Qualitative Findings – EPIC I Madelyn Law & Janet Yamada University of Toronto On behalf of Dr....
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Transcript of Qualitative Findings – EPIC I Madelyn Law & Janet Yamada University of Toronto On behalf of Dr....
Qualitative Findings – Qualitative Findings – EPIC IEPIC I
Madelyn Law & Janet YamadaMadelyn Law & Janet YamadaUniversity of TorontoUniversity of Toronto
On behalf of Dr. Bonnie StevensOn behalf of Dr. Bonnie StevensSick Kids, University of TorontoSick Kids, University of Toronto
EPIC/PHSI Training Workshop, Toronto, Ontario
November 9th-10th
A Qualitative Examination of A Qualitative Examination of Changing Practice in Canadian Changing Practice in Canadian Neonatal Intensive Care UnitsNeonatal Intensive Care Units
Bonnie Stevens, Shoo K. Lee, Madelyn P. Law, Janet Yamada Bonnie Stevens, Shoo K. Lee, Madelyn P. Law, Janet Yamada and the Canadian Neonatal Network EPIC Study Groupand the Canadian Neonatal Network EPIC Study Group
In press – Journal of Clinical Evaluation and PracticeIn press – Journal of Clinical Evaluation and Practice
OutlineOutline
Brief overview of theoretical background Brief overview of theoretical background and qualitative methodsand qualitative methods
ResultsResults
What to think of as you move forwardWhat to think of as you move forward
Purpose of the EPIC StudyPurpose of the EPIC Study
To implement and evaluate a national To implement and evaluate a national system for practice change in NICU’s system for practice change in NICU’s based on evidence and data. based on evidence and data.
Quantitative research componentQuantitative research component Qualitative research componentQualitative research component
Purpose of the qualitative studyPurpose of the qualitative study
The purpose of this study was to identify:The purpose of this study was to identify:
(a) existing successes and problems, (a) existing successes and problems,
(b) factors that affect successes and problems, (b) factors that affect successes and problems,
(c) potential challenges to change (c) potential challenges to change
associated with the implementation of changes to associated with the implementation of changes to infection control/chronic lung disease infection control/chronic lung disease practices in NICUs across Canada. practices in NICUs across Canada.
Driving Theoretical BasisDriving Theoretical Basis
Research on change in the Vermont Research on change in the Vermont Oxford NetworkOxford Network
• Pediatrics Issue111(4)Pediatrics Issue111(4)
Organizational structure and changeOrganizational structure and change• (Baker et al., 2003; Pettigrew, 1987)(Baker et al., 2003; Pettigrew, 1987)
The Improvement Cycles The Improvement Cycles • (Langley et al., 1998)(Langley et al., 1998)
MethodologyMethodology 13 sites13 sites
7 Chronic Lung Disease7 Chronic Lung Disease 6 Nosocomical Infection 6 Nosocomical Infection
154 participants154 participants 76 Individual interviews76 Individual interviews 14 Focus groups14 Focus groups
Health professionals representing the full Health professionals representing the full spectrum of NICU servicesspectrum of NICU services neonatologists, nurses, pharmacists, respiratory neonatologists, nurses, pharmacists, respiratory
therapists, managers, educators, parents therapists, managers, educators, parents
Data AnalysisData Analysis Thematic AnalysisThematic Analysis
“…“…involves the search for common threads that extend involves the search for common threads that extend throughout an entire interview or set of interviews.” throughout an entire interview or set of interviews.”
(Morse& Field, 1994)(Morse& Field, 1994)
First level of coding – Open coding:First level of coding – Open coding: Researchers read the interviews line-by-line and descriptive Researchers read the interviews line-by-line and descriptive
code names are written in the right hand margin of the transcript.code names are written in the right hand margin of the transcript.
Second Level of coding – Selective Coding:Second Level of coding – Selective Coding: Categorize, recategorize and condense all first level codes into Categorize, recategorize and condense all first level codes into
the main categories that will reflect the informationthe main categories that will reflect the information
ResultsResults
Three Overarching Themes found at Three Overarching Themes found at both CLD and Infection Sites:both CLD and Infection Sites:
1) Human resources1) Human resources
2) Organizational Structure2) Organizational Structure
3) Communications3) Communications
Human ResourcesHuman Resources
Staffing issuesStaffing issues SizeSize of staff of staff RatioRatio of educator to staff of educator to staff EducationEducation and experience levels and experience levels Staff Staff turnoverturnover
Consistency in practiceConsistency in practice InconsistenciesInconsistencies in practices even after a new practice in practices even after a new practice
was introducedwas introduced Need support from the Need support from the leadershipleadership to institute and to institute and
maintain new changesmaintain new changes
Organizational StructureOrganizational Structure
Approval ProcessApproval Process Long and tediousLong and tedious with many levels of approval with many levels of approval Loss of momentumLoss of momentum for the change for the change
Multidisciplinary Approach to careMultidisciplinary Approach to care Success attributed to the Success attributed to the engagementengagement of of
multidisciplinary teams multidisciplinary teams Peer Leaders/ChampionsPeer Leaders/Champions from the team to from the team to
lead the changelead the change
CommunicationsCommunications
Frequency and consistency Frequency and consistency of communicationsof communications
Variety of channelsVariety of channels for for communicationscommunications
InundatedInundated with information with information Disconnect Disconnect between the between the
generation of new information and generation of new information and practice to print form (i.e. updating practice to print form (i.e. updating manuals and website)manuals and website)
Rationale for changeRationale for change Need to know the Need to know the “WHY”“WHY” and and
“HOW”“HOW”
CommunicationsCommunications
Feedback ProcessFeedback Process UpdatesUpdates and results on how the change had and results on how the change had
impacted clinical problems in order to help impacted clinical problems in order to help reinforce the new practicereinforce the new practice
Include practitionersInclude practitioners in designing, in designing, implementing and evaluating changeimplementing and evaluating change
Unique to Chronic Lung DiseaseUnique to Chronic Lung Disease
Identification of Policies related to CLDIdentification of Policies related to CLD Participants had Participants had difficulty identifying the difficulty identifying the
existing policiesexisting policies and practices that were and practices that were currently in place to deal with CLD or to help currently in place to deal with CLD or to help prevent CLDprevent CLD
Creating a Creating a preventivepreventive and not reactive focus and not reactive focus to the care of CLDto the care of CLD
Unique to InfectionUnique to Infection
Unit specific policies for Unit specific policies for infectioninfection Differences in policiesDifferences in policies in the NICU in the NICU
compared to overall hospital policiescompared to overall hospital policies
Disconnect between policies Disconnect between policies and practiceand practice Staff are aware of policies and Staff are aware of policies and
procedures but also stated that procedures but also stated that these policies were these policies were not always not always followedfollowed
Unique to InfectionUnique to Infection
Environmental Environmental Design of the unitDesign of the unit in relation in relation
to number of sinks, to number of sinks, ventilation, traffic in the unit, ventilation, traffic in the unit, etc.etc.
VisitationVisitation in relation to in relation to number of people allowed at number of people allowed at the bedside and controlled the bedside and controlled entrances to roomsentrances to rooms
What to think of as you move What to think of as you move forward…..forward…..
Context (site) specific barriersContext (site) specific barriers What are the barriers related to the practice environment at your What are the barriers related to the practice environment at your
hospital?hospital?
The human side of changeThe human side of change Inform individuals why and how they should change their practiceInform individuals why and how they should change their practice Provide feedback on new knowledge and results of implementing Provide feedback on new knowledge and results of implementing
changechange Involve them in the change processInvolve them in the change process
What to think of as you move What to think of as you move forward…..forward…..
Structure for successesStructure for successes Focus on the team, champions, Focus on the team, champions, cultureculture, readiness for , readiness for
changechange Address human resources strategiesAddress human resources strategies
Communicate effectivelyCommunicate effectively Communications PlanCommunications Plan
Create a Culture of ChangeCreate a Culture of Change
Greater level of awareness
Level 1: Artifacts(meetings, reports, work environment)
Level 2 Values(moral codes, philosophies, values in use)
Level 3: Basic Assumptions(dominant values that have moved into the organizations members unconsciousness)
Visible but often not decipherable
Taken for grantedInvisible preconscious
Schien, 2004
Thank You!Thank You!