This is the model for improvement, which you’ve already heard about in week three and which Paul Batalden spoke about at the beginning of week five. You will hear more about the model for improvement in week six. For now, let’s just look at the three questions that are in the model for improvement. What are we trying to accomplish? How will we know that a change is an improvement and what changes can we make that will result in an improvement? What we’re going to do is give you some more detail that you can put into these three questions to help you plan your intervention.
Paul Batalden mentioned the work of Susan Michie and other psychologists on how we can change behaviour and he mentioned something called behaviour change techniques. So these are simply the active ingredients of an intervention which is designed to influence the causal processes that regulate behaviour. Most interventions have more than one BCT and the model for improvement is founded on four very powerful BCTs, which
are: one, goal setting, two, self-monitoting, three, feedback, and four, action planning.
Paul Batalden spoke about the importance of monitoring and measurement. In fact, he called them the “friends of change” and he also mentioned eight principles of sustainable measurement. So let’s look at those, again. They come from a paper that was published in 1998 and some of these have already been discussed in week three. So the key thing is that you want usefulness. You want measurement, or measures, that the front line clinical teams feel are useful and they don’t have to be perfect. You must have a balanced set of process, outcome, and cost, or measures of unintended consequences or balancing measures. You need to keep the measurement simple.
You should use qualitative as well as quantitative data, so just talking to people and recording what they think and tell you is a form of measurement. You ought to write down operational definitions of your quantitative measures and when it comes to doing samples, it’s much better to have small repeated samples than very big samples. And critically, the idea of self-monitoring means that you build measurement into the daily work of the team. They need to contribute to the measurement. You need to develop a measurement team of all the people who are going to be involved and who should comment on the measures. Now we’re going to consider what improves the effectiveness of feedback.
The evidence that I’m going to discuss comes from a Cochrane review. That reference is given here. Cochrane reviews are often thought to be about the effectiveness of treatments but Cochrane actually, as well as looking at randomised trials of new treatments, has a whole group that is called “Effective practice and organisation of care”. So what they look at are interventions that are about changing professional behaviour to improve the quality of patient care and this particular Cochrane review focused on audit and feedback, so it’s relevant to our consideration of antimicrobial stewardship. The interventions that they included were across the whole range of health care, so not just about antimicrobial stewardship but the findings are relevant.
So they found that in analysing data from over 50 randomised trials taken together, that evidence said that feedback is likely to be more effective when the source is a supervisor or colleague from the clinical team, when it’s provided more than once, when it’s delivered in both verbal and written formats, and when it includes an explicit target and an action plan. What they mean by explicit targets is rather than saying we want to reduce the use of cephalosporins, the explicit target would say, we want to achieve a 20% reduction in the use of cephalosporins within the next three months.
The question “What are we trying to accomplish?”, in the model for improvement is really all about goal setting and in this question you should focus on the care process that you’re wanting to improve and we’re going to go on to look at administering antibiotic prophylaxis. So if we just take the example that we want to make sure that all patients receive antibiotic prophylaxis within an hour of the incision, then the goal setting threshold would be something like we want to make sure that at least 95% of patients receive antibiotic prophylaxis within an hour and that we aim to achieve that target within three months.
And then participant awareness and involvement is about the need right from the start to talk to all of the stakeholders– in this case, the surgeons, the anaesthetists, and the theatre nursing staff, the pharmacists– about why we’re doing this and about getting them to agree to the targets that you’re going to set. The next question in the model for improvement is “How will we know that change is an improvement?” The first thing that you need to consider here is, again, goal setting. This is where the higher order goals come in. So in the “What are we trying to accomplish?” question, it’s all about the reliability of the process of care. In the “How will we know that change is an improvement?”
question, we need to make it clear why improving that process will lead to important outcomes. So this is where you need to link it to clinical outcomes and to outcomes that are important to the organisation as a whole, which includes costs. The second thing you need to be thinking about here is self-monitoring of behaviour. Because that’s the way that the front line teams will know that the changes that they’re making are working. If they’re actually monitoring the impact on management of their patients, then they can see it in front of their eyes. You need to also give them regular feedback and we’ve considered already the idea that this needs to be more than once.
It needs to be in verbal and written format. It needs to come from a member of the team and you need to really think about what’s the content of the feedback and, again, to emphasise the importance of higher order goals. What Dr. Mike Cooper told you is that if you say, congratulations, you have reduced mortality in our hospital, and then go on to talk about the care processes that they have made more reliable which have lead to that, it’s a much more impactful statement. The third and last question in the model for improvement is “What changes can we make that will result in improvement?”. Again, we return to goal setting because this is where the idea of sub-goals is important.
So that’s saying that you need to really understand the whole pathway of care that leads to the point that you want to improve. In the case of the giving antibiotic prophylaxis within an hour of operation, one of the things that you should do is sit down with the clinical teams and go through the whole care pathway from the arrival of the patient in the operating theatre until they leave, and be clear about where are the opportunities for improving the reliability of administering the prophylaxis and what things could be done to improve that. So that’s then leading you on to action planning, which is about thinking about the changes that could be made.
And again, and what’s important is not just to think about the content of the action planning but who have you involved. And it’s going to work best if the whole team feel they have been involved or contributed their ideas.