About the Clinical Innovation Agency Dept of Human Services, Victoria

1. Enter toolkit About the Clinical Innovation Agency Dept of Human Services, Victoria About the Patient Flow Collaborative Acknowledgements

2. Acknowledgements Introduction Dr Jenny Bartlett Chief Clinical Advisor Project Director Patient Flow Collaborative Department of Human Services, Victoria Ruth Smith Acting Manager Clinical Innovation Agency Department of Human Services, Victoria Dr Marcus Kennedy Clinical Lead Patient Flow Collaborative Department of Human Services, Victoria Kim Moyes Planning Group Member Patient Flow Collaborative Rochelle Condon Improvement Lead Patient Flow Collaborative Department of Human Services, Victoria Fiona Dickson Improvement Lead Patient Flow Collaborative Department of Human Services, Victoria John T Walker Communications and Logistics Lead Clinical Innovation Agency Department of Human Services, Victoria Toolkit goals Overview and strategy Health service teams Leadership Change concepts Diagnostics and tools Resources Home

3. Introduction Introduction Who should use the toolkit? The toolkit will promote discussion and innovative solutions to support sustainability of initiatives undertaken in the PFC. Anyone with responsibility for managing patient care, units and departments will benefit from this tool. How should the concepts be implemented from this toolkit? Local Patient Flow Collaborative teams should discuss tools and concepts, adapting these to their local context. How to navigate through the toolkit. Use the menu on the left side to select information areas on sustainability. For sections with multiple pages, hit the “click to continue” button located at the bottom right of screen. What is the patient flow sustainability toolkit for? This sustainability toolkit has been designed for teams working to improve patient care throughout the patient journey. The toolkit provides a sustainability framework, risk screen and self assessment tool, additional reading material and key contact information. What are the aims of the toolkit? The Patient Flow Collaborative (PFC) aims to improve patient flow throughout the whole system by eliminating key bottlenecks identified by each health service. It is recognised that the successful innovations developed during the PFC will need to be sustained and become mainstream for organisations to continue to deliver timely and safe treatment for all the patients accessing the health care system. Toolkit goals Overview and strategy Health service teams Leadership Change concepts Diagnostics and tools Resources Home Page 1 of 1

4. Toolkit goals Introduction Strategies that will facilitate your sustainability initiative include: • maintaining the innovation/change concept • eliminating dual pathways • defining and building on accountability • providing sufficient support to managers and clinicians leading the initiative. The sustainability of patient flow innovations ensures improved patient care by providing timely access to services through the elimination of unnecessary delays in the patient journey. Your feedback Feedback on this version of the Patient Flow Collaborative Sustainability toolkit is welcome and will be used to update future versions. Click here to provide your feedback Introduction The toolkit has been produced as part of the Patient Flow Collaborative and is designed to assist with sustaining innovation in patient flow. Goals Key elements to sustaining patient flow innovations are: • effective management • good communication • planning for relapse • managing resistance • ongoing measurement • making innovation mainstream. Toolkit goals Overview and strategy Health service teams Leadership Change concepts Diagnostics and tools Resources Home Page 1 of 1

5. Overview and strategy Introduction How do we plan sustainability? Planning for sustainability should occur from the outset of any change initiative. Predicting barriers to the change and engaging key stakeholders are essential elements of this, as is streamlining processes and having clear lines of responsibility for tasks. Activities to assist with planning sustainability can be found in the Diagnostics and toolssection of this toolkit. What is meant by making it mainstream? An innovation can be considered part of the ‘mainstream’ when responsibility for the monitoring and maintenance has been allocated, resources have been assigned and the organisation accepts the improvement as the standard to meet. Once mainstreamed, the innovation deserves recognition and celebration to acknowledge the improved way of working. • What is sustainability? • Sustainability in this context can be described as an innovation in patient flow that has been made and does not change over time. In addition the innovation has been effectively adopted in the attitudes, culture, working practice and daily working lives of staff. • How is sustainability different to spread? • The terms spread and sustainability are often used together when discussing health care innovation, however they are quite different. • For example: • • Sustainability of the initial innovation/change concept overtime is desired, this is transferred or spread to another process, environment or clinical area. • Spread of the initial innovation/change concept may be desired but may need significant adaptation to be adopted across difference processes, environment, clinical areas or organisationally. Toolkit goals Overview and strategy Health service teams Leadership Change concepts Diagnostics and tools Resources Home Click to continue Page 1 of 13

6. Overview and strategy Elements of a sustainability model Introduction Eliminating dual pathways Maintenance of the innovation/change concept for a sufficient time Toolkit goals Managing resistance Overview and strategy Building in accountability Health service teams Planning for relapse Leadership Sufficient support to line managers and clinical leaders Scalability Change concepts Ongoing measurement Diagnostics and tools Celebration Making it mainstream Resources Home Click to continue Page 2 of 13

7. Strategy Scalability As we go through the plan-do-study-act process, starting with small samples, moving into larger involvement we start to identify how to scale up the innovation/change concept. Key features for successful scale up of innovation include: Introduction Toolkit goals • peer to peer discussion and involvement; doctor to doctor, nurse to nurse, pharmacist to pharmacist • innovation/change concept is low in complexity and practical in application and does not increase in detail (commonly described as making life easier) • scale up has been part of initial planning. Overview and strategy Scalability Health service teams An example is Box Hill Hospital’s creation of a traffic light system, prioritising the provision of daily discharge medications to the specified patients. The successful trial of this specific change concept allows for the trial to be expanded across the organisation (scaled up). Leadership Change concepts Warning! As the detail and complexity of your improvements increase, potential for scalability decreases. So remember to keep it simple, steady and supervised. Flexibility to adopt the innovation is beneficial while keeping to the original elements/themes of the concept. Diagnostics and tools Resources Home Click to continue Page 3 of 13

8. Strategy • Planning for relapse • Relapse or reverting to the ‘old ways’ of working is a natural part of human behaviour. Some key elements that may contribute to this phenomenon include: • failure to plan for the relapse • decrease in accountability and monitoring • underlying premise of change did not hold up over time • compliance was not factored into assessment/reward systems • system allowed ‘two roads’ dual pathways • poor example from leaders • removal of barriers to change was temporary • low personal confidence in ability to maintain change • inadequate training and mentoring • lack of value and praise in how change has improved patient care • lack of support while staff are in discomfort of change. Introduction Toolkit goals Planning for relapse Overview and strategy Health service teams Leadership As people experience the discomfort of change it is easy to return to the comfort of the previous process/system. To sustain innovation, support and attention will need to be given to behaviours, attitudes, processes and systems. Relapse to the previous way of working is natural and should be dealt with sensitively. Change concepts • allocating time and effort during the change process to normalise, predict and plan for relapse • attempting to eliminate alternative pathways • rewarding compliance to the new way of working Be prepared - plan for the relapse phase by: • team leaders setting good examples • monitoring barriers to change • being serious about accountability and responsibility • honestly reviewing the original premises for change. Diagnostics and tools Resources Home Click to continue Page 4 of 13

9. Strategy Managing resistance Just as there may be some resistance when you started implementing changes in your organisation, we also know that resistance can in fact increase during the maintenance phase. Therefore, managing resistance is crucial when planning for successful sustainability and the move to mainstream. Introduction Managing resistance Toolkit goals Overview and strategy • Remember that: • resistance can take many forms • working with resistance is not about ‘proving you’re right’ • focusing on solutions is the most productive way of moving forward • resistance is often only a reflection of where the particular individual or group is on the journey of change. Health service teams Leadership Change concepts Overcoming resistance always requires listening The key skills in dealing with resistance begin with active listening. Active listening involves asking open ended questions, reflecting back to the person what you have been told, using short summaries and acknowledging emotions. Responding to all resistance in all forms may lead to even better innovation ideas. Diagnostics and tools Resources Home Click to continue Page 5 of 13

10. Strategy Positive challenging Empathise with the paradox “It must be difficult trying to care for your patient, on the one hand you believe X and yet you also feel Y” Explore barriers and create ownership “What would you do to change this situation for all our patients?” Introduction Managing resistance Toolkit goals Overview and strategy Explore ambivalence “What would be the advantages of changing? What would be the disadvantages?” Health service teams Over-agree “So there is no possible way you could follow through on this program, even though there is so much potential harm to our patients not accessing or departing from the system when they need to?” Solution focus “What would the change look like to overcome this issue?” Leadership Change concepts • Strategies for working with people who do not want to change patient care • seek detailed explanation of concerns • empathise with the difficulties they have • seek suggestions to how things can be improved • place clear and accountable boundaries • do not place boundaries that you are unable or unwilling to enforce • agree on a timeframe for review. Diagnostics and tools Resources Home Click to continue Page 6 of 13

11. Strategy Eliminating dual pathways When sustaining change it is important to remove all alternative or dual pathways to the new way of working. This will give a true reflection of the benefits of the change and help to achieve compliance. Introduction Eliminating dual pathways Toolkit goals Overview and strategy If dual pathways exist people will be tempted to revert to the ‘old ways’ of working especially at times of adversity (such as times of stress or emergency) despite knowing the beneficial aspects of the change. If the temptation is removed, the patient will always benefit regardless of the work environment. Health service teams Leadership • When removing dual pathways remember the following: • inform key stakeholders that alternative methods or ‘old methods’ of working are no longer acceptable • communicate why the change has occurred • educate staff about the improved ‘new way’ of working • reward compliance • promote the benefits of the innovation for the patient • provide opportunities to discuss concerns, anxiety or stress of adherence to the new way of working. Change concepts Diagnostics and tools Resources Home Click to continue Page 7 of 13

12. Strategy Maintenance of the change concept/innovation for a sufficient time When sustaining change it is important to give the process time to become mainstream or the ‘standard way’ of working. Ultimately during the change process you want the change/innovation to transition from the ‘new way’ to ‘the norm’ and this takes time. The timescale to become the ‘norm’ will depend on implementation, size of change, how often the new way of working is used in normal daily tasks and training for staff change overs. Introduction Maintenance of the innovation/change concept for a sufficient time Toolkit goals Overview and strategy Health service teams Leadership It is important not to abandon the innovation before adequate time has passed to allow for this transition. Do not automatically assume innovation failure if the transition is taking longer than expected. It may just be that unpredicted or unplanned issues are causing the delay. If the innovation is a true benefit to patient care it will become mainstream or ‘the norm’ over time. You may wish to set review dates to assist with monitoring the adoption of change. Change concepts Diagnostics and tools Resources Home Click to continue Page 8 of 13

13. Strategy Building in accountability Accountability is one of the most important factors in sustaining change. When people are made responsible for specific tasks during the sustainability phase of change, they are more likely to comply with the change itself and also encourage those around them to do the same. It is a fantastic way of creating ownership, empowering staff and building team work when ongoing system and process management is required. Introduction Building in accountability Toolkit goals Overview and strategy Health service teams If accountability for sustaining change does not exist, relapse may occur, dual pathways will develop or resurface, resistance will increase and the change concept /innovation may be in danger of failing. An example of accountability being integrated into a role and position description is the newly created Patient Flow Coordinator position at Melbourne Health. Among the varied responsibilities of this role, a chief component is to maintain the successful processes that have been developed. Leadership Change concepts • To build accountability and promote success, remember: • accountability must be clear and consistent • boundaries on the scope of accountability must be set • accountability must be enforced • accountability should be reviewed over time • praise should be given for taking active accountability. Diagnostics and tools Resources Home Click to continue Page 9 of 13

14. Strategy Sufficient support to line managers and clinical leaders In order for change to be sustained, line managers and clinical leaders heading the initiative must be supported by their peers and senior management to assist with dismantling barriers, engaging key stakeholders and financing the improvement strategies required. Introduction Toolkit goals Sufficient support to line managers and clinical leaders Overview and strategy Health service teams • If line managers and clinical leads are not supported there is a high risk of the following: • removal of barriers may only be temporary • leadership of the initiative may wilt when significant resistance is met • existing culture may sabotage the initiative • being happy with only ‘some’ success • islands of improvement. • Strategies to support managers and clinical leads • be available • listen • communicate with key stakeholders • motivate and encourage • define accountability • celebrate and promote success. Leadership Change concepts Diagnostics and tools Resources Home Click to continue Page 10 of 13

15. Strategy Ongoing measurement Ongoing measurement of a change concept will assist in maintaining focus and provide teams with information about their progress, as well as support the impetus to maintain or extend the change itself. The adage “you cannot manage what you cannot measure” is paramount when sustaining change. Introduction Toolkit goals Overview and strategy Continuing to measure the change concept and the impact on patients will allow you to intercept problems early and redesign processes to minimise any negative affect. For example, it can highlight potential or actual relapse or resistance, identify if any dual pathways exist and areas which need more planning. Ongoing measurement Health service teams • Ongoing measurement is also a powerful tool for determining the positive effects of change and can assist in highlighting success. Bendigo Health Care Group undertook development of their own program measures and statistical process control charts from very early in the collaborative and are an excellent example of sustaining success via sustained measurement. • Strategies for ongoing measurement: • The team should select one or two key measures they feel really captures the essence of what they did and what they would like to see sustained. • Build these measures into an existing system within the organisation to ensure regular and automatic reporting. • Feedback results through staff meetings and formal reports. • Any reduction in performance is to be quickly recognised and actions taken to address this by the people responsible for the system. Leadership Change concepts Diagnostics and tools Resources Home Click to continue Page 11 of 13

16. Strategy Making it mainstream When discussing giving a change concept adequate time to become ‘the norm’ we touched on the concept of moving to mainstream. Making it mainstream does not only refer to the time required to make an improvement ‘the norm’, but also takes into consideration the following issues: Introduction Toolkit goals Overview and strategy • Is this new process aligned with the values, vision and goals of the organisation? • Is it someone’s responsibility to ensure that the improvement maintains or even progresses? (Refer to building in accountability) • Has resource been allocated to support the continuation of the new way of working? • Are things set up to support the change? Making it mainstream Health service teams Leadership • Strategies to ensure the change becomes mainstream • Make sure the change features within regular reporting mechanisms of the organisation and business planning cycle. • The change should be celebrated within the annual report. • The ‘new way’ of working should be built into job roles, job descriptions and also be reflected in the performance management appraisal system. • The team which created the change could come together from time to time to review whether it has been sustained. Change concepts Diagnostics and tools Resources Home Click to continue Page 12 of 13

17. Strategy Celebration We often celebrate the initial improvement efforts, but maintaining the improvement may draw little attention. Make the effort to celebrate periodically the fact that the improvement has stayed at the target level over time. For example, “We are celebrating six months of effective bed management using the web tracker. The percentage of patients transferred to Ward B from the Emergency department in less than 6 hours is 97%” Introduction Toolkit goals Overview and strategy Celebration Health service teams Celebrating is an effective method of renewing motivation for the improvement and can act as a stimulus for aiming even higher. Leadership • Strategies to assist with celebration and target renewal • make definite plans in advance to celebrate continued success • set a new goal or aim, and try to improve even more • make it a continuous improvement effort, never really settle into simple maintenance mode • monitor weakening targets and satisfaction with progress so far • use the excitement of improvement to keep the issue in peoples mind. Change concepts Diagnostics and tools Resources Home Page 13 of 13

18. Health service team It is essential for patient flow sustainability to have a skilled, trained and committed innovation team. The team should consist of representatives of all staff groups involved in patient flow and patient/consumers. Management clinical/non clinical Nursing enrolled and registered nurses who manage patient flow Clinical medical officers who provide patient care Technical health service staff members whose services impact on patient flow eg. pharmacists and allied health staff Administration quality managers who monitor safety and organisational progress towards departmental targets Patient/consumer patient in long term care or consumer who is not presently receiving treatment Introduction Toolkit goals Overview and strategy Health service teams Leadership Change concepts Diagnostics and tools Resources Home Page 1 of 1

19. Leadership Introduction • When leading an improvement initiative through the sustainability phase it is important to avoid the following pitfalls: • having no clear leadership • trying to fix a process rather than changing it • focusing on theory of sustainability rather than processes • failing to address the people issues • doing six things at once. Toolkit goals Overview and strategy Health service teams • Tips to assist leaders to sustain improvement work • clear leadership must be established • data is king - don’t rely on anecdote • the story of why change was needed has to be told incessantly • evaluation of the improvement must involve more than one person • no mistakes mean no change • share decision making responsibilities • plan! plan! plan! Leadership Change concepts Diagnostics and tools Resources Home Page 1 of 1

20. Change concepts Introduction • Aim • To sustain patient flow improvements beyond the length of the PFC. • Change concepts • allocate time and effort during the change process to normalise, predict and plan for relapse • manage resistance via active listening • remove dual pathways • make people accountable for the sustainability of the improvement • provide support to line managers and clinical leaders sustaining the improvement work • continue to measure performance at least quarterly • make the improvements mainstream • make definite plans in advance to celebrate continued success • build a patient safety team. Toolkit goals Overview and strategy Health service teams Leadership Change concepts Diagnostics and tools Resources Home Page 1 of 1

21. Diagnostics and tools Introduction • Sustainability Risk Screen • Sustainability Assessment Tool Toolkit goals Overview and strategy Health service teams Leadership Change concepts Diagnostics and tools Resources Home Page 1 of 1

22. Resources Introduction Engaging individual staff in service improvement: How does it happen? Who should be engaged? A Discussion Paper - June 2004 The Spread of 'See and Treat' Research into Practice. Summary Report No.11 March 2004. Layers of Leadership: Hidden Influencers of healthcare improvement. Research into Practice. Report No.10. March 2004. Spreading Sustainable Improvement. Case Study Research: National Booking Programme Summary Report No.9. February 2004. Evaluation of 4th Wave 'Moving to Mainstream‘. Summary Report No.8 February 2004. No Going Back. A review of the literature on sustaining organizational change. Literature Summary. Research into Practice Report No.7 November 2003. A 'Deep Think' Day on Sustainability. Meeting Summary - report number 6. Teamworking for improvement: Planning for spread and sustainability. Summary Report No. 5 - August 2003 Spread and sustainability of service improvement: factors identified by staff leading modernisation programmes. Summary Report No. 4 - February 2003 Spreading and sustaining new practices: sharing and learning from the Cancer Services Collaborative (CSC). Summary Report No. 3 - October 2002 NBP Sustainability and Spread in the National Booking Programme. Summary Report No.2 - September 2002 From Scepticism to Support - what are the influencing factors? Summary Report No. 1 - July 2002 Toolkit goals Overview and strategy Health service teams Leadership Change concepts Diagnostics and tools Resources Home Click to continue Page 1 of 2

23. Web links Introduction Patient Flow Collaborative Clinical Innovation Agency, Department of Human Services Modernisation Agency, NHS British Medical Journal Institute for Healthcare Improvement Quality and Safety in Healthcare  Toolkit goals Overview and strategy Health service teams References Leadership ·Gollop, R. Whitby, D. Ketley, D. ‘Influencing sceptical staff to become supporters of service improvement: a qualitative study of doctors’ and managers’ views’. Quality and Safety in Health Care Journal. Vol.13 2004 ·Improvement Leaders Guide to Sustainability and Spread – NHS Modernisation Agency, UK 2002. ·Fraser, S and Greenhalgh, T. ‘Coping with complexity: educating for capability.’ British Medical Journal Vol.323 Oct 2001. ·Fraser, S. ‘Spreading good practice.’ Health Management. June 2000 ·Berwick, D. ‘A primer on leading the improvement of systems.’ British Medical Journal Vol.312 Mar 1996. Change concepts Diagnostics and tools Resources Home Page 2 of 2

24. About the Patient Flow Collaborative Introduction • The Patient Flow Collaborative is an ambitious innovation program designed to eliminate delays throughout the patient journey and to improve the quality and safety of patient care. • The Patient Flow Collaborative is designed to assist health services to systematically analyse the barriers to the flow of patients through the continuum of care. The key to the collaborative is the use of the Breakthrough series methodology, which is complimented by whole system tools and techniques, process data and complexity system theory. • The key aims of the Patient Flow Collaborative are to: • reduce unnecessary waits and delays within the continuum of care • embed innovations tools, techniques and service improvement skills in Victorian health services. • For further information: Patient Flow Collaborative Toolkit goals Overview and strategy Health service teams Leadership Change concepts Diagnostics and tools Resources Home Click to continue Page 1 of 2

25. Introduction Toolkit goals Overview and strategy Health service teams Leadership Change concepts Diagnostics and tools Resources Home Page 2 of 2

26. About the Clinical Innovation Agency, Department of Human Services, Victoria. Introduction Toolkit goals • The Clinical Innovation Agency (CIA) is delivering the Patient Flow Collaborative on behalf of the Hospital Demand Management Strategy and the Chief Clinical Advisor. • The role of the Clinical Innovation Agency is to: • lead large scale programs designed to improve patient care via the development of innovative systems • test innovations in access, safety and quality • train, embed and discover new service improvement tools and techniques. • The CIA is responsible for: • Patient Flow Collaborative • Victorian Travelling Fellowship Program • Clinical Innovation Fund • Contacts • Jenny Bartlett Ruth Smith • Chief Clinical Advisor Acting Manager, Clinical Innovations Agency • Jenny.Bartlett@dhs.vic.gov.auRuth.Smith@dhs.vic.gov.au Overview and strategy Health service teams Leadership Change concepts Diagnostics and tools Resources Home Page 1 of 1