caused by an imbalance of humors and miasma. He published a dense and opinionated book on his findings, which was a difficult read for his target audience. Semmelweis erred in matters of the ‘Heart’ by using an authoritarian and coercive management and communication style that was common at the time (and still exists) that alienated his audience and fostered resentment. Regarding the ‘Hands’, instead of identifying and engaging clinical champions and gathering a critical mass of early supporters, Semmelweis focused on forcing the unconvinced to embrace his innovation. He did not plan for resistance and his efforts were therefore thwarted by vocal resistors. Several factors facilitate change management in QI. Reflecting on these lessons from medical history demonstrates how attention to matters of the ‘Head’, ‘Heart’ and ‘Hands’ can accelerate adoption of change, optimize the use of resources, and maximize the impact and sustainability of QI interventions during this time of rapid innovation to meet the challenges of the COVID-19 pandemic. An example of this in the current environment is the success attained in decreasing transmission of COVID-19 among healthcare workers by (i) gathering the evidence behind personal protective equipment (PPE) and vaccination and paying attention to tracking and sharing data (Head); (ii) paying attention to communication around COVID-19 transmission, PPE shortages, physical distancing, and mass vaccination efforts (Heart); and (iii) standardizing workflows, staff training, and clinical decision support that incorporates the use of PPE, daily huddles, and telemedicine (Hands) [11, 12]. Within this framework, supportive leadership and an organizational culture of quality help ensure that these changes are sustained [8]. Ulfat Shaikh: 6506005372 The authors confirm that the data and references supporting their conclusions are available within the article. None declared.
Source: IJQHC Communications
Authors: Ulfat Shaikh, Peter Lachman
Language: English
Subfield: General Health Professions
Field: Health Professions
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $2,160
OpenAlex ID: W3192990020