Where We Fall Short: Reducing Sepsis and Other Diseases through Change Management
The human toll of sepsis—the number one preventable cause of mortality in hospitals—is staggering. Of the more than 750,000 severe sepsis cases each year in the United States, 215,000 patients die, making it the leading cause of death in non-cardiac intensive care units. It also accounts for a significant financial burden, equating to $16.7 billion in unnecessary healthcare expenditures.
Considering that even modest mortality reduction through improved sepsis care at the average 150-bed hospital could save 21 lives and $1 million to $1.75 million per 6,000 discharges, it is easy to understand why such a high priority is being placed on finding a solution to the sepsis problem. This is based on an annual incidence rate per discharge of 2.65% (135 cases per 6,000 discharges) wherein appropriate care resulted in an 15.4% improvement in mortality rates (Nguyen et al., 2007), coupled with a 27% cost reduction (Angus et al., 2001) and risk adjusted cost of $27,367 to $48,017 per case (Vaughn-Sarrazin et al., 2011).
Hospitals throughout the country typically try to affect improvement in healthcare in general, and sepsis in particular, through reform, technology, proper utilization of supplies, etc. Those approaches are necessary but not sufficient to drive significant quality improvement. The healthcare team must also work collaboratively and have appropriate tools to implement detection and treatment.
Unfortunately, though, highly reliable teamwork is not always in place when a prevention program is introduced, necessitating the need for skill building in this area. For example, nurses need a reliable screening tool, while at the same time the pharmacy needs to have antibiotics on the floor or available within 45 minutes of an order placed after a diagnosis. That’s where change management comes in.
To effect change, it’s important to train clinicians directly involved in treatment, primarily RNs, to identify areas for improvement and take a leadership role in devising fixes, including new clinical guidelines, reporting tools, and administrative procedures. To achieve the greatest success, it’s important to build a change management model that’s structured to support each of four pillars—individuals, team, organizational culture, and process:
- The “individuals” pillar focuses on developing awareness of one’s own preferences and on cultivating emotional intelligence, including an understanding of how one’s actions influence the work and everyone involved in it.
- The “team” pillar focuses on how high-performing teams function, complete their work, communicate, and ensure accountability.
- The “organizational culture” pillar focuses on developing political savvy—that is, an understanding of both formal and informal power sources within an organization, along with skills related to strategic communication, stakeholder identification, and forming allies.
- The ”process” pillar tends to be more technical in nature, focusing on evidence-based practices related to the activity to be improved, relevant data and quality improvement indicators, how to use data to predict the next test of change, and other related issues.
One success story is the University of California, San Francisco’s Integrated Nurse Leadership Program (INLP), which in December 2008 launched a 22-month, 9-hospital collaborative focused on reducing deaths from sepsis. This was accomplished by using the four pillars change management model to give nurses and physicians on the front lines the tools, skills, and resources to create sustainable system-wide change. The goal was to foster a universal set of problem-solving skills rather than fix a particular problem through a stand-alone initiative. The model recognized the value of linkages across staff and departments in sustaining and spreading innovations. It operated on the premise that technical “know-how” related to quality improvement science is insufficient. It paid particular attention, too, to “soft” issues such as leadership development and change management to promote wide-spread adoption and long-term sustainability.
As part of the California study, which was profiled by the Agency for Healthcare Research and Quality (2012), participating hospitals adopted four common approaches: 1) sepsis screening of all patients, 2) a fast-track workup to confirm the diagnosis, 3) initiatives to promote adherence to protocols that call for prompt initiation of appropriate treatment, and 4) ongoing monitoring. The result was a 54.5% reduction in average mortality rates within three years of the study’s launch.
Four years later, all nine hospitals reported continued declines in mortality rates. Additionally, the overall cohort-wide mortality rate was down 49.8% relative to the baseline.
Empowering the Front Line
It often takes calling out an issue to clearly articulate both the problem and the path for resolution. Sepsis is a prime example. Mortality rates remain unacceptably high. Reducing them requires addressing factors like inefficient communications and workflow that contribute to missed or delayed diagnoses.
As outlined above, a change management approach provides clinicians with the training necessary to develop appropriate problem-solving skills and the protected time to do improvement work. The INLP model empowers frontline clinicians to lead change. It provides them with training in advanced leadership and change management, adequate time to do the work, and legitimacy in doing that work. The nurses see themselves not simply as “soldiers fighting the daily work battle,” but rather as innovators who have the power to identify and solve problems and promote quality improvement. Their success changes their self-perception; they recognize their contributions to institution-wide quality improvement and are proud of the positive impact they have on the quality and safety of patient care.
Working Smarter, Not Harder
The big opportunity is to automate the data gathering and use the smart intelligence of the clinicians to direct the decision pathway. One could argue, in fact, that an organization must start with a trained group of healthcare providers who understand what it takes to make change happen in their own unique environment so they can continue to practice at top of license using the best-available evidence.
Ongoing processes to monitor performance must be developed and implemented. In addition, organizations must give frontline personnel dedicated time to create, monitor, and improve care processes. These individuals know what needs to be changed, as they work on the front lines every day and understand where the fault lines are. Consequently, they—not senior leaders—are best positioned to identify solutions. Senior leaders, however, must provide clear, direct communication and support to those on the front lines. They cannot simply pass down a quality improvement directive (e.g., “do this”) or list quality improvement goals in a memo.
Individuals sometimes think that simply working harder will lead to quality improvement, when in reality, working as a team is the key to success. High-performing teams should include representatives from across the hospital. Bringing these stakeholders together at an early stage creates an interdisciplinary set of ambassadors who promote the change and take ownership over the change process. In addition, interdisciplinary teamwork ensures that solutions are valid and practical within the context of existing work processes and disciplines affected by the change. This notion of interdisciplinary teamwork fits in with the system orientation of the four pillars model for change management.
Efficacy and Sustainability: Powerful Motivators
Efficacy and sustainability are powerful motivators for clinicians who are being asked to adopt new clinical practices and workflows. Physicians want to make sure that the things they are being asked to do actually improve patient care. Though change management represents just one element of the sepsis mortality reduction program, this demonstration of its long-term impact is validation that an approach to disease management that looks at multiple aspects of both the system and workflow is the right path to follow.
Communication about quality improvement efforts should occur regularly, even if for only a few minutes at a monthly meeting. These meetings provide an opportunity for senior leaders to hear about progress and for frontline workers to discuss their needs and expectations related to senior-level support.
The Best Step toward Improvement
To effect a breakthrough to reduce the mortality rate, treating physicians and nurses need access to technology coupled with change management and leadership training. Organizations that implement quality improvement teams that include physicians, nurses, and senior leaders put themselves in the best position to succeed in reducing sepsis and other hospital acquired conditions (HACs) through change management. The key is recognizing the value of linkages across staff and departments in sustaining and spreading innovations.
Also influencing success is an emphasis on acquiring and delivering to physicians and nurses the real-time patient data and evidence-based clinical decision support they need to make more informed care choices. This closes care gaps and enhances clinical efficiencies, which translates into improved outcomes.
This confluence of technology and change management presents the healthcare industry with its greatest opportunity to achieve a breakthrough in reducing sepsis mortality rates. Workflow functionality facilitates seamless exchange of information and significantly reduces communication time lags among physicians, nurses, and pharmacists. Hospitals must give front-line clinicians the tools, skills, and resources to create sustainable system-wide change.
Effecting real change, then, requires guidance and expert consultation to build appropriate teams, develop an infrastructure and framework for organizational improvement, and align key stakeholders across a facility. The goal is to foster a universal set of problem-solving skills rather than fix a particular problem through a stand-alone initiative.
Julie Kliger is principal and CEO of The Altos Group (www.thealtosgroup.com), an organizational improvement and management advisory firm that works exclusively with healthcare organizations. Over the past 26 years, Kliger has established herself as a leading voice for patient safety and improved outcomes, and designed the four pillars change management model. Her work in addressing practice redesign in healthcare has been nationally recognized for its unprecedented achievements in reducing medication administration error and sepsis mortality. Currently, she concentrates on the critically important work of healthcare’s frontline clinicians. Kliger may be contacted at julie@thealtosgroup.com.
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