Implementing Planned Change
Implementing Planned Change
1. Problem identification: The number of complaints from patients about the lack of quality in hospital services has increased tremendously, when compared to the last few years. The number of complaints have tripled when compared to previous years. Complaints are received in both verbal and written form on a daily basis. Patients are most affected by the lack of quality in nursing service. Staff and care providers are also agitated by the increase in the number of complaints. From the nature of complains we understand that the patient dissatisfaction exists at different levels. Some complained of having to wait for long time to see a doctor. Lack of appointments, not enough chairs in waiting room, delay in registering, waiting in long ques, rude behavior of the hospital staff, delay in health care services were most common complains.
Our Lady of the Lake Medical Center, is the largest private medical and surgical health care provider located in Baton Rouge, Louisiana. It attends to an average 3, 50,000 outpatients and 25,000 inpatients. It has 600 physicians and 2000 staff members. As Louisiana becomes culturally diverse, the hospital is now facing a new challenge of delivering a culturally appropriate health care. The hospital has only few executives who have cultural and linguistic competence. The formal organization culture at the hospital is patient centered. The hospital aims to respect, recognize and protect patients from all background and culture. The medical services provided at the hospital are data driven and every physicians is expected to deliver the best possible service to patients. We have a workforce that has a fair representation from all major ethnic and cultural background of the state. The hospital motivates it staff towards excellence, honesty, integrity, continuous improvement, efficiency, effectiveness and team work. The interaction of employees, at lunch and at the break room, suggests an egalitarian attitude among its staff in informal settings. Though staffs are expected to be rational in their approach towards patients, a few are fuzzy and emotional in adhering to rules and regulations. There is lack of fluidity and flexibility in the service provided is likely to affect patient care. The staff operate to meet set boundaries and targets. The number of people visiting the hospital has increased, tremendously. There was no simultaneous upgradation in the number of staff or hospital facilities. The problem identified in the hospital can be summarized as patient dissatisfaction, shortage of staff, facilities and technology.
As a first step in analyzing the who, when, what or how of the problem, we may need a brainstorming session with chosen members of the team. These members will be able to provide the administration with opinions and solutions, which will help to prioritize and help take right decision. This practice can also provide new ideas to solving the problem and also provide suggestions on what to avoid. Meditation on the problem at hand, can also help to focus and finalize the list of problems that cause patient dissatisfaction.
Let us consider that the hypothetical list includes the following problems:
Unavailability of appointments.
Lack of chairs in waiting room.
Delay in registering.
Waiting in long ques.
Long waiting time taken to get service.
Rude behavior of staff.
Overall dissatisfaction with the treatment.
The problems were then prioritized based on the frequency of occurrence:
Unavailability of appointments – 100/300 complaints.
Delay in registering -56/300 complaints.
Dissatisfaction with treatment -56/300 complaints
Rude behavior of staff’s -15/300 complaints.
Long waiting - 15/300 complaints.
Shortage of chairs -3/300 complaints.
2. Review of literature to identify current trends or research about problem:
Though there are many ways to implement change into the system, the best way to implement change is through purposeful, calculated and collaborative efforts. Health care is a constantly evolving enterprise, and it is necessary for the health care team to remain updated and prepared for the new challenges associated with the changing times. Implementing change is more challenging than identifying the problem. Various forces can drive change in a health care set up: financial constraints, demand for workforce, professional commitments, advances in science and technology, population characteristic, patient satisfaction, promotion of hospital reputation are all examples of factors that drive change. (Hughes, 2008)
According to Roger, change is a 5 step process. It involves awareness, interest, evaluation, trial and adoption. Lipitt divided Rogers’s steps into further sub steps. Awareness stage involves diagnosing the problem, assessing motivation and capacity for change. During the interest, evaluation and trial stage, there is progressive introduction to change objectives and personnel’s are assigned to appropriate changed roles. The final sub-step in this stage is providing help to maintain change. During the adoption stage, the guidance provided for maintain change is removed, as the change has successfully integrated into the system already. (Mitchell, 2013)
Considering the patient’s experience, is important towards providing high quality patient centered care. The affordable care act has provisions to reimburse 1% of the total medical care reimbursement to hospitals that provides high standards of patient care. Unlike in other business enterprise, patients cannot be always treated like customers in a hospitals. However providing excellent service, will ensure patient loyalty and in turn the success of hospital and doctors. Unavailability of appointment dates and waiting for long hours to get care is a result of low staff to patient ratio in the hospital and prolonged stay of previously admitted patients in the hospital.
3. The driving forces and restraining forces affecting the change situation: A SWOT analysis could be used to determine the positive forces that will support change and also identify negative forces that restrain change. The forces that restrain changes could be: budget restrictions, shortage of health care staff for recruitment, new registering technology, lack of supervisors to monitor staff behavior, lack of experience of doctors and nurses. The forces that motivate change: Need for survival, community and peer support, effective communication, community support. The nurse’s personal characters like skill, ethics, nursing care deliver and intervention, patient characters, organization, staffing, team work, group dynamics and leadership can determine the motivation for change. If the intensity of restraining forces are high, then the implementation of change will be difficult.
The first problem is to address the shortage in staff and their efficiency in handling patients. It now becomes necessary, to known the number of nursing staffs that will be required. Determining staff ratio is the immediate research question that will arise on analysis. Before suggesting any change, a detailed research will be necessary in the following areas: What is the suitable staff: patient ratio?; Are the nursing staff cordial and polite in dealing with patients?; Are the nursing staff skilled in dealing with patient condition. This will require field work and literature review.
The care of nurses is important for acutely ill patients. The demand of nurses have gone high with the growth in the intensity of care, increase in the number of invasive procedure, prescription of powerful medicine and increase in the number of chronic illness. One of the greatest impediment to recruiting nurses, is the additional money the hospital has to spend in the staffing process. The nurse to patient ratio in most community hospitals is 1:5.25, and 1:4 in academic medical centers. Once plans and resources are created to implement the change like: recruiting additional staff or providing training for better patient care, the next step is to measure the success of change.
4. Develop measurable goals to measure change: It is important to measure the change, so as to understand, if the efforts to bring about change are proceeding in the right direction. Very often effort can lead to unintended result and additional efforts may be required to bring it to acceptable levels. The rationale behind measure is that good practices leads to good outcomes. Developing measures to study change in a health care setting is complicated as the attribute variability is very high. Cognitive reasoning, discretionary decision making, problem solving and experimental knowledge are all required for analyzing the outcomes. Two types of benchmarking can be used to measure the success of change in an organization: internal benchmarking and external benchmarking. Internal benchmarking to compare the performance of the organization against its own standards at different time point. External benchmarking refers to measuring the performance of the organization, against a better performing organizing. In the given study, measuring the increase or decrease in patients complain and satisfaction level will help in measuring change.
5. Plan change strategy and implement change: Managers and their leadership strength can affect the outcome of a change project. Effective communication and team work are keys to implementing change successfully. A detailed plan or draft of proposed change needs to be developed. Leader can discuss with existing nurses their willingness to attend extra patients for more pay. It is important to maintain comfortable workload, as excessive workload can make a nurse impatient and lead to patient dissatisfaction. The average time spend on each patient can be calculated to determine, the maximum number of patients that can be accommodated per nurse. Taking prior appointment can reduce the time spend on waiting, as the patient need to arrive only at his allotted time. Provision to immediately handle patients who need emergency care must be made. (Aiken, 2002)
Long wait time can be reduced by faster discharge of previously admitted patients. Improper treatment or lack of cure can increase patient’s stay in the hospital. Providing the right health care can help to reduce hospital stay. Overcrowding and waiting, not only affects the patients, but also results in financial loss to the hospital. Boarding patients for long in the hospitals is associated with long waiting times, diversions, medical errors, sentinel events and mortality.
Increasing the number of bed and infrastructure according to the increasing demand may be necessary. In the absence of another suitable healthcare provider, the state administration can be requested to help the hospital with interest free loans to finance the extension of existing infrastructure.
Improving community health and awareness, can promote healthy lifestyle, reduce the incidence of diseases and the number of patients visiting hospitals. More the number of patients visiting the hospital, more is the healthcare cost. Recruiting more health care nurses and staff may be necessary to accommodate more patients during the day. This can increase the number of appointments made per day.
6. Process of change implementation and staff education: Change is fundamental to improving one’s quality and service. While implementing change, we change old way to new ways and prevent it from reverting it back to old ways. Leaders introducing change must think well to predict possible resistance and develop ways to address them. Change helps to anticipate, adapt and respond well in a changing environment. Change can be of two types: revolutionary or evolutionary. In revolutionary change, change is brought about in all dimensions of an organization: structure, strategy, ideology, power relations, cultural and control. This is mainly motivated by external politics or market. Evolutionary changes on the other hand help to fine tune an organizations function, without changing its structure and systems. It happens slowly at different levels of the organization.
The willingness of the healthcare professionals will decide the speed in which change is implemented. The goal of implementing change is to reduce treatment related harm and injury, to reduce patient wait time, increase reliability and accountability, reducing cost of care, reduce disparity and finally giving patients more voice, control and competence.
Statistics shows that majority of the efforts to implement change do not succeed. To successfully implement a change, it is important to engage people in the organization to accept change. Effective monitoring and review process will help to sustain change. It is important that people and staff in the organization have the capability to carry out their duties independently. Lack of skill among staff, is a big restrain to facing change.
It is also necessary to give the nurses the necessary confidence. Building a socially supportive climate, can help to buffer the dissatisfaction and agitation that may arise from implementing a change. It is important that the leader demands realistic expectations from his team and provide all the resources and facilities needed to implement change. Communicating constantly the need and importance of change will help to change the perceptions and response. Leaders can implement change as a process of learning. This will help to restructure one’s thought process and transform the individual and team to embrace change.
Aiken, L. (2002). Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. JAMA, 288(16), 1987. doi:10.1001/jama.288.16.1987
Hughes, R. (2008). Patient safety and quality. Rockville, MD: Agency for Healthcare Research and Quality, U.S. Dept. of Health and Human Services.
Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing Management, 20(1), 32-37. doi:10.7748/nm2013.04.20.1.32.e1013