One of the tenets of performance improvement and change management is standardization .”
“ That is tough to achieve when each unit in the hospital has its ’ own culture as well as patients with different demographics , risk factors , etc . In other words , the challenges faced by healthcare personnel in the emergency department differ from those in the intensive care unit and caring for geriatric patients is different than caring for pediatrics .”
— Ann Marie Pettis , RN , BSN , CIC ,
FAPIC
beneficial it would be to behave a certain way , aligned with the evidence .”
Schaffzin continues . “ It ’ s human nature to want to know the reasoning behind making a change , as many people may naturally resist change in general . And so , if you introduce a change , the first question you ’ ll often get is ‘ What ’ s the evidence ?’ If you can demonstrate evidence or synthesize evidence , oftentimes it either helps take that concern away or it helps people think more broadly about it and understand what you ’ re trying to do . Sometimes it can be a challenge to find definitive evidence in one direction or another , but for the most part if you can find the equipoise of evidence , I think it carries a lot of weight in today ’ s healthcare environment , no matter who you ’ re talking to or at what level you ’ re discussing it .”
The authors of the SHEA / IDSA / APIC practice recommendation acknowledge the complexities of the acute-care setting and the numerous barriers to proper practice .
“ One of the tenets of performance improvement and change management is standardization ,” says Pettis . “ That is tough to achieve when each unit in the hospital has its ’ own culture as well as patients with different demographics , risk factors , etc . In other words , the challenges faced by healthcare personnel in the emergency department differ from those in the intensive care unit and caring for geriatric patients is different than caring for pediatrics . Healthcare isn ’ t like industry , where you can standardize processes more readily . Another challenge is the hierarchical structure in healthcare which makes it difficult to engage all stakeholders and it often deters staff from ‘ stopping the line ’ or speaking up when observing colleagues not following best practices .”
As Trivedi and Schaffzin , et al . ( 2023 ) observe , “ Foundational to any implementation effort is understanding factors that promote or hinder change . Promoting factors are called ‘ facilitators ’ and hindering factors are ‘ barriers .’ Determinants of these factors may be individual , such as the preferences , needs , attitudes , and knowledge of HCP , hospital leaders , patients , and visitors . An individual may be a strong , engaged leader ( a facilitator ) or an unengaged obstructor ( barrier ). Determinants may include a team ’ s composition or ways of communicating , an organization ’ s culture and capacity , or a system ’ s policies and resources . Organizationally , implementation may be facilitated or impeded by expectations and allocation of time ( competing priorities , data collection burden , provision of time to dedicate to an effort , fast turnaround at the expense of sustained processes ), resources ( ease of adapting the EMR , staff capacity , and turnover ), and leadership support or follower buy-in .”
Barriers to proper practice can be broken , but understanding what keeps those barriers in place is essential to the process of dismantling them .
“ People tend to make processes more complicated than they necessarily need to be ,” says Schaffzin .
“ In healthcare , people will adopt a practice , they ’ ll modify a practice , they ’ ll do something consistently and it becomes a custom . They think , ‘ I always do it this way , and I like to do it this way . I ’ ve had good experience with doing it this way ,’ whether or not it ’ s evidence-based , or whether or not it ’ s necessary , and what that does is introduce complexity , because others don ’ t have the same mental model as they do .”
He continues , “ Implementation is about simplifying what we need to do , and that can challenge people ’ s customs . It ’ s not meant in a mean or insulting way , but when you ask people ‘ Why do you do it that way ?’ or ‘ Why didn ’ t you wash your hands ?’ often people will say , ‘ Oh , I don ’ t know ,’ or “ I forgot .’ That ’ s a reasonable answer , but likely they forgot because something else was going on and they were distracted by something that they may not even be aware of . That could be one reason why people have a hard time implementing evidence amidst their complex healthcare environment .”
“ The opposite can happen if people look at the end result of an implementation project and it seems so simple ,” Schaffzin adds . “ They may think , ‘ Oh , that ’ s all they had to do ,’ and think implementation itself is simple . The thing is , that is misleading . Any five-page paper represents months , if not years , of experiments . You can ’ t flip a switch and change people ’ s behavior right away . So , the process may tend to look relatively simple , but the path to change takes time and involves careful , detailed experimentation along the way . Sometimes people look to the end product and say , ‘ Well , it ’ s common sense , let ’ s just do that ,’ but it ’ s not that simple .”
Pettis alludes to the challenge of the myriad improvement programs that hospitals might implement , triggering fatigue among healthcare personnel .
“ There is often pressure to adopt quality improvement ‘ flavor of the month ’ so staff are ‘ waiting it out ’ since in their minds since ‘ this too shall pass ,’” she says . “ They may refuse to fully embrace the proposed change in practice . Another barrier , although not new but heightened since COVID , is securing funding for new technology or extensive initiatives due to financial concerns as well as staffing shortages .”
When the realities of something like the COVID-19 pandemic intrude upon healthcare delivery , existing barriers can be exacerbated , and new ones created .
“ Barriers are multifactorial , but people — in their essence — haven ’ t really changed , and human behavior being what it is , means that the challenge of ensuring good practice continues , whether we are in a pandemic or not ,” Schaffzin says . “ We all understood very early into the pandemic that things will never be the same , yet people kept trying to return to the past . Our lives are different , the world is different . I can ’ t tell you how many times during the pandemic somebody said , ‘ When can we go back to normal ?’ and I told them , ‘ I ’ m terribly sorry , but change happens no matter what you do ; sometimes it happens very slowly , but sometimes it happens
16 september 2023 • www . healthcarehygienemagazine . com