IHI Open School Supplementary Learning for Social...

IHI Open SchoolSupplementary Learning

for Social Work

Quality Improvement in Social Work

Regional Programme

Contents

Introduction 1

PS 106 - Introduction to the Culture of Safety 2

QI 102 - The Model for Improvement 5

QI 103 - Measuring for Improvement 18

QI 104 - The Life Cycle of a QI Project 22

QI 105 - The Human Side of Quality Improvement 23

PS 102 - Human Factors and Safety 34

PS 103 - Teamwork and Communication 38

L 101 - Becoming a Leader in Healthcare 43

References 49

Acknowledgements 50

IntroductionThis supplementary learning has been developed for social workers in Northern Ireland who are undertaking the IHI Open School Modules as part of the Quality Improvement in Social Work Programme.

How to use this supplementary learning for Social Work

You will need to read this learning material in conjunction with the relevant IHI modules and answer questions as they arise.

You will also be required to discuss your learning on the HSC Knowledge Exchange Discussion Forum in order to meet the Northern Ireland Professional in Practice (PIP) programme requirements.

When you see this symbol, you will be required to complete a task on the Knowledge Exchange Discussion Forum.

Your turn

When you see green box with “Your Turn” exercise, please complete on your hard copy of the Supplementary Learning for Social Work.

Bring this to the next session for discussion with your mentor.

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PS 106 - Introduction to the Culture of Safety Lesson 1: The power of speaking up

Practice Example

Kelly is a newly qualified social worker (NQSW) in an older people’s team. She has been there for four months and during this time she has received a planned induction and has been allocated a manageable workload, with fortnightly supervision. She has also availed of support via the Social Care Governance Team’s quarterly support group for NQSWs. Kelly has enjoyed her experience to date. The team manager and the team have always reinforced with Kelly the importance of asking questions and speaking up if she is not sure about something – Kelly has found this has really helped her to learn. She has also valued the team commitment to ‘H.O.T.’ principles (Honest Open Transparent) which underpinned her induction.

In the last month Kelly’s manager has gone on sick leave and she is not sure when he will be back. The team had been managing, although Kelly has been asked to ‘monitor’ some vulnerable adult cases that were considered to be settled; this would allow one of her colleagues to take on some of the manager’s work. Kelly had been anxious about doing so, she had not yet been on safe-guarding training, but she could see how stretched the team were and she wanted to demonstrate her competence as a team player. Her colleagues had told her they would ‘keep her right’. Now two of these colleagues have also gone off sick and Kelly is getting worried that she has not had supervision and her workload is becoming unmanageable.

Kelly meets with her NQSW Advisor from the training team to discuss her forthcoming mid-point appraisal. The advisor begins each session by asking Kelly about support. Kelly decides to share her concerns with her advisor.

Your turn

Q. Why was it important for Kelly to speak up?

a) To ensure the manager and team were disciplined

b) To ensure the NQSW Advisor was aware of her ability to manage complexity

c) To ensure safe and effective practice

Q. List some of the reasons why it might be difficult to speak up

1.

2.

3.

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In relation to question one, of course Kelly had to report her concerns to ensure safe and effective practice, speaking up is not about finding someone to blame or trying to promote yourself. Speaking up about concerns is the right thing to do.

In your response to the previous question you may have identified that some of the reasons staff do not speak up are because they feel powerless, they don’t want to cause trouble, they fear they will not be supported or they don’t see it as their job. However every person in an organization, whether a leader, a staff member, or service user, has a vested interest in fostering a culture of safety. A culture of safety is built on the principle that all employees have two jobs:-

1. Run the business / do the job

2. Improve the business / service Ref https://www.virginiamason.org/default.cfm

Lesson 2: What is a culture of safety?

In Lesson 2 you will read about the main characteristics of a culture of safety:-

• Psychological safety. People know their concerns will be received openly and treated with respect.

• Active leadership. Leaders actively create an environment where all staff are comfortable expressing their concerns.

• Transparency. Safety problems are not swept under the rug. Team members have a high degree of confidence that the organization will learn from problems and use them to improve the system.

• Fairness. People know they will not be punished or blamed for system-based errors

You should be able to identify a number of these characteristics in the NQSW scenario that enabled Kelly to speak up.

In Lesson 2, you saw how briefings can be used to promote a culture of safety. Briefings are one way that effective leaders share and elicit information. Health care briefings usually involve taking a minute or two, before a procedure, to discuss the plan and the expected outcome. This gets everyone on the same page. When team members know what the goal is, it is much easier for them to spot the things that are going awry.

Your turn

• How could briefings be used in social work/social care to promote a culture of safety?

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Practice Example

A Family Intervention Team have started to use weekly briefings to promote safe practice and better communication. Each Monday morning the team meet at 9.00am for 45minutes to review the week ahead using the whiteboard. Each staff member has the opportunity to share their diary for the week and any issues of concern arising. This approach has been particularly useful in identifying when a home visit should be undertaken with a colleague to reduce risks to staff and in giving staff an opportunity to consult colleagues for practice advice.

Lesson 3: How can you contribute to a culture of safety?

No further supplementary learning material required.

Knowledge Exchange Forum Task

PS106 Introduction to the Culture of Safety

1. What do you think would happen in your world if you spoke honestly about a mistake you had made in your practice? How would your colleagues respond and why would they respond that way?

2. Identify two things that you can do which will contribute to a culture of safety in your organisation.

Post your responses to the questions above to the Knowledge Exchange Discussion Forum

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QI 102: The Model for Improvement: Your Engine for Change As you work though this module of the IHI Open School you will be asked to download and complete a Personal Improvement Project Worksheet. Please make sure you do so as we will use this template to inform mentor sessions and to guide your project work.

Task: Bring the worksheet with your personal improvement project completed to the next mentor session

Lesson 1: An overview of the model for improvement

Challenging behaviour incidents in supported living settings can impact negatively on the lives of people with disabilities - both the people exhibiting the behaviour and the people on the receiving end of the behaviours. Here’s an example of how a team working in a supported living setting could use the Model for Improvement to help improve a resident’s incidents of challenging behaviour in a house.

Step 1: Form a team

This team includes key people from the psychology / behaviour support team, the social work team and any other relevant multi-disciplinary therapists working with the individual and the direct support staff team in the house.

Step 2: Set an aim

The team have a discussion about the aim of their project and are cognisant that the aim they choose needs to state exactly ‘how good?’, ‘by when?’, and ‘for whom?’.

They are aware that a general statement such as ‘We will reduce our rate of challenging behaviour incidents’ isn’t good enough. The aim they decide on is that they want to decrease John’s number of challenging behaviour incidents from 70 a week to zero a week within nine months.

Step 3: Establish measures

The team are also aware that they need feedback to know if a specific change actually leads to an improvement, and that quantitative measures can often provide the best feedback.

The team decided that they would measure the rate at which challenging incidents were happening - their outcome measure.

They also decided to measure how often staff members were actually doing the things they were asked to do to prevent incidents - their process measures.

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Step 4: Identify changes

In order to help reduce John’s incidence of challenging behaviour the house team decided to test a bundle of changes:-

• Having staff implement a step-by-step guide to dealing with specific outbursts, such as maintaining a low arousal environment and checking the number of interactions daily which had also been shown to reduce the rate of incidents

• Using a checklist during a time-out before intervening in a challenging behaviour incident.

Step 5: Test changes

This is where the Plan, Do, Study, Act (PDSA) cycle came in. The behaviour support team trained the direct support staff working in John’s house on all the changes and then measured how well everyone stuck to the new protocol.

Here’s what they found:

The graph above displays the two process measures used by the team to help reduce John’s incidents of challenging behaviour in the house. The graph shows that the team were doing a pretty good job complying with the use of the checklist (the blue line above), but not as good a job on implementing the step-by-step guide (the red line). This was the ‘Study’ step of the PDSA cycle. In January and February the team used the additional PDSA cycles to tweak the process so staff would comply more often.

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The team also monitored an outcome measure: the rate at which challenging behaviour incidents were happening. The solid blue line in the chart below shows the rate of incidents. Note that the incident rate each month dropped rather dramatically after the team began testing new changes, as marked by PDSA 1(March ) 2 (July) and 3 (September ), and by November it had dropped to zero.

Step 6: Implement changes

After testing a change on a small scale, learning from each test and refining the change through several PDSA cycles, the team created a new policy governing the management of behaviour for John. They started training all staff who rotated through the house on the new protocol. In other words, they made the new procedures part of everyday work life.

Step 7: Spread changes

After the team successfully changed the way this house handled behaviour incidents, the behaviour support team used the same protocols for measuring behaviour incidents in other houses. However, the behaviour support plan and interventions that they used were tailored for each individual and their specific needs.

Lesson 2: Setting an aim

No additional supplementary learning required.

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Lesson 3: Measuring for Improvement

Lesson 3 tells us that measurement helps to answer the second question in the Model for Improvement: how will we know a change is an improvement?

It also tells us that without some type of feedback, we have no way of knowing whether the changes we are making are leading to improvement.

Here’s what measurement could look like in a disability service. Let’s say that the aim of an improvement project in a house is to: decrease the average incidence of challenging behaviour of the service users in the house to less than seven incidents a week within 12 months.

The team have identified everyone in their service user population who has challenging behaviour. They have set up a reminder system to automatically notify everyone on the staff roster for that house that they need to follow the behaviour support protocol (as written up for each of the service users in the house) and that they need to measure the number of incidents daily and weekly.

But are these new protocols actually leading to improvement?

The only way that the team can tell is to look at an outcome measure: average weekly number of challenging behaviour incidents for service users.

Has the number decreased? Has there been a decrease in the average number of challenging behaviour incidents for service users in the house? That’s how the team will know if the changes they are making are an improvement.

Measurement for research versus measurement for learning and improvement

MeasurementMeasurement for research Measurement for improvement

Purpose To discover new knowledge To bring new knowledge into daily practice

Tests One large blind test Many sequential, observable testsBiases Control for as many biases as possible Stabilise the biases from test to test

Data Gather as much data as possible, just in case

Gather just enough data to learn and complete another cycle

Duration Can take a long time Short duration

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Lesson 3 highlighted the difference between measurement for research versus measurement for learning and improvement.

Practice Example

Two houses want to increase compliance with service users using public transport (to build independence and save on company transport).

At House A, the plan is to meet as a team and start with three service users. The team will note how many staff supported service users to use public transport, to learn what might be the barriers to supporting this activity. The team will continue to track three service users per week as various interventions are tested and then will determine if staff support with using public transport gets better over time.

At House B, the plan is to meet as a team and choose a test to implement. The team will randomly assign service users and staff to two groups, making sure both have similar attributes. The team will then develop a database, and over the next six months, measure how many staff in each group supported service users to use public transport. After that, the team will implement the chosen intervention with one of the groups and reassess the use of public transport as compared to the control group.

Your turn

Question: Which of the houses is measuring for improvement?

a) House A

b) House B

Outcome, process and balancing measures

Improvement teams typically use three types of measures: outcome measures, process measures, and balancing measures.

Outcome measures: where are you ultimately trying to go?

Outcome measures tell you whether changes you are making are actually leading to improvement. These are the measures you ultimately want to move. They tell you how the system is performing - what is the ultimate result?

An example of an outcome measure in the case of challenging behaviour could be: average rate of incidents per person with challenging behaviour.

Process measures: are we doing the right things to get there?

To affect the outcome measure, you have to improve your processes. Measuring the results of these process changes will tell you if they’re leading to improvement. Are the parts or steps in the system performing as planned?

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An example of a process measure, in the case of an improvement project on managing behaviour could be: percentage of times that both the checklist was completed and the step by step guide was implemented.

Balancing measures: are the changes we are making to one part of the system causing problems in other parts of the system?

Balancing measures tell you if changes designed to improve one part of the system are causing new problems in other parts of the system. They are often measures that are not directly related to the aim.

A balancing measure in the case of an improvement project on managing challenging behaviour could be: amount of extra time spent with each person with each person with challenging behaviour that cuts into time with other service users. Based on the aim of each project below, indicate whether each of the following measures on the next page is an outcome measure, a process measure, or a balancing measure.

Aim: Reduce the incidence of injury by reducing the number of behaviour incidents in the house by 20% within five months.

Your turn

Question 1: Average number of days with behaviour support incidents?

a) Outcome measure

b) Process measure

c) Balancing measure

Question 2: Percentage of people with injuries associated with behaviour incidents?

a) Outcome measure

b) Process measure


Question 3: Sick leave of staff due to injuries associated with behaviour support incidents?

a) Outcome measure

b) Process measure


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Aim: By June 2009, raise the average level of use of public transport by service users by 10% by delivering evidence-based support 100% of the time.

Your turn

Question 1: Percentage of service users who used their travel passes measured twice in the past year?

a) Outcome measure

b) Process measure


Question 2: Average use of public transport for population of service users with travel passes?

a) Outcome measure

b) Process measure


Question 3: Percentage of problems that arose related to the use of public transport?

a) Outcome measure

b) Process measure


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Lesson 4: Developing changes

Change concepts in Social Work and Social CareChange concept: Change targets

Example: Energy is wasted when lights are left on in unoccupied rooms. One house had this problem with its bathrooms. The team eliminated this problem by arranging bathrooms to have the light turn on automatically when the door is opened and turn off automatically when the door is closed.

Change concept: Recycle or re-use

Example: In one service, a team discovered that staff were generating excess waste because they were not able to recycle the water bottles for the water cooler. The team persuaded the supplier to let them return the bottles for refills.

Change concept: Reduce classifications to remove complexity reduce complexity

Example: Having a lot of appointment types actually increases total delay in the system because each appointment type creates its own differential delay and queue. For example, if a psychologist performs clinical assessments only on Tuesday afternoons, a service user needing a clinical assessment may have to wait several weeks until a Tuesday afternoon slot is available. The more criteria, the more time it takes to put people in the line.

Change concept: Reduce controls on the system

Example: Organisations can benefit from allowing staff to come up with innovative solutions to problems. For example, one organisation gave its smoking-cessation team the flexibility to decide who would do what tasks as long as the job was accomplished. The team soon learned that on one team, the social worker was better at counselling, while on another team it was the manager. The team assigned roles based on skill and availability.

Change concept: Eliminate multiple entry

Example: Many services have implemented computerised administration record systems that link plans with outcomes achieved/not achieved, accidents / incidents / risk assessments / rights restrictions.

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Change concept: Use sampling

Example: A behaviour support team estimated the triggered incident rate in a house by following up on every challenging behaviour incident to see if it was triggered by incorrect interventions. They used the concept of sampling to change the process, taking a sample of 10 incidents each day and then estimating the number of these that were triggered by incorrect interventions. They were able to cut down on additional staff support needs because of the reduction in the number of incidents with using correct interventions.

Change concept: Remove intermediaries

Example: One area of service identified 10 steps involved in completing a service user referral from the house to the occupational therapist. After identifying these steps, the team removed intermediaries by asking the key worker to call the occupational therapy administration staff, bypassing their own administration staff, which eliminated two of the 10 steps.

Change concept: Use substitution

Example: An organisation working on improving access to its psychology department tested a change by having the psychologist type all consultation reports directly into the computer system at the time the service user is seen, instead of hand writing a report for administration staff to type up and amend later. Several efficiencies are gained: less use of paper materials; immediate access to old notes; ability to review what other consultations have been requested / done and the outcome of these which gives a broader picture of the service user’s interventions; ability to re-read the psychologist’s own notes prior to writing the plan; and immediate records on the system.

Change concept: Benchmarking

Example: Comparing your own process to “best practice” can help you identify where your own system falls short. Based on that analysis, you can develop ideas for improving your performance. This is known as benchmarking. Here’s another way to think about this idea: Benchmarking in its simplest form is merely looking around at how others are doing things and trying to learn new approaches and possibilities. A formal benchmarking process provides a method with some structure for making these observations, and then using this information for improvement.

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Lesson 5: Testing changes

Practice ExampleIncreasing social roles: A PDSA cycle in the disability support setting.

How might a PDSA cycle work in the setting of a disability service? Here’s an example showing how a team starts with a small-scale test in their quest to increase the number of social roles for people supported.

Aim: To increase number of social roles by 30 percent within six months.

Test of change (PDSA cycle): Determine the feasibility and effect of the team leader focusing on this one outcome for six months.

PlanObjective of the test: To test a way to ensure that the team leader focuses on this one outcome for six months

Prediction: The team leader will be the best person to drive this and ensure the outcome is focused on for six months

Develop a plan: We will test this change on one service user (Anne) over the next week. The team leader will notify the key-worker who will work with the service user to determine their preferred choice of social role. The staff on duty will support the service user to carry out the social role eg. deliver the free local paper to the neighbours’ houses on Thursday.

DoThe day before the test, we discussed the plan with the staff on duty, who agreed to the small test. The day of the test, we selected six houses where the paper was to be delivered. Anne delivered the paper to five of the six houses, due to only being able to get five papers when she went to the shop. Anne did not get to meet the neighbours in two of the houses

StudyWe checked into why there were only five papers available in the shop: they only get a small supply as they are a small shop. We also discovered that the reason Anne did not meet the neighbours in two of the houses was that she called while they were still out at work. We also discovered that the staff member on duty was from an agency and not familiar with the shops or neighbours in the area.

ActThe team decided that, because it was difficult for an agency staff member to have all the relevant information on the neighbourhood, a permanent staff member would have to write up a protocol for Anne’s social role.

The team thought that the papers could be collected from a bigger shop that is not much further away, so they will do that for the next test. For the next test, the support staff will accompany Anne at the same delivery time. The team will work on another person being available to support Anne who could go with her at a later time and they will test that plan by next week.

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Your TurnYou’re the manager of this disability service. You’re trying to think about how you and your team should conduct the next PDSA cycle.

Question 1: When testing changes, you should be sure to gain consensus and buy in.

a) True

b) False

Question 2: You and your team should reflect on the results of every change.

a) True

b) False

Question 3: You should never end a test of change before the planned time.

a) True

b) False

Increasing social roles in a disability setting: Linked tests of change

So what do linked PDSA cycles actually look like in a disability setting?

Let’s go back to the team that was working on increasing social roles. The team knew that one way to do this was to make sure that the team leader focuses on this one outcome for six months.

Their first PDSA cycle was designed to test the change of having the team leader focus on this outcome. Not everything went perfectly: the service user was not able to get enough papers to deliver. So what did the team do next? The graphic on the next page shows how they tested and implemented the change through several linked PDSA cycles.

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Learning from linked tests of change.

Cycle 1:

We selected six houses to deliver the paper to. Anne delivered the paper to five of six houses, due to only being able to get five papers when she went to the shop. Anne did not get to meet the neighbours in two of the houses. Is that a failure of the test? No, just useful information for the next test.

Cycle 2:

In this cycle staff support Anne to collect papers from the larger shop where there is a bigger supply of papers. That works 100% of the time. Looking good!

Cycle 3:

In this cycle, a volunteer is assigned to accompany Anne to deliver the papers at a later time to ensure that she meets all six of the neighbours. Again, this change seems robust.

Cycle 4:

The team leader excited about the change presents her results to her manager. They agree to try it for three months.

Cycle 5:

The manager presents the results to the quality enhancement team, which is successful in getting agreement to spread with other service users and teams.

Cycle 6:

The whole service implements the change and agrees to the idea of focusing on the one outcome.

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Testing several changes at the same time

Now, how do you run a test of change when you’re dealing with several changes at once?

Practice Example

Your house is looking for ways to cut costs without lowering the quality of care. One promising place to start, your team decides, is in the area of more independent / supported living. Your team wants to cut down on the time staff spend in the houses each evening supporting service users by using assistive technology. After an initial outlay of money, this measure could produce savings in pay costs and increase levels of autonomy for people supported.

1. Instead of providing the traditional high levels of constant staff support, you want to test the use of staff coming and going in the house and leaving service users alone for periods of time. In this way, service users can be supported safely when they need support, yet they will become used to managing on their own for periods of time also.

2. You also want to use some assistive technology appliances to remove the need for constant staffing while still ensuring safety, and to help people develop better levels of independence.

When you are testing several changes at the same time, start the PDSA cycles for the reduced staffing and the PDSA cycles for the assistive technology at different times, but run them concurrently. That way you can see how the changes work together.

Knowledge Exchange Task

QI102 The model for improvement

Having undertaken this module on the Model for Improvement, what benefits do you see to using this approach in practice.

Share your thoughts on the Knowledge Exchange Discussion Forum

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QI 103: Measuring for Improvement Lesson 1: Establishing a Family of Measures

Defining the data you want: An example is provided here from a residential care setting.

What are you trying to measure?

The percentage of times that staff in a residential setting respond immediately to ‘behaviours that challenge’ by focusing on teaching more positive behaviour. This is measured over a specified period of time.

What specific measures did you select for this purpose?

The number of times recorded on incident forms that staff have recorded an immediate response of a focus on teaching more positive behaviours. There needs to be agreement in advance of what defines ‘behaviour that challenges’ and what defines ‘a focus on teaching more positive behaviour’.

How are you defining the measure?

Numerator: Number of times staff recorded a reaction consistent with a focus on teaching more positive behaviour.

Denominator: Total number of instances of challenging behaviours exhibited in the residential setting, over the specified period of time.

What’s your data collection plan?

A manual review of 20 behaviour / incident reporting forms per month for three months (ie. April, May, June 2013) by the residential home manager.

What’s your baseline measurement?

In this case the baseline is simply the number of times where staff have responded immediately to ‘behaviours that challenge’ with a focus on teaching more positive behaviour over a specified period of time, before any changes or solutions have been put in place (i.e. January, February, March 2013).

What are the targets or goals for this measure?

To identify if the service is maximising opportunities to reduce incidences of ‘behaviours that challenge’ by utilising a focus on teaching more positive behaviours immediately when an incident occurs. This information is useful in so far as it may highlight areas where staff training and support can be targeted for better service user outcomes.

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Operational definitions

Behaviours that challenge can be defined as:

Behaviours of such intensity, frequency or duration that the physical safety of the person exhibiting the behaviour or others is at risk or behaviour which limits or is likely to limit a person’s access to normal facilities

The residential home manager undertaking the review of the incident forms needs to make a decision, based only on the information supplied on the incident forms, whether or not a focus on teaching more positive behaviour was employed.

Lesson 2 - Displaying data

This is a sample run chart based on the example for Lesson 1

Percentage time staff reacted to behaviours that challenge by focusing on more positive behaviour.

The online module material contains many examples to illustrate the displaying and interpretation of data.

Over the page there are further examples from social care improvement initiatives.

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Example 1: Improvement in developing staff confidence in setting up direct payments.

Example 2: Reducing unallocated cases through implementing electronic recording

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Example 3: Increasing attendance at goal planning meetings.


QI103 Measuring for improvement

Can you think of three reasons as to why social work outcomes should be measured?

Share your thoughts on the Knowledge Exchange Discussion Forum.

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QI 104 – The Life Cycle of a QI Project No supplementary learning material required.


QI104 The Life Cycle of a QI Project

What do you need to consider to make your innovation spreadable?

Post your comments to the Knowledge Exchange Discussion Forum

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QI 105 – The Human Side of Quality ImprovementLesson 1 Many People Don’t Like Change

Change in social care is not perceived all that differently from change in any other context. When organizations make changes to processes, procedures and policies, even if those changes are improvements, the people involved with those processes, procedures, and policies are often a little bit annoyed, a little bit frustrated, and maybe even anxious to figure out a way to go back.

When we talk about change and improvement, we often focus on the numbers, the processes and the graphs - and we sometimes forget the people. In this lesson, you will learn about barriers to change as well as different ways that people might respond to change in a social system. You’ll also be introduced to a basic model of change that includes unfreezing the old way we do things, moving to the new way, and then refreezing the way we want the future to be.

Why People Resist Change

Before you can help people become comfortable with a change and make lasting improvements, you need to understand some of the common reasons people resist change.

Let’s start with an example.

Practice Example

You are a social worker with 15 years’ experience working in a busy social work department in an Older People’s Team. Monday morning arrives and with it an email from the principal social worker announcing a new electronic tool has been made available for the capturing of carer assessments in the Trust. Staff will be required to use the tool to record all carer assessments offered, accepted and declined.

Your Turn

Take a piece of paper and write down all of the reasons you might resist complying with the new policy. Make sure you come up with at least three reasons.

Here’s an example below:-

Reasons to Resist New Policy

1. The new tool is for too time consuming to complete.

2.

3.

Reasons for Resistance

Did your list include any of the following reasons?

• “This tool is way too long – I don’t have time” “I’m not sure I have the computer skills” • “How will I get time to actually see service users when I have this to write” • “I have my own way of recording when I offer carer assessments and it works for me!” • “This is yet another new idea …here today … gone tomorrow and we are expected to just

get on with it” • “The old way was fine - why complicate things”

Let’s consider some of these reasons for resistance below.

In his book The Limits of Organizational Change, Herbert Kaufman identified a number of barriers that can affect the implementation of significant change in health care, including the following:-

The expected autonomy or independence of health and social care workers: Often, Health& Social Care professionals perceive themselves as single providers working independently to provide care. If a health/social care provider feels a change may reduce or alter that autonomy, he or she may be reluctant to embrace a change.

For example: “I want to use my own style”

Stability that comes with routine: Routines such as standard procedures, certain recurring behaviours, or institutionalized ways of communicating create stability for people. This is reflected in the common statement, “We’ve always done it this way, and I’m comfortable with it, so why change now?”

For example: “Why complicate things”

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Programmed behaviour or behaviours that result from processes within a system, including division of labour, recruitment, reward structures, and promotions: This is when a system or process can hinder change. For example, if your pay is tied to the speed or accuracy of accomplishing a task and you perceive that a change could alter your performance and consequently your pay, you may be very resistant to the new system or process.

For example: “How will I get time to actually see service users I work with when I have this to complete”

A limited focus or tunnel vision, resulting from only being able to see the impact of change from one individual perspective: Sometimes people become so focused on their part of the puzzle that they cannot see how a change in a process will affect the whole system or process of care, which they are just one part of.

For example: “The sections look repetitive”

A real or perceived limit on resources: People involved in a change may think it will take too much time, money, or equipment, and thus they are reluctant to try it.

For example: “The template is way too long- I don’t have time”

An accumulation of policies, procedures, regulations, and other things that constrain the ability to change: Often, a change is perceived as “just one more thing” in a long list of things to do.

For example: “This is just another new policy that’s here today, gone tomorrow.”

It’s probably not a surprise to you, but many improvement projects in social care come up against at least one of these types of barriers, and possibly others, too.

Your Turn

After a briefing with the APSW regarding the new Carer Assessment Recording Tool, you hear many of your colleagues discussing the changes:

What barrier to change is best represented by each of the following statements?

Question 1 “Nice idea, but there’s no chance I’ll have the time to fill out another form. We’re understaffed, and I’m just too busy.”

a) Expected autonomy of health and social care workers

b) An accumulation of policies and procedures

c) A real or perceived limit on resources

d) Stability that comes with routine

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Question 2 “I’ve been doing this job for thirty”I’ve been doing this job for years. I don’t need an electronic tool to record my practice ….”


b) Programmed behaviour resulting from processes within a system

c) Limited focus or tunnel vision

d) An accumulation of policies and procedures

Question 3 “Don’t we already do a pretty good job of offering carer assessments? What’s wrong with how we do it now?”

a) Programmed behaviour resulting from processes within a system

b) A real or perceived limit on resources

c) Stability that comes with routine

d) Limited focus or tunnel vision

Question 4 “Great, another form. Don’t they realize how many hours we already spend at the computer?


b) Limited focus or tunnel vision

c) Programmed behaviour resulting from processes within a system

d) An accumulation of policies and procedures

How to respond to Resistance to Change

Your Turn

Earlier in this lesson, you listed reasons to resist the introduction of the new electronic tool for capturing Carer Assessments offered. Now imagine you’re one of the architects of the new policy. Take a moment and, in the right-hand column, list specific things you might say or do to anticipate and address the barriers you previously listed in the left-hand column.

Here’s an example:-

Reasons to Resist New Policy How I might Anticipate Objections

This template is way too long - Try a test run of the new tool before deciding it I don’t have time. is too long - in reality has it taken you longer?

•

•

•

•

• Complete this task before moving on.

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Anticipating Barriers to Change

As a reminder, the following are some of the barriers we considered for adopting the new tool and potential responses to those barriers:

Barrier: “This tool is way too long – I don’t have time”

Response: Try a test run of the new tool before deciding it is too long – in reality has it taken you longer?

Barriers: “How will I get time to actually see the service users when I have this to complete?”

Response: Provide education on the value of the new tool. In areas which have introduced the tool they report that the tool provides more accurate numbers of carers assessments completed and provided ‘real time’ data for accountability reports

Barrier: “The sections look repetitive”

Response: Ask your chosen test group of staff to discuss the reasons that the tool may appear repetitive. Can they identify good practice reasons why the information is required. For example is there a good reason why we have to record when an assessment has been declined?

Barrier: This is yet good idea from ‘up above’ and we are expected to just get on with it”

Response: Provide the staff group with evidence from elsewhere who have already introduced a system like this - what have been the benefits to the service users, carers and staff?

You might consider meeting with staff to ascertain their first hand views of the tool and how they felt when their information was recorded in this way. You could record this meeting to show to others. Often ‘real’ feedback from other staff in a similar role can contextualise the reasons why the organisation needs to introduce a change and lead staff to a point whereby change makes sense to them.

The Diffusion of Innovations

Your Turn

Let’s take a minute to practice identifying the different types of adopters. This will help you identify different approaches to change in your own change efforts.

Practice Example

The child protection team in your department are preparing to implement a new IT system which will manage all interactions with service users. Bob, Susan, and Gretchen are social workers.

Bob has been a part of the implementation team and is excited about the new system. He heard about it at a recent regional conference and has spoken to colleagues in other areas who have piloted similar systems. He is well respected by others on the team as someone who is knowledgeable about new technology and how it may improve social work practice.

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Susan is resistant to implementing the new system. She says it’s complicated and confusing, and she much prefers using the old paper files. She’s heard about the advantages of the new system, but she claims she is more efficient when jotting things down on sticky notes and then transferring the information to the service users paper file. Gretchen is undecided. She respects Bob and has agreed to participate in testing the new system. She knows it is the way of the future and is pretty confident the new system will make the team much more efficient, but she’s cautious and still wants to do more research.

Your turnQuestion 1 In this scenario for implementing the new IT system, which type of adopter is Bob? a) Innovator

b) Early adopter

c) Early majority

d) Late majority

e) Laggard

Question 2 For the proposed implementation of the new IT system, what type of adopter is Susan? a) Innovator

b) Early adopter

c) Early majority

d) Late majority

e) Laggard

Question 3 For the proposed implementation of the new IT system what type of adopter is Gretchen? a) Innovator

b) Early adopter

c) Early majority

d) Late majority

e) Laggard

This lesson provided a brief glimpse of common barriers that may hinder someone’s ability to change, as well as ways to respond to those barriers. The best-planned improvement initiatives will fail if the elements of human behaviour regarding change are not respected and addressed. The ideas in this lesson can be incorporated into your plans for using the Model for Improvement (refer to QI 102)


QI105 The Human Side of Quality Improvement Task One

How can you use the learning from this module to address resistance and get ownership for your service improvement initiative?

Share your comments to the Knowledge Exchange Discussion Forum

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Lesson 2: What Motivates People to Change?

What makes a Person Tick?

In quality improvement, teams focus on setting clear aims, studying systems and processes, testing changes and using data to understand the effects of those changes on the performance of the process. For people with an analytical mind, it just plain makes sense. Below is a practice example of the difficulties in getting people to change.

Practice Example

Consider this example:-

You are a social work manager in a busy social work team which invariably has waiting lists to manage. To ensure the risks are safely managed on these lists you want introduce a ‘duty’ system whereby staff analyse and review the levels of risk apparent on a structured and regular basis.

This system appears to make complete sense as the risk within these waiting list cases can change daily upon receipt of new information. Neighbouring social work teams report great success in managing the risk when this system was implemented.

However several of the social work team leaders are reluctant. In your opinion the system will work and it is supported by evidence from other areas that it can be a success – yet here you are not knowing how to proceed.

How does understanding what motivates people relate to service improvement in social work and social care

Practice Example

How does this relate to social care? Imagine a new checklist is being introduced for duty social workers to ensure their first point of contact with service users gathers the key pieces of information necessary. The duty social workers are already intrinsically motivated to provide an excellent service however the more that they understand how a new process may have a direct influence on improving service, the more motivated they are to follow that process.

In order to ensure that the checklist is used on all new referrals the social work team leader decides that for one month, the best performing worker will get a gift certificate to a popular local restaurant.

While the team leader’s intention is good, as soon as they announce this extrinsic motivator, the emphasis shifts from service improvement to winning the certificate. The result could be that the social workers complete the checklist for every service user, but they may not pay enough attention to the overall service being provided. This is obviously not the intention of the team leader, nor would it be the intention of the social worker - but creating an extrinsic motivator can have unintended results.

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Your Turn

Consider the following example when answering questions 1-3.

Your social work department has completed an audit of case files and found several that have been assessed as safe to close however remain ‘open’ cases because the further assessment/closure documentation has not been completed by staff. Social Workers indicate they are much too busy to prioritise the administration needed to affect closure of these cases.

To ensure this work is complete your principal social worker is offering a prize – a day out to a local spa for the social worker that completes the most further assessment/closure forms correctly in a three month period.

1) The day out to a local spa is an:

a) Intrinsic motivator

b) Extrinsic motivator

c) Opportunity for further continuing education

2) The work of W. Edward Deming and Alfie Kohn suggests that after the three-month period is over and the day out to a local spa has been awarded, the following will likely happen:

a) Social Workers will use the closure documentation more

b) Social Workers will use the closure documentation less

c) There will be no change to the social workers’ use of the closure documentation.

3) According to the work of Deming and Kohn, a better motivator for using the checklist might be:

a) A trip to Hawaii

b) A bonus

c) Tying number of completed closure documentation into performance reviews and compensation

d) Showing that using the closure documentation can reduce the number of open cases

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Lesson 3 – Culture Change versus Process Change

Testing a New Form for referrals dealing with domestic violence

Consider the following example:-

Practice ExampleThe social work team leaders within your department are actively working to address the ever increasing numbers of domestic violence referrals being received by the Gateway team. In order to work toward better outcomes for children in this area the team leaders are trying to communicate more effectively with the children and families affected by domestic violence. Using the model for improvement, the team leaders make a plan to design a service user feedback/quality assurance form to assist in tailoring social work services to the needs of this client group. After finalising the form the team leaders ask one of the intake teams to test the form.

Your TurnQuestion 1 In this example, what type of change does the form represent?

a) Culture change

b) Process change

c) Both culture and process change

d) None of the above

Question 2 In this example, how will you know when the culture has changed?

a) When the form has been tested on all users of social work services for domestic violence

b) When fewer clients access the social work services for domestic violence

c) When service users say that they feel the organization is much more open to listening to them

d) When the form has been implemented across your organization

The Model for ImprovementBack in Quality Improvement 102, you learned that the Model for Improvement is a strong engine for change, whether personal or professional. But how can using the Model for Improvement be considered a process change?

To answer the question, let’s look at an organization that doesn’t use any particular framework or approach - whether the Model for Improvement or any other — when making a change:

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Practice ExampleYour principal social worker has requested additional agency social workers to assist the fostering team. The principal social worker believes that the extra staff will result in improved performance and additionally, completed foster care assessments. The principal social worker has based his assumptions on the fact that the social workers on that team are extremely busy and feels that they don’t have adequate time to do all of their work. The request for additional staff is approved. Overall the burden on the fostering team appears to be lighter but the private agency costs have gone up.

Did the principal social worker make a wise choice in requesting the additional staff? It’s hard to tell – because the request was not based on data.

Using Data to make Decisions

One major cultural shift that can occur when organizations use the Model for Improvement is the transition to valuing data. Without data, all we have to go on are our past experiences, our perceptions, our memories, and our opinions. Data, however, provide us with an objective look at what’s happening.

Let’s go back to the fostering department example. This time, the principal social worker uses data to make decisions.

Practice ExampleThe principal social worker requests that the fostering team track their time spent completing assessments compared with the number of assessments actually completed. This information is then aggregated so that the principal social worker has a clear picture of the true activities in which the social

workers are engaged. With data in mind the principal social worker can see what’s already obvious – that the social workers are just too busy. But there’s something else he can see – the social workers are spending a significant amount of time on administrative duties. Instead of adding more social workers the principal decides to ask for just two additional administration staff. The social workers later report that their workload is lighter, the costs are also now lower and the social workers are now spending more direct contact time with the service users and foster parents.

In this case, using data results in a culture focused on objective information that leads to very deliberate, informed decisions.

While it is easy to become focused on fancy charts and graphs, we sometimes forget that the methodical and objective approach that accompanies the Model for Improvement can dramatically change our people and organizations. When organizations change their process by emphasizing inquiry, applied research, and improvement, there is significant opportunity for transformative culture change.

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Changing Culture doesn’t necessarily Improve a ProcessSo far, you’ve learned that changes to a process won’t take root - and better outcomes won’t be achieved - unless the culture changes, too. But can culture change alone lead to better outcomes? To put this a different way, think about a manager who tries to improve performance by distributing mugs and t-shirts emblazoned with the company’s mission statement. These measures may lead to greater awareness among employees. But do they achieve the desired effect: a change in behaviour?

Consider this case:

Practice ExampleRafael, a social worker, goes through a highly rated communication skills and team-building workshop. As part of the experience, he learns that better communication among a social work team can reduce the likelihood of errors leading to poor outcomes for children. Excited by what he’s learned, he returns to his job and attempts to improve performance by sharing what he’s learned with his unit. But he doesn’t propose a process change - a change in the way his team performs a key task. Although Rafael can see the value in better teamwork and staff members appreciate the information, there’s no improvement in outcomes for service users.

A common misconception is that changes in organizational culture will necessarily result in process improvement. Unfortunately, this is not usually the case. Let’s consider some examples of process changes that aim to change culture but that might not result in process improvement:

1. Giving awards for improved performance 2. Focusing on transparency and posting performance data 3. Improving communication through informational e-mail blasts and newsletters 4. Providing team building training to enhance the collaboration of teams

Many of these activities can be quite valuable in the right context, but if an improvement team focuses all its efforts on changing culture and attitudes, behaviour and outcomes are unlikely to shift. The team needs to focus also on changing the way people actually do their work. Let’s take a look at how Rafael’s case might have gone differently:

Practice ExampleWhen Rafael returns to his job, he shares what he’s learned with his unit. He then proposes testing a communication-related change at the end of the week using a check list. Convinced by Rafael’s passion as well as the evidence he has presented the staff members agree to give it a try. On Friday, they test the checklist in relation to one social work file.

In this case, Rafael attempts to change the culture of his unit by presenting evidence and showing his enthusiasm. But he also suggests a distinct process change. This is no guarantee that improvement will occur – but when culture change is paired with efforts to change the way people actually do their work, improved outcomes are more likely to occur.


QI105 The Human Side of Quality Improvement Task 2

Does your project rely on cultural changes? What steps are needed to address any changes needed?

Share your comments on Knowledge Exchange Discussion Forum.

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PS 102 – Human Factors and Safety Lesson 1: Understanding the Science of Human Factors

Why people make Mistakes

Human Factors Principles in Health & Social Care Settings

The examples on the IHI module show how factors contributing to error are at play in our daily lives.

But what about in Health & Social Care organisations?

Do you believe that your performance at work will not be affected by these circumstances because you are smart and well educated and you will try very hard not to make mistakes?

Vigilance and hard work can be effective to a point. In the long run, however, these contributory factors take over and we cannot sustain performance by merely trying hard and paying attention.

The science of human factors plays a role in health and social care every day:-

• When an inexperienced crèche worker ignores rough handling of a child by the service manager, because she is afraid of the consequences to herself if she reports it or makes a complaint

• When a social worker delays in seeing and talking with a child about whom a new child protection referral has been received because she is familiar with the family and assumes that it’s just another case of a neighbour making trouble for a single mother.

Practice Example

Jean is a social care worker with many years’ experience. At the moment she is assigned to a house, Heather View, in the local community which is home to four males ranging in age from 19-30.

The residents are adults with a learning disability and present with some behaviours that can challenge. The environment can be challenging and emotive at times which may manifest in feelings of joy and frustration in equal measure.

It is a difficult week in the house as some of the staff are on leave and the house has always operated with a self-staffing rota which means there is a consistency of staff and the staff cover for each other. A staff member has a family bereavement this week and is on leave also. This means Jean has to work longer hours.

Jean is on her own on Tuesday evening. Tom, one of the residents returns from work and is not feeling well, he is feverish, has vomiting and diarrhoea and is gone to bed for the evening.Jean goes to check on Tom before she finishes work to find that he has been sick again. As she is about to look after Tom’s personal needs, she hears loud voices from the sitting room and runs up to check what is going on. Two of the other residents are fighting over the remote control for the TV and she knows that this can escalate and therefore needs to attend to this immediately. She tells Tom she will be back shortly to help him.

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Your Turn

Jean’s ability to attend to Tom is impacted by:

• Fatigue

• Stress

• Interruptions

• Distractions

• All of the above.

After talking to the two residents about the remote control, Jean returns to Tom to help him get cleaned up and reassure him only to find that Tom tried to clean himself up but fell onto the floor and is unable to get up. Tom is in a state of distress, cyanosed and as he has epilepsy, Jean now needs to get some medical assistance and calls Tom’s GP to discuss his condition. Tom’s GP indicates that he will see Tom within an hour.

Your Turn

Jean is now distressed because of the following issues:-• She is not trying hard enough

• She is not paying close attention to what she is doing

• She is working in an environment where distraction, fatigue and rostering practices increase her risk of making a mistake.


PS102 Human Factors and Safety

Jean’s situation highlights the errors associated with human factors. Are there any potential errors associated with human factors that your service improvement initiative will seek to minimise?

Share your comments on Knowledge Exchange Discussion Forum.

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Lesson 2: Changes based on Human Factors Design Principles

The science of human factors or the study of the interrelationship between humans and their environment has identified design principles that include the following:- • Simplify • Standardize • Use forcing functions and constraints • Use redundancies • Avoid reliance on memory • Take advantage of habits and patterns • Promote effective team functioning • Automate carefully.

The following sections discuss how some of these design principles relate to social care.

Standardize

Some examples are the Reform Implementation Team (RIT) products, such as caseload weighting or the supervision proforma; the UNOCINI and NISAT Frameworks for assessment.

Use Forcing Functions and Constraints

Constraints make it difficult to complete a task. A constraint can be defined as the state of being checked, restricted, or compelled to avoid or perform some action

In child protection work, the requirement for a social worker to have her team leader sign off on certain procedures e.g. seeking a care order or requesting a child protection case conference may be considered as being a constraint. This requires a worker to reflect on evidence before potentially having to justify significant actions to a senior colleague, who even then may overrule her.

Forcing functions make it impossible to do a task incorrectly. They create a hard stop that you cannot pass unless you change your actions.

In child protection systems, the requirement to hold a multi-agency child protection conference before a child is placed on a child protection register or notification system may be seen as a forcing function. Requiring a statutory service to bring together key professionals, parents, children/advocates forces a review of concerns, risks and protective factors before making a significant decision on a child’s and family’s relationship and freedoms.

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Avoid reliance on memory

You will have seen on the IHI module some examples of how checklists can be used to avoid reliance on memory. Some examples of checklists in social care include the following:-

• A checklist for setting up a Direct Payment• A checklist for Person Centred Reviews• A checklist of information to be sought when vetting applications of persons wishing to be

considered as foster carers • A risk assessment checklist used when a young person is admitted to a high support

residential service.

Lesson 3: Using Technology to Mitigate the Impact of Error

Throughout health and social care, we are beginning to see how technology is used in many ways to improve the consistency of care. For example

Child Care Information Systems can assist in standardising processes within statutory child protection and welfare services. Requiring workers across a large geographical area to collect and record standard data, often within set timeframes, provides consistency of practice as well as real-time data that is essential for quality assurance and service planning.

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PS 103 – Teamwork and Communication Lesson1: Why Are Teamwork and Communication Important? Below is an example of the importance of good communication and how things can go wrong.

Practice Example

Mr X is a 36 year old man with a history of drug induced psychosis and bio-polar disorder. Mr X has been re-admitted to an acute mental health ward with a relapse in his condition with possible recent drug use. Mr X has also been homeless for 4 months and has little or no contact with family or friends.

On initial assessment Mr X present with low mood, reduced memory functioning and heightened anxiety. On day 2 of admission Mr X reported to staff that he needed “an injection.” However staff dismissed this due to background history of drug use. Shortly after this Mr X started to behave differently and was observed to be sweating, dizzy and reported to be feeling hungry.

Staff made contact with Mr X’s G.P who advised staff that Mr X has Type 1 diabetes and would require his insulin injections.

Better communication between community staff and hospital at admission could have kept Mr X safe; instead assumptions were made.

The next example demonstrates how similar issues led to tragic consequences.

The Tragic Consequences of Ineffective Teamwork in Health and Social Care

Practice Example

Victoria Climbié was prematurely discharged from hospital, having been admitted with suspected non-accidental injuries. Sources of the confusion were multiple, but included a nurse’s fax that said Victoria was ‘fit for discharge’ being interpreted by the social worker as meaning the ward staff had no concerns at all.

At the time, Ms A. (social worker) says she understood the phrase ‘fit for discharge’ to mean that the hospital no longer had any concerns about Victoria in the general sense. By contrast, several hospital staff in their evidence to the Inquiry said that ‘fit for discharge’ meant that Victoria was medically fit to leave and they assumed the social workers would make the necessary inquiries of her home and family before that actually happened.

As can be seen by the examples above, a critical element in effective teamwork is communication. Teams that do not communicate well are not truly teams, but merely groups of individuals working side by side. When teams do not communicate effectively, bad things can happen. According to The Joint Commission, communication failures account for the occurrence of a large number of serious adverse events.

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Lesson 2: Basic Tools and Techniques

SBAR enables staff to give information in a structured manner. Standing for Situation, Background, Assessment, Recommendation, this structured communication technique is used to standardize communication between two or more people. It helps set the expectation within a conversation that specific, relevant and critical informational elements are going to be communicated every time a service user is discussed.

See the following example:-

An out of hours social worker calls the Doctor-on- Call with concerns about a woman who has a mental illness and is known to Psychiatric Services. This is what the social worker reports to the Doctor-on- Call.

Practice Example

“I’m afraid Martha has gone off again….her mood’s low and I would say she’s not really been taking her meds half the time… or sleeping properly …so today she fell out with all the family … not that unusual for this family .. they have a lot of conflict but it’s been really bad today and a knife has been brandished …it’s likely she’s responding to voices again … so probably good if you could pay a wee visit before something awful happens.”

The above statement contains critical information about risk that could be misunderstood or over-looked. See the example below which demonstrates how using SBAR improves communication.

Practice Example

S: I am the Out of Hours SW and I’m calling you about Martha Brown, (D.O.B 01.06.75) because I am concerned that her mental health is deteriorating, and she is putting herself and others at risk.

B: Martha has Schizophrenia and has been known to the Community Mental Health Team for 10 years. She has been well for the last two years and is seen on a regular basis by the CPN. Martha’s sister is concerned that Martha has not taken her medication because she did not collect it this week and she has been up all night making threatening phone calls to family members. Martha’s sister rang the Out of Hours Team for assistance because Martha was threatening to come to her house with a knife saying “Beelzebub told me to get you”.

A: The Out of Hours Social Worker gives her assessment that Martha’s mental health has deteriorated, possibly due to being off medication for a week and lack of sleep. She is possibly responding to voices and may put herself or others at risk.

R: The Out of Hours Social Worker recommends that the Doctor-on-Call accompanies her on a joint visit to assess Martha and decide what actions are required.

Can you see how SBAR identifies the key pieces of information and the important facts about risk?

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Psychological Safety

A critical element of good teamwork is psychological safety. Psychological safety occurs when an individual feels comfortable expressing an opinion, mentioning problems, or correcting errors.

Within psychologically safe team environments:-• Every team member is comfortable speaking up • Every team member and what they have to say is treated with respect at all times • Disrespectful actions are not tolerated.

Psychological safety is critically important in teams, as people act tentatively and defensively when they don’t feel safe, thereby inhibiting their willingness to participate and speak up. When team members feel they or their suggestions may be criticized, a very unhealthy dynamic occurs, eroding team cohesion. A critical element of psychological safety is respect. And conversely, disrespect can erode psychological safety quickly and sometimes irrevocably.

Practice ExampleA health visitor has been working with a family about whom there have been a number of child protection referrals. Social services have now called a child protection case conference and the nurse has been invited to attend. Unfortunately, this nurse has had an on-going difficult working relationship with the allocated social worker. The nurse has found the social worker to be dismissive about her opinions and concerns that she has raised about other families. On the morning of the case conference, the nurse calls in sick rather than face this social worker. As a result, key information about protective factors which the nurse has observed in the mother’s relationship with her children was unavailable.

A lack of psychological safety has prohibited this nurse from contributing valuable information to a child protection case conference.

If an organization believes in creating a safe work environment in which all employees are treated with respect at all times, then it needs to be very clear that management will consistently model those values and anything less is not acceptable.

So what is your role in using these teamwork and communication techniques? Every member of a health and social care team has a responsibility to actively use the communication techniques and team behaviours discussed in this lesson. The more people invest in team development and communication skills, the more productive and safe the care we provide will be.

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Lesson 3: Communication During Times of Transition

Consider Transitions in Health and Social Care

These transitions, sometimes called ‘shift handovers’, are very risky times. There is a lot going on, frequent interruptions, providers who are unfamiliar with one another and usually a great deal of information to communicate in an extremely short amount of time. Because of their complexity and the issues associated with human factors inherently present during handoffs, interruptions, stress, distractions, fatigue, and so forth, ineffective handovers can increase the likelihood of error and harm.

The Benefits of Good Transitions

Although poor transitions can lead to harm, effective transitions in which relevant information is communicated quickly, accurately and thoroughly can help reduce the likelihood of error and harm.

Practice ExampleAn emergency foster care placement is needed for two brothers (ages 4 and 6) whose mother has been arrested after a drunken altercation at their home. The social worker has made contact with a foster carer. It’s 1.30am:-

Social Worker Tina: Hi Mary. I have two little lads needing a safe place tonight. Let me give you a quick rundown:

S - We’ve two brothers, Tom and Liam, aged 4 and 6 who have just been taken into care.

B - They’ve never been in care before and both are very upset at being away from mum. The eldest lad Liam has a mild learning disability and is not toilet trained.

A - We need care for at least one night until we can review what their short/medium term needs are.

R - I’d like to bring them over to you. Can you arrange beds for them in the same room and I can be with you in 45 minutes after we pick up some clothes for them.

Mary (Foster Carer): Tina, we’ll be happy to take them. I will prepare their room and be ready to settle them in.

Within this communication, the social worker and carer exchange relevant information quickly and ensure that the needs of the children will be addressed.

Verbal Repeat Back

In addition to SBAR and checklists, another communication tool that can be particularly helpful in care transitions is the verbal repeat back. This is a type of communication tool that “closes the loop” between sender and receiver. The tool involves four distinct actions:-1. The sender concisely states information to the receiver. 2. The receiver then repeats back what he or she heard. 3. The sender then acknowledges that the repeat back was correct or makes a correction. 4. The process continues until participants verify a shared understanding.

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Within this model, responding to a message with an “okay” or an “uh-huh” is not sufficient to close the communication loop. The message must be explicitly restated and acknowledged.

Believe it or not, closed-loop communications occur in everyday life all the time. Think about the last time you went to a fast-food restaurant. You ordered a cheeseburger with no pickles, French fries, and a small vanilla shake. The person taking your order repeated back your order to make sure she heard it correctly. You verified the repeat back or corrected her as necessary. Think about the last time you went to Starbucks. The barista repeated back your drink order before preparing it to ensure he made the correct drink.

Within the airline industry, air traffic controllers and flight crews repeat back several critical pieces of information to ensure flights are headed in the right direction at the right time in the right way. Within health care, verbal repeat backs are used to confirm critical information, such as medication orders, or to confirm other important information, such as the correct site, side, and patient before a procedure.

Practice ExampleA child in care (Emma) has gone missing from her placement with a residential children’s centre during the night. The on-duty childcare worker (Sean) makes contact with the child’s social worker (Sally).

Sean: Hi Sally. Emma has been missing since about 5 o’clock during the night. We have been unable to contact her on her mobile phone and there was no sign of her when we drove around the area at 6:00.

Sally: Okay, so Emma has been missing since for possibly 5 hours and we currently have no knowledge of her location.

Sean: One of the other girls says she has been seeing an older guy who hangs around the training centre some days. Not sure of who he is but the name “Brian” was mentioned.

Sally: Did anyone try contacting her older brother? She has headed off to his flat in the past.

Sean: No

Sally: Alright. Let me confirm. It’s possible that she has linked up with this Brian chap, but we also need to check with her brother. Can you make a call to her brother, see has he heard from Emma. I will contact the PSNI and let them know we have someone missing from care. Don’t leave the centre. I will be over in 20 minutes. Ring me on my mobile if you come up with any information.

Sean: See you soon.

Closed-loop communication, such as repeat back, provides a smooth transition between care providers and helps ensure that no critical information is lost. Although transitions in care can be risky, by using effective communication tools such as SBAR, checklists, and verbal repeat back, you can lessen the likelihood of error, overcome the effects of human factors issues, and ensure that the information communicated is accurate, complete, and timely.


PS103 Team work and Communication

What have you learned about teamwork and communication and how will you put in it into practice in this project? Share 3 ideas on the Knowledge Exchange Discussion Forum.

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L101: Becoming a Leader in Healthcare Lesson 1: Taking the Leadership Stance

Practice Example

Sarah is a newly qualified social worker who has just started work in the area a few weeks ago. She had completed her second practice placement as a member of the team and is familiar with many of the issues and challenges which are facing families in the area. Sarah has been assigned to the Child Protection team by her Assistant Principal Social Worker due to the backlog of referrals which has built up in recent months.

Sarah has noticed a pattern in referrals relating to ‘smacking’ in a particular neighbourhood which is causing the team some concern. She notices that although not exclusively the case, the majority of the referrals appear to relate to the families of children attending the same school.

In discussion with her colleagues she discovers that this is a pattern which has been noticed for some time. Having participated and trained in facilitating a parenting programme whilst in college, she has some ideas about how the team might go about examining the impact of this and in persuading her manager that this is a worthwhile use of staff resources in the context of significant day to day pressures being experienced by the area.

Ann, an experienced member of the team who has been working in the area for several years, speaks to Sarah in private about how she was not convinced that this would be a good approach. Ann is not the only colleague to express this view to Sarah:

• “This has been tried before and with no impact. We have far too much other work to do and can’t keep up with the volume of work we already have”

• “You have to understand where these families are coming from. Unless you can address the other stressors in their lives, this will always be a problem”

• “It’s a cultural issue you know. I’ve seen it time and time again where parents from a specific ethnic group do not see anything wrong with hitting their kids as a form of discipline. You can’t change that”.

Nevertheless, Sarah feels strongly that there are merits in her approach and that it will have an impact if followed through. She has studied the positive effects which parenting programmes can have and is clear in terms of her rationale and evidence base.

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Let’s look at the seven things a leader can do to help guide Sarah:

1. Form a clearer picture of the real situation: This is done by gathering data, not just listening to opinions: Ask how big a problem is this really? Record over the next month the total number of referrals received in this category by neighbourhood and referrer. How significant is the ethnic background of the parents? Is this a factor?

2. Reframe the problem: “This is a way of improving liaison with local referrers and changing the perception of social workers as not being available or providing feedback. If it works it could potentially reduce the number of referrals and decrease the pressure on the teams also”

3. Connect the problem of the powerless to the strategic and business concerns of the powerful: Social Services places considerable focus on developing local community partnerships and reducing the number of inappropriate referrals. Unless there are opportunities to engage with families in a real way at a local level through the provision of services, this task will be more difficult.

4. Connect the problem of the powerless to the hearts of those in power: “This initiative will make a real difference to the experience and safety of children. It will support parents to explore alternative and more effective ways of disciplining their children and ultimately lead to better outcomes by addressing an intergenerational culture where physical chastisement is seen as ok.”

5. Seek a powerful ally: “I bet the Child Psychiatrist and the Area Manager would support this. Do you remember they worked together in implementing a public awareness campaign in relation to bullying last year? This had a significant impact in addressing concerns about youth mental health and suicide. The Assistant Principal Social Worker has also spoken very passionately about this.” 6. Start looking for strong ideas about how to solve the problem: “Let’s see if we can talk to one of the school nurses and a member of the CAMHS team about joining us in providing this programme and then we can speak to our team leader about it as it will be more sustainable if it is not just social work led. Some of the social care and family support staff may be interested also”.

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7. Put it together in an action plan: “We need to try this. If we ask the school nurse and speak to the local school also we can gain support and won’t be doing this on our own. We need to have local buy in terms of greater knowledge of the families and what approach would work best. Perhaps a representative from one of the local ethnic communities’ advocacy groups would be more effective to ensure that all cultural aspects are considered. The initiative is also more likely to succeed if it is seen by families as non-judgemental and supported by a number of agencies providing services. We will ask our team leader to also discuss with the Assistant Principal Social Worker to raise at the area management team meeting and that we would be willing to present our proposal with the information we have gathered”.

None of these approaches is guaranteed to succeed. But just sticking with the same approach because it is comfortable or safe is not leadership.


L101 Becoming a Leader in Health Care Task One

Think back to a situation when colleagues were complaining about something that was wrong and the role you played in that conversation.

How could you have taken a leadership stance in that situation?

Share your ideas on the Knowledge Exchange Discussion Forum.

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Lesson 2: The Leadership Stance is Not a Pose

Sarah, as a newly qualified social worker and in a similar way to Meridith, the doctor in the IHI Programme’s example, has taken a leadership stance. She initiates action. However, some of her colleagues are also not as convinced as they appear to be.

What do you think some of them might really be thinking?

The plan which Sarah proposed appears, on the surface at least, to have the support of the team. It has been agreed at the recent department meeting and several of her colleagues have volunteered to help. Sarah’s Team Leader has spoken to the Principal Social Worker who has secured the support of the Area Manager to explore further with the Director of Nursing and the Child Psychiatrist to release staff to participate in the initiative.

Although supported by the school principal, the teacher nominated to assist with the programme is not keen on the idea. He believes that all concerns relating to children should be dealt with by the social work department as there simply are not the resources within the school to allocate to such a preventative programme. He is not convinced as to the overall merits of the approach. The school is in an area suffering from acute disadvantage where the problems it faces on a daily basis are particularly complex.

Nevertheless, Sarah now has a better grasp of the problem. Should she go the PSW and Area Manager to raise these objections with the school principal? Some of her colleagues are close to saying “I told you so” as there have been on-going problems concerning interdisciplinary working not only with schools as all services are facing similar resource pressures. Other social workers have been enquiring when the parenting programme will be starting as they have clients which they would like to refer.

What should Sarah do?

Here is what Sarah does. Do you think it shows leadership?

With the support of her team leader, Sarah jointly facilitates a meeting with representatives from CAMHS, school nursing, family support service and John, a representative from the local drugs task force who has experience of delivering the ‘parenting plus’ programme. John provides a brief presentation on the evidence base for the approach and the outcomes from programmes he has facilitated to date. This information is warmly received and results in the nominees requesting to participate in a training programme so they can become trained facilitators. The teacher has the opportunity to express his concerns but these were addressed by the strong evidence base which was clearly demonstrated and through the outcomes achieved where similar programmes had been successfully delivered. This led to a long discussion about the effective targeting of available resources on what works.

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Lesson 3: Influence Persuasion and Leadership

Sarah has faced opposition in developing a targeted parenting programme to respond to a cluster of physical abuse referrals. She is conscious of the enthusiasm of some of her colleagues who have wanted to have a programme such as this to refer some of their clients to for quite a while and that this is a real opportunity to pull together support to make it happen. The clear opportunity and potential which a recognised parenting programme such as this presents in making a real difference is a strong motivating factor to continue.

There is a lot of material here for Sarah to think about to move from planning to implementation of her idea.

Here’s an example of what Sarah in our story does:-

• Prepares a presentation for the next large social work department meeting and requests the PSW to put on the agenda for the meeting for discussion;

• Secures agreement from her line manager to ring-fence 3 hours of her working week towards training and establishing the parenting programme. It was also agreed that a colleague will be released to support her based on another member of staff volunteering to participate;

• Sarah writes to the Director of Nursing and the Clinical Director for CAMHS service (co-signed by the PSW) requesting to make a presentation to a team meeting in order to try to obtain multidisciplinary input

• After a meeting with the Area Manager, she obtains agreement to propose establishing a multi-disciplinary working group to oversee the planning and implementation of the programme.

Remember:

1. Some people are logical (or “rational”) and will only be moved by reasoning with clear presentation of data and evidence to support a proposal.

2. Others are more formal (or “physical”) and will be looking for signs that those in power and authority agree

3. BUT the majority of people do not tend to be influenced most powerfully by logic or formal authority, but connection needs to be made with their emotions, their hearts.

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Lesson 4: Measuring Leadership

Your Turn

Is Sarah, a new member of the social work team, an effective leader?

What are your views?

How has she demonstrated leadership?

Certainly Sarah has taken action. She has undertaken an analysis of data, of referrals made to the duty team, identified patterns of concern and made a proposal to address what she has identified in consultation with her colleagues and managers.

Ultimately and as is often the case, the outcome rests outside of Sarah’s control and ability to just make it happen. Or does it? How might Sarah re-frame the problem?

Your Turn

Look at Drucker’s “10 Things Every Good Leader Knows” on the IHI module page 3 and decide whether Sarah is an effective leader.

Which of Drucker’s points are areas of strengths for Sarah and which are areas of weakness?


L101 Becoming a Leader in Health Care Task Two

How can you use the learning from Sarah’s example to demonstrate effective leadership in your service improvement initiative?

Share your ideas on the Knowledge Exchange Discussion Forum.

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ReferencesKaufman H. The Limits of Organizational Change. Transaction Publishers, 1995

Kohn A. Punished by Rewards: The Trouble with Gold Stars, Incentive Plans, A’s, Praise, and Other Bribes. New York: Houghton Mifflin Company; 1993. Deci EL,

Koestner R, Ryan RM. A meta-analytic review of experiments examining the effects of extrinsic rewards on intrinsic motivation.Psychological Bulletin. 1999;125(6):627-668.

Laming H. (2003) The Victoria Climbié Inquiry: Report of an Inquiry by Lord Laming, p.148. TSO (The Stationary Office).

Deming W.E. The New Economics for Industry, Government, Education, 2nd Edition Cambridge: The MT Press, 2000

Drucker http://www.inc.com/leigh-buchanan/10-traits-of-a-drucker-like-leader.html

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AcknowledgementsWe would like to acknowledge the work of the Health, Information and Quality Authority (HIQA), Dublin and thank them for giving us permission to use the supplementary material they developed to support the IHI Open School Programme for their social workers in 2014.

We are particularly grateful for the support of Marie- Kehoe O’Sullivan, Director of Safety and Quality Improvement, HIQA, in the development of this supplementary learning material.

Their material has been adapted for the Regional Quality Improvement in Social Work programme in Northern Ireland by the programme implementation team.

Programme Implementation Team:-

• Pat McAuley Social Care Governance Facilitator, South Eastern HSC Trust

• Eileen McKay Learning & Development co-ordinator, South Easter HSC Trust

• Pauline Thompson Social Care Governance Facilitator, South Eastern HSC Trust.

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Compiled by Pat McAuley, Eileen McKay and Pauline Thompson.South Eastern Health and Social Care Trust December 2015

Designed by Communications Department, South Eastern HSC Trust

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