Engagement: it’s all about the how of implementation
P. James A. Ruiter, MD
Implementation of initiatives is a challenge — change always is. But understanding the current context, in both engagement and safety, reveals some important insights into an approach for successful implementation of patient safety initiatives. In this third and final article of a series, I present a way forward, based on work with over 300 health care teams using the moreOB program approach.
In parts 11 and 22 of this series, we made the case that, to effect meaningful and sustainable improvement in the quality and safety of health care, it is essential to re-engage front-line staff. However, physicians and front-line staff need to know that their input is valued and that, when they do engage, their reward for doing so is timely, relevant, and needed change.3,4
Accordingly, ownership is required, not buy-in.1 The front-line team must help identify the problem, own the problem, develop an effective solution, and implement it. Leadership’s role is to build the infrastructure and provide the capacity to support the approach. Leaders become the enablers of the process.5Top
Developing front-line ownership to support the implementation of projects requires leveraging those who understand how the work is actually done and can, therefore, best project how any change will impact them within a complex and adaptive system.1,3,5-8 There is little doubt that an ownership-focused approach needs guidance, nurturing, support, and time. However, once established, the unit flourishes and transforms from reactive to proactive.9 This investment is what Gardam calls “going slow to go fast” (M. Gardam, personal communication, 2018).
In our experience, successful engagement requires the leadership of a small representative interprofessional group from the unit.10,11 This core team is the driving engine of successful change.7 It must represent every professional group in the given unit. Its role is to select and prioritize relevant improvement projects, develop interventions, and manage their roll out. This “engine” may not, at least initially, feel comfortable in this role and it is fragile: it must be nurtured and empowered.
To effectively implement change, the core team needs to be unranked, a heterarchy, which is visibly supported by the formal organizational leadership.7 Such nurturing is not a traditional role for leadership, but without it, meaningful and creative improvements that really work in the specific context of the unit will be stifled.12 Support can only occur following organizational alignment. Although the capability of the core team is important, only the organization can provide the capacity for the team to exercise its newfound capability. Without organizational alignment, leadership, both at the meso and macro levels, will not support the core team or its recommendations, and lack of engagement will persist. Finally, a key requirement for the team to thrive is progressive movement toward the establishment of a psychologically safe unit, one where people are not hindered by interpersonal fear.13Top
It is important to enable the core team to experience success quickly. Early quick wins built into implementation plans will rally the rest of the department and encourage the core team to continue its work. Although continuity is valuable, turnover on the core team is also important to prevent its burnout, allow for fresh ideas to germinate, and prevent the formation of a new hierarchy.
Although traditional department leaders may not be the best choice to lead the core team, they need to be present to facilitate realizing the identified changes. Ideally, the core team should be led by front-line staff and include balanced representation of the professions that make up the unit. As such, having interprofessional co-chairs is optimal.
Re-integration of safety into quality
The team must work on a relevant intervention meaningful to the majority of the unit, and not seen as directed from the top down. This helps develop ownership and addresses the ever-important question: what’s in it for me? The intervention should be built on a robust continuous quality improvement (CQI) framework, one that helps make the improvements “sticky.” It also offers the opportunity to re-marry safety with quality.1,11 The use of a robust CQI framework makes sure that every part of the intervention has a deliberate purpose in achieving the chosen goal within a human-centred work environment, one that understands and supports how people learn, unlearn, and apply.
The initial focus of the core team should be on closing the unit’s perceived quality gaps. Focusing on perceived gaps helps ensure the relevance of the project to most. It allows for quick wins, and develops comfort and skill in the core team’s growing capabilities. As the core team matures, structures must be put in place to help identify the unit’s un-perceived gaps. This approach is proactive and adds to a positive culture, which further supports the re-engaging of staff. Of note, none of these activities is a reaction to harm events; as a result, most of the improvement in the quality of care occurs within a positive context.2Top
Key elements of a robust CQI framework
It is a given that psychological safety is being built while the process described is being developed, and that every activity is interprofessional.
1. What have we learned that may be important for our unit/department to work on? What is the gap?
2. Is the gap relevant to our unit/department, population served? Endeavours that are not relevant to the unit or wider team should be abandoned. If they are relevant: what would success look like? In other words, what are we trying to achieve? How much? By when? What are the measures?
It is important to find measures that speak to the unit and are likely to improve sooner rather than later. They become the reward for engagement; these are leading indicators — pulse points or vital signs.14,15 Avoid overabundance: one or two measures per project are fine. This will help avoid data glut.1
3. An intervention, led by the core team to close the gap, needs to be built and executed. To be successful and support the process as well as the way humans learn and unlearn, three fundamental elements are required:
What individual learning activities must be completed by each member of the larger team — as base knowledge — to begin to close the identified gap? Identifying these allows all staff to begin a discussion on application of knowledge within their unique context with the same evidence in mind.
Although a common knowledge base is necessary, it is not sufficient: the translation and application of knowledge to practice within a unit’s unique context must occur. This is a “contact sport.”16 For knowledge to be applied successfully in a complex system (which requires an approach agreed on by all professions), it must be processed through an interprofessional venue6 — unit-wide workshops or in-situ simulations — designed to question and challenge the status quo.17 Knowledge must be assessed through the lens of every profession in the unit for it to be applied in the most effective way in that unit’s context. As a result, the interprofessional venues are not lectures, but case discussions that challenge the unit to discover how best to apply the knowledge in the unit’s unique setting. This is how robust solutions and harmonization of care occur: the re-integration of safety into quality.
Finally, as humans will revert to older ways through habit, a reminder-process with a view to sustainability of the new must be integrated into the intervention. When the core team moves on to its next project, what has been left in place to act as a reminder to embed the newly agreed-to knowledge in the fibre of the unit?
4. Reflection then occurs: analysis of the success and challenges in achieving the measures and going through the change process. An understanding of what worked well, and what did not, makes the core team more and more effective and efficient as it tackles new projects. This is the fast part of Gardam’s phrase, “go slow to go fast.” Top
At least one or two of the recom-mendations that come out of the interventions, that are relatively easy to implement, and that have tangible impact should be initiated and communicated quickly. This visible action helps reverse the trend of disengagement and builds evidence that the front-line’s voice is valued.4
Experience suggests that if some recommendations gleaned from interprofessional venues cannot be enacted within 2–3 weeks, it is probably better not to start — the organization is simply not ready. “You only have one opportunity to make a good first impression.” If the core team fails on launch by not creating meaningful change as perceived by the unit, engagement will be the victim. Disrupting traditional processes and applying recommendations swiftly to see tangible benefits is critical in making the core team, and the process, successful.7,18
Remedies to linear thinking
In-situ simulations (an example of an effective interprofessional venue) can act as remedies to linear thinking.7 They offer an opportunity to stress organizational processes and their safety boundaries.18 They foster an awareness of the interdependencies among professionals that is essential to robust successful quality improvement efforts supporting a resilient organization.19 The perspective of each profession is important in finding the local solution to the local problem; every profession seeing the problem through their unique lens facilitates creative, comprehensive, and durable solutions that reduce the organization’s vulnerability.3,20 Furthermore, the activity can function to build trust and develop the interprofessional team culture.13Top
Reconciling WAP with WAD2
It is in the interprofessional team-based venues that one begins to reconcile work as prescribed (WAP) with work as done (WAD). True psychological safety must be established to encourage the small voice in the back of the room to state: It is all well and good that our policy says X, but we had Mrs. Smith here last week, and we did Y. These moments are key to understanding how to learn from the way work is actually done.18 When research evidence is placed in tension with the health care workers’ experiences, it leads the team to accept a social proof and develop a unit-based harmonized approach: evidence-based practice. Quality and safety are reunited so that the solution fits as well as possible into the unique context of that unit.6 These opportunities need to be anticipated, nurtured, and facilitated for true relevant change to be accelerated. Top
Quality can be spread, safety is local1
Solutions in complex adaptive systems2 do not travel well between contexts.14 This explains why system-wide standardization attempts can fail. Although quality per se (the evidence) can be seen as “universal” and, therefore, is transferable, safety (or the application of the evidence) is site specific. As a result, some solutions just cannot be standardized, and health care teams implicitly know this. The willingness of all levels of leadership to visibly support and facilitate modification of processes to take into account local context is another win for culture, engagement, and safe quality care.4
In the CQI-based approach, nothing is done by chance; everything is part of a deliberate plan led by the core team and communicated clearly. A simulation done on the unit or a series of interprofessional workshops are not tasks done by rote on a schedule, but an integral part of a quality improvement project specifically designed to arrive at tangible results. These results include the narrowing of team-selected gaps that matter to the unit. Everyone will know the why of any activity and how it relates to improvements on the unit. The path to success is easy to follow and visible to all stakeholders who want to know (always begin by working with those who want to work with you). Top
Guidance may be needed
Although the above elements are necessary, they may not be sufficient. Many core teams benefit from a coach who understands complexity science, high reliability organizations, organizational and behavioural psychology, resilience engineering, and the importance that relationships play in complex adaptive systems.2,7 A partnership is established between the coach and the core team, who understand their own context, culture, community, geography, physical plant, etc.7 After developing an implementation plan together with the core team, the coach keeps the team accountable to the timelines it has set for itself.
Furthermore, the coach guides the core team against using a poor solution for a problem, such as using a tool created for a complicated system but ill-suited to a complex one. The use of inappropriate tools leads to front-line fatigue, disinterest, disengagement, and continuation of work as done.2 Combining the coach’s expertise with current safety and quality improvement techniques, along with the core team’s local context knowledge, experience, and skill, helps core teams successfully navigate their unit’s patient safety journeys.
In our experience, we find that engaging an external coach, who is not an employee of the hospital, is a strength and allows the coach to help the core team identify and remove barriers to success. Top
Evaluate to improve
The importance of evaluating the process of change by the rest of the department cannot be overstated. Measuring engagement of the larger team, in the intervention designed by the core team, is itself a leading indicator of movement toward a culture of patient safety by design and of successfully embedding a powerful implementation engine that can then be leveraged for other projects. In this way, a powerful and robust process that respects how humans change and learn is developed, leading to a new culture by design; this, in turn, provides leverage for the front line to lead systemic changes necessary to advance safe quality care.
A final powerful approach to consider on your journey is the deliberate implementation of routine debriefing of normal cases. In health care we often debrief the bad, as we should. However, debriefing the good allows us to better understand how and why we managed to succeed, allowing us the opportunity to improve processes to recreate the good more often (again psychological safety is necessary for the unit team to be open in disclosing what work as done truly looks like).13 It also allows teams to remedy small system glitches (and other un-perceived gaps) that may have been identified along the pathway of care, but never led to harm.
Furthermore, debriefing the good changes the safety and quality conversation. In hospitals that only debrief the bad, quality improvement occurs infrequently as a reaction to a negative outcome.2 As a result, improvement occurs episodically and predominantly within a negative context. Debriefing when cases go well builds an increasingly positive culture.
What can physicians do?
Safety science has evolved to what is now known as its third era, while health care’s approach to safety is, in many ways, firmly entrenched in the first era described by Heinrich in the 1940s and 1950s19 — safety processes developed for systems that do not even come close to resemble the complexity of health care today. It is time to move forward, and physicians can, and should, play a leading role, no longer accepting out-dated approaches to develop improvements in quality and safety.
This series has looked at why, in general terms, the status quo is not working and is only serving to disengage the very people who are holding the system together. The status quo is neither supporting our colleagues, nor those we serve. Physicians can, and should, lead the prescription for change. Top
The approach presented in this article is not considered as an integral part of typical work for most professionals. However, it is clear that it needs to become so. Physicians are leaders in our health care system, and their involvement is integral as they invest in system improvements that improve quality of life at work and the quality of care their patients receive. The process described speaks of interprofessional work, a sine qua non for best outcome. It is about “going slow to go fast.”
It is clear... that the next great saving in lives (human life of those we serve and the professional lives of our colleagues) will not come from a new instrument or a new pill but from a well-executed, proven, effective, and reproducible patient safety approach that seeks to place safety into the DNA of our health care teams.21
As physicians invest in change — and in developing a culture by design — they mold the change. They can choose to be on the sidelines and be buyers of change created by others, and never find true joy at work — or they can be investors and own the change. At the end of the day: If not we, then who? Top
Engagement is all about the how of implementation. Leveraging ownership requires a complete understanding of what created the disengagement we all witness today. If it sounds like this series describes the growth of psychological safety and of a culture to bring about successful engagement and implementation of safety initiatives that matter to the front line, then our purpose has been successful. Safety is all about that culture.13,22 I have presented a process based on experience and an understanding of health care and safety today from the perspective of a complex adaptive system to lead units to that culture by design. Complex systems are not built; they are grown, tweaked over years from their very unique context, to a point where they just work, and their performance is inextricably linked to culture.7 For too long, safety in health care organizations has been managed as in a complicated system: by restricting humans in the activities they perform. In many ways, this has led to disengagement. It is time we recognize that while parts of health care are indeed simple and some are complicated, the largest components are complex and adaptive. If we are to see major movement in safety and quality, it is those who do the adapting that must be leveraged to make it happen — the human as the resource — in balance with the human as the liability.
Systemic change will occur from the ground up, as leaders allow the process to occur. As relevant change begins to occur, it will rebuild the engagement of our workforce to bring about renewed successes in patient safety. We need to work with our complex system, not against it. Every one of us plays a central role in the evolution of that realization. Top
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5.Carney B, Getz I. Give your team the freedom to do the work they think matters most. Harv Bus Rev 2018;10 Sept. https://tinyurl.com/ya6jcopb
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8.Geary M, Ruiter PJA, Yasseen III AS. Examining the effects of an obstetrics interprofessional programme on reductions to reportable events and their related costs. J Interprof Care 2018. DOI: 10.1080/13561820.2018.1543255
9.Ruiter PJA, Cameron C. Birth models that nurture cooperation between professionals: pizza and other keys to disarmament. In, Daviss BA, Davis-Floyd R, editors. Speaking truth to power: childbirth models on the human rights frontier. London: Routledge; 2019 (in press).
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11.Burke C, Grobman W, Miller D. Interdisciplinary collaboration to maintain a culture of safety in a labor and delivery setting. J Perinat Neonat Nurs 2013;27(2):113-23. DOI: 10.1097/JPN.0b013e31828cbb2a
12.Kim SH, Weaver SJ, Rosen MA. Managing creativity and compliance in the pursuit of patient safety. BMC Health Serv Res 2019;19(1):116. DOI: 10.1186/s12913-019-3935-2
13.Edmondson A. The fearless organization: creating psychological safety in the workplace for learning, innovation, and growth. Hoboken, N.J.: John Wiley & Sons; 2019.
18.Ruiter PJ. In-situ simulation - a practical guide: reflections on low-tech simulation after 17 years of MOREOB. Unpublished; 2018.
19.Martinetti A, Chatzimichailidou MM, Maida L, van Dongen L. Safety I-II, resilience and antifragility engineering: a debate explained through an accident occurring on a mobile elevating work platform. Int J Occup Saf Ergon 2019;25(1):66-75. DOI: 10.1080/10803548.2018.1444724
20.Leykum L, Kumar P, Parchman M, McDaniel RR, Lanham H, Agar M. Use of an agent-based model to understand clinical systems. J Artif Soc Soc Simul 2012;15(3). DOI: 10.18564/jasss.1905
21.Ruiter J. Patient safety series, a comment. Am J Obstet Gynecol 2011;205(4)e10. DOI: 10.1016/j.ajog.2011.05.034
22.National Patient Safety Foundation. Free from harm: accelerating patient safety improvement fifteen years after to err is human. Boston: National Patient Safety Foundation; 2015. Top
P. James A. Ruiter, BMSc, MD, MCFP, is medical director and vice president at Salus Global Corporation, which helps health care organizations achieve better clinical, economic, and operational outcomes through its interprofessional patient safety and quality improvement programs. Dr. Ruiter is also on the knowledge translation and implementation science faculty at the Canadian Patient Safety Institute and, since 2009, has chaired the Obstetrical Content Review Committee of the Society of Obstetricians and Gynaecologists of Canada.
Because of its focus, the Salus Global Corporation is not considered a commercial interest under Accreditation Council for Continuing Medical Education standards. It is owned by the Society of Obstetricians and Gynaecologists of Canada, the Healthcare Insurance Reciprocal of Canada, and the Canadian Medical Protective Association.