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Local clinical audit implementation, are we ready for change?
The importance of the change recipients’ readiness for change for the
implementation of improvements within local clinical audit cycles
Master’s Thesis SCM MSc Supply Chain Management Faculty of Economics and Business
University of Groningen The Netherlands August 27, 2017 Frits Klein Student number: 3026841 E-mail: f.j.klein@student.rug.nl
Supervisor: dr. G.A. Welker E-mail: g.a.welker@umcg.nl Co-supervisor:L. Hut-Mossel MSc
E-mail: p.a.mossel@umcg.nl Co-assessor: prof. dr. ir. C.T.B. Ahaus
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ABSTRACT
In healthcare, quality and patient safety are very important. Clinical audits are considered to be one of the best quality improvement methods to ensure that optimal care is given. During the clinical audit improvements are suggested and implemented. This research is performed at the UMCG hospital in the Netherlands and is a case comparison based on interviews about local clinical audits. The research aims to investigate if a relation exists between the success of the implementation and the readiness for change of healthcare professionals involved in the care targeted by the clinical audit. The researched clinical audits in the UMCG are adapted for educational use and have no formal process steps after the formulation of improvements. All improvements were minor changes in the care process. A mechanism that explains the workings of readiness for change dimensions in relation to the success of the audit is put forward. This mechanism is partly derived from the change management literature on small changes. It stresses the importance of finding a change leader and it is observed that in this the readiness for change dimension appropriateness is most important. Once a change leader is found, other dimensions of readiness for change begin to exert influence. Change specific efficacy seems to play a very minor role as the changes are minor.
2 TABLE OF CONTENTS PREFACE ...3 INTRODUCTION ...4 LITERATURE RESEARCH...6 Clinical audit ...6 Implementation of improvements ...7
Readiness for change ...8
Research framework ...9 METHODOLOGY ... 10 Research Design ... 10 Research Setting ... 10 Case selection ... 10 Data collection ... 11 Data analysis ... 12 RESULTS ... 14 Within-case analysis ... 14 Cross-case analysis ... 30 DISCUSSION ... 32 Summary of results ... 32
Interpretations and propositions... 32
CONCLUSION ... 35 Theoretical implications ... 35 Managerial implications ... 36 Limitations... 36 Further research ... 36 REFERENCES ... 37 APPENDICES ... 41
Appendix A: Interview protocol ... 41
Appendix B: Codebook ... 51
Appendix C: Modified implementation stages ... 54
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PREFACE
This thesis came into being with the help of a number of people. I would like to thank prof. dr. ir. C.T.B. Ahaus and dr. G.A. Welker for allowing me the opportunity to complete my education in a fun and engaging manner by choosing me to participate in this interesting topic. During the writing process I greatly appreciated the support shown by my supervisors Dr. G.A. Welker and L. Hut-Mossel MSc. Their guidance, support and feedback made this thesis possible and I could not have realized it without their help. I also would like to thank all the interviewees that were willing to participate in this research. Without their participation this research would not have been possible. The willingness to make time in their full
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INTRODUCTION
In healthcare, quality and patient safety are very important. The complexity of care in modern hospitals creates an environment in which errors can occur that harm patients. There is a widespread consensus that this is unacceptable and can at least be partly prevented (Graban, 2016). Many quality improvement methods and processes exist to assist in this, such as Lean, Six sigma, change management, patient surveys and clinical audits (Al-Abri, & Al-Balushi, 2014; Chassin, 2013; Dixon 2011a). Of these, a clinical audit is “very often the single best method of ensuring that the care which is provided is in line with best practice” (Burgess, 2011, p. xiii). Two types of clinical audit exist, the local and national. This research focuses on the local clinical audit that aims to improve patient care and the outcomes of this care through a systematic examination of the provided healthcare in the local situation (Bullivant & Corbett-Nolan, 2010; National Institute for Clinical Excellence, 2002). Within a clinical audit a potential problem is identified, measured and when necessary improvements are formulated and implemented. As such, the clinical audit process caries parallels to a quality improvement process which realizes change (Dixon, 2011a). But although the process of conducting a clinical audit has been described in detail in best practice guidelines (Burgess, 2011; Hamer & Collinson, 2014), the change, or successful implementation of
recommendations for improvements in the patient care process, often falls short (Dixon, 2011a; Prasad & Reddy, 2004). Less than 40% of suggested recommendations are actually implemented (Balogh & Bond, 2001; Prasad & Reddy, 2004).Ivers et al., (2012, p.33-34) note that the field of clinical audits can benefit from “explicit use of theory, empirical evidence and logic” as tools to improve on clinical audits. Both change experts and
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that they really own the changes which are introduced”. In this research, the term recipient encompasses any healthcare professional involved in the care targeted by the clinical audit.
While the importance of the involvement of the recipients in a clinical audit is acknowledged, the link between a clinical audit and the concept of the recipients’ readiness for change is missing. Understanding the impact of readiness for change on local clinical audits may improve the ability to successfully implement improvements (Holt, Helfrich, Hall & Weiner, 2010). The absence of this concept within clinical audit literature, especially within the improvement implementation phase, leads to the following research question:
“How is the implementation of improvements resulting from local clinical audits influenced by the readiness for change of the recipients involved?”
This research aims to explore the relation between the recipients’ readiness for change and the success of implementing the improvements that were formulated during the clinical audit. By answering this research question this research explores the importance of the readiness for change of the recipients and potentially links the readiness for change concept to local clinical audits. From a scientific point of view this can provide insight into the extent to which the change management literature applies to local clinical audits. This can give insight into how improvements can be implemented in complex environments, such as hospitals. From a practical point of view, knowledge about this relation could make the implementation of improvements in future local clinical audits more successful. Greater understanding on this topic could potentially impact the way local clinical audits are performed.
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LITERATURE RESEARCH
Clinical audit
The clinical audit is a quality improvement process (Dixon, 2011a), that aims to improve patient care and the outcomes of this care through a systematic examination of the provided healthcare (Burgess, 2011). Two major types of clinical audit exist: the local and the national clinical audit. Local clinical audits are internally initiated by the health care professionals themselves and tend to focus on a certain process, department or a care pathway within a hospital. These local audits verify against agreed standards, they use national standards or create their own standards based on local working agreements (Bullivant & Corbett-Nolan, 2010). The local audit uses a bottom-up approach in which local personnel identifies a problem within their work environment and uses this as an audit topic (Copeland, 2005). National clinical audits are more top down and are mostly externally initiated, cover multiple hospitals, and benchmark the compliance to national care standards in the local practice (Bullivant & Corbett-Nolan, 2010). This research focuses on the local clinical audit in which the audit subjects are systematically evaluated by local healthcare professionals, using defined criteria. During the audits, recommendations for improvement of the care process at the individual, team, or service level are formulated and implemented. Conformation of change is achieved through a re-audit, the last phase of the audit cycle, where after an agreed period the audit is repeated as a way to re-evaluate practice (Dixon, 2011a; Dixon, 2011b; National Institute for Clinical Excellence, 2002). Figure 1 “The audit cycle” gives an overview of this clinical audit process.
Figure 1: The audit cycle (source: Benjamin, 2008, p. 1241)
Stage1: Preparing
for audit
Stage 2: Selecting criteria
for audit review
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This paragraph gives a more comprehensive description of the clinical audit process based on the comparison of several descriptions of clinical audit literature (Benjamin, 2008; Burgess, 2011; Dillmann, Wagner, Schellekens, Klein, Jager & Grinten, 2016; Gillam & Siriwardena, 2013). A clinical audit starts with a preparation phase in which the audit topic is chosen by the conductor of the audit, the audit leader. The audit leader can be any clinician or team as long as they possess the relevant knowledge, skills and experience (Burgess 2011; Dillmann et al., 2016). Initial preparations are made which include identifying the stakeholders, such as nurses and specialists, who should be involved in the formulation of the audit goal and an initial search for applicable quality criteria. This phase is followed by the criteria formulation phase in which the audit leader determines the measurement standards and data collection method. Next, in the performance measurement phase, these standards are measured. Once measured and collected they are analyzed and reported on by the audit leader. The following phase concerns itself with the formulation and implementation of the improvements. This is done based on the earlier collected findings that are presented to the involved professionals and improvement recommendations are made by the audit leader. The last phase is the sustaining improvements phase. The goal of this phase is to ensure the improvements made have a lasting effect. A common way to verify this is through a re-audit which checks the success and sustainability of the improvements and is in essence a complete repeat of the audit. According to Dillmann et al. (2016), smaller monitor and assessment events which check against the desired results have become an alternative to a complete re-audit. Their benefit is that they take less time and allow for easier adjustment in order to reach the desired goal. Doing a re-audit is then only necessary if more serious problems are encountered.
Implementation of improvements
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implementation. The initiation stage (1) covers the initial awareness of the content, value and urgency of the topic of the clinical audit amongst those involved with the clinical audit. The adoption stage (2) covers the decision making process of which improvements should be implemented. The adaptation stage (3) follows up with the adaptation of the improvements into the daily practice and processes. Once this is done the involved employees need to
embrace the added value of the improvements and act to employ these into practice; this is the acceptance stage (4). Once the use of these improvements is applied on a larger scale in the organization and is no longer seen as unusual, the stage of routinization (5) is achieved. The last stage, infusion (6), has completely institutionalized the improvements into daily work as a best practice. The success of the implementation of improvements is rated trough these stages.
Readiness for change
There are many theoretical foundations and terms used to define the construct of change readiness, thereby causing a lack of consistency in the conceptual terminology (Stevens, 2013; Weiner, Amick & Lee, 2008). Many authors note that organizational readiness for change can be considered a multi-level construct due to readiness being present at multiple levels of organizational size. These levels range from individuals and groups to departments and whole organizations (Rafferty, Jimmieson & Armenakis, 2013; Holt, Armenakis, Field & Harris, 2007a; Weiner, 2009). Weiner (2009) also notes that the concept of readiness for change on each of these levels has its own interpretation, measurement and relations with other variables. Therefore not every model is useful for the individual level on which this research focuses. Choi and Ruona (2011) compared multiple definitions for the individual level and conclude that overall “individual readiness for organizational change involves an individual’s evaluation about the individual and organizational capacity for making a successful change, the need for a change, and the benefits the organization and its members may gain from a change” (Choi & Ruona, 2011, p. 51). The many different interpretations of readiness for change have led to many different instruments that can be used to assess
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readiness for change is influenced by the following dimensions; change specific efficacy, appropriateness, management support and personal valence. Change specific efficacy targets the confidence in the capability to implement the recommended change. Or in other words, does the individual feel confident in that he or she possesses the skills needed to execute the activities and tasks associated with the implementation of the proposed change.
Appropriateness is about an employees’ perception of the suitability and usefulness of the proposed change for the organization. Management support means that the individuals feel that leaders are committed and support the proposed change. And finally, personal valence is about how beneficial the change is to the individual organizational members. Does the individual feel that the change will cause personal benefit or disadvantages in e.g. status, relations or career?
Research framework
When a clinical audit generates suggestions for improvements, these improvements should be implemented in order to improve the practice of care. The degree of implementation success is measured by using the modified stages of implementation derived from Cooper and Zmud (1990). This research uses the dimensions of readiness for change that are put forward by Holt (2007b). These dimensions affect the recipients’ readiness for change and are thereby
expected to influence the degree of success in implementing the improvements. It is therefore interesting to explore each readiness for change dimension during the execution of the clinical audit. And thereby investigate how readiness for change influences the success in
implementing improvements. This leads to the research question “How is the implementation of improvements resulting from local clinical audits influenced by the readiness for change of the recipients involved?” and results in a research framework shown in figure 2 “Research framework”.
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METHODOLOGY
Research Design
This research aims to explore how the readiness for change of the recipients, influences the success of the implementation of improvements that result from local clinical audits. The method chosen to investigate this is a multiple case study.According to Yin (2009) a case study is best used when faced with a combination of a ‘how’ research question, with a lack of control of the behavioral events and a contemporary focus. Since the focus of the research lies on past clinical audits, this represents a lack of control on the behavioral aspects. As this research focuses on past events, the collected data is susceptible to recall bias. The focus was therefore on recently performed or contemporary clinical audits in order to limit recall bias. A multiple-case study is used to enhance the robustness of the conclusions, since evidence collected from multiple cases is widely seen as more reliable and thus more compelling. As a multiple case study addresses “the same research question in a number of settings using similar data collection and analysis procedures in each setting” (Herriott & Firestone, 1983, p. 14).
Research Setting
The dataset used in this research is composed of a number of transcripts of interviews with residents that act as clinical audit leader and their supervisors from different departments within the University Medical Center Groningen (UMCG). The UMCG acts as a tertiary care facility for a large part of the north-eastern provinces of the Netherlands, as well as providing second-line care with over 12.000 employees. The UMCG serves a population of around 3.5 million people. Annually the UMCG has over 34.000 clinical admissions.
Within the UMCG a number of residents1 are obligated to organize and perform a clinical audit in the context of their education to become a medical specialist. This allows local priorities of residents or departments to be addressed using clinical audits, thereby improving the patient’s safety and quality based on local needs (National Institute for Clinical
Excellence, 2002). The UMCG started integrating these concepts of patient safety and quality improvement into the medical training of residents in 2012.
Case selection
In a multi-case study each individual case can be seen as a “whole” study. Each case reaches a conclusion based on its own facts. These individual conclusions are then input for the
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replication between cases and the overall conclusion (Yin, 2009). The unit of analysis in this research is defined as a single clinical audit. According to Eisenhardt (1989) the
recommended range of cases to include in a case study is between four and ten cases. For this research, four cases were selected that all were performed in the same hospital, thereby minimizing cultural, regulatory and contextual differences. This research aims to use theoretical replication which assumes that there will be differences in outcomes for explainable reasons (Karlsson, 2016; Yin, 2009). The research question focuses on the implementation of improvements that are the result of the clinical audit. The case selection was aimed at selecting cases with strong differences in implementation success. This is known as sampling for “polar types” which allows for more ready observation of contrasting patterns within the data (Eisenhardt & Graebner, 2007). As the available clinical audit documentation gave no inkling to implementation success, a quality employee that assisted the residents in performing their clinical audits was asked to indicate which clinical audits she perceived as being effective and less effective. This employee had access to the archive of past clinical audits.
Data collection
12 Data analysis
The transcripts were managed by using an analysis program (Atlas.ti version 7.5.7) for coding and analyzing the qualitative data gathered. The data analysis was based on the procedure of Miles, Huberman and Saldaña (2014) using three concurrent sub-processes; data
condensation, data display and the drawing and verification of conclusions. The data condensation step was aimed at focusing the collected data by simplifying, abstracting and condensing it. Coding was used to identify the relevant statements in the interviews and to catalogue them by subject (Saldaña, 2009). This was done through a combination of deductive codes originating from theory and inductive codes originating from the data (Fereday & Muir-Cochrane, 2006). The concepts used in the coding and data analysis are defined and
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Concept Definition/measure Reference
Degree of implementation of improvements
The degree of implementation of improvements can be assessed through the use of the six stages of implementation that were adapted from Cooper and Zmud (1990). Stage one and two describe process steps that occur before implementation while steps three to six describe the actual implementation. The stages are: Initiation (1), Adoption (2), Adaptation (3), Acceptance (4), Routinization (5) and Infusion (6). The more stages that are achieved, the more successful the implementation is considered to be.
Cooper and Zmud (1990)
Individual Readiness for change
“involves an individual’s evaluation about the individual and organizational capacity for making a successful change, the need for a change, and the benefits the organization and its members may gain from a change”. “Furthermore, readiness collectively reflects the extent to which an individual or individuals are cognitively and emotionally inclined to accept, embrace, and adopt a particular plan to purposefully alter the status quo”.
Choi and Ruona (2011, p.51); Holt,
Armenakis, Field & Harris (2007b)
Change specific efficacy
“the extent to which one feels that he or she has the skills and is or is not able to execute the tasks and activities that are associated with the implementation of the prospective change”
Holt, Armenakis, Field & Harris (2007b, p.238-239) Appropriateness “the extent to which one feels that the organization will or will
not benefit from the implementation of the prospective change” and “feels that there are or are not legitimate reasons and needs for the prospective change”
Management support
“the extent to which one feels that the organization’s leadership and management are or are not committed to and support or do not support implementation of the prospective change”. In the context of this research management begins at the level of the team leaders and heads of department and extends up to all hierarchal levels of the organization.
Personal valence “the extent to which one feels that he or she will or will not benefit from the implementation of the prospective change”
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RESULTS
This section displays the results and the interpretation of the analyzed interviews. For each of the cases a within-case analysis has been made providing an overview of the clinical audit in question. In order to answer the research question the within-case analysis of the cases primarily looks at clinical audit implementation success and the readiness for change
dimensions. For the attention given to the readiness for change dimensions, a four point scale (a little, some and very much) is used as a way to create a consistent overview. Also a short case description and notable other observations were included to provide some context to the cases. Due to the uniqueness of the clinical audits a number of identifying details were anonymized, this was necessary to guarantee interviewee anonymity. Appendix C “Modified implementation stages” provides a short overview of the meaning of each implementation stage as presented to the interviewees. The interviewees were asked to rate the success of their clinical audit using these stages. Their answers are summarized in table 2 “Clinical audit implementation stage overview” which presents the answers given by the interviewees of each audit.
Implementation stage reached according to: Case identifier Quality employee Audit leader Supervisor Clinical audit one Less effective Stage one Stage one Clinical audit two Effective Stage four Stage four Clinical audit three Effective Stage one No stage reached*
Clinical audit four Less effective Stage two Stage two * The supervisor indicated that stage one wasn’t reached Table 2: Clinical audit implementation stage overview
Within-case analysis Case one
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lead educator internal medicine who was also a member of the clinical audit commission assigned two residents to this audit. One resident acted as audit leader and the other as
supervisor. The supervisor, a resident nearing the end of his education, left during the clinical audit as he found employment elsewhere, he was present up until the data collection phase of the clinical audit cycle. Before he left he contributed “extensive experience in the supervision of nurses for this kind of issues” as well as “providing an overarching view”.
Audit success
The clinical audit of case one was indicated by the quality employee to be less effective. The audit leader claimed that “from the implementation stages I believe we have not reached further than stage one”, the initiation stage. The supervisor concurs with this. This stage covers the initial awareness of content, value and urgency of the audit topic amongst the participants of the audit. It did not realize any improvements. Only a small number of people from the department were aware of the existence of the audit. The audit leader argued that this contributed to the lack of follow up. She felt that the follow up on the audit suggestions for improvement would have been better if more members of the quality commission would have attended her final presentation as knowledge of these recommendations would then have been spread amongst more specialists. The audit leader noted that it was detrimental that not all involved care givers were present and that the recommendations were not discussed in depth. Both she and the supervisor did not feel motivated to realize the suggested improvements, since they already knew that they would soon be working elsewhere. The audit leader saw this audit as a final checkmark to finish her education.
Appropriateness
The involved care providers were, according to the audit leader, convinced of the necessity to regulate the patients’ blood value and of the use and benefits of the regulation protocol. According to the audit leader, the clinical relevance was significant and her colleagues saw that. The audit leader indicated that she possessed no further knowledge of what the recipients experienced with regard to appropriateness. Based on their earlier experiences with the
16 Change specific efficacy
The supervisor left before the audit cycle stage of ‘making improvements’ and can therefore say little on the recipients’ perceptions. It was the supervisors’ belief that they would
experience no difficulty because the improvement was likely to have little impact on the tasks required of the recipients. The audit leader could not describe with certainty the initial
perception of the recipients, but believes that they would be confident in their capabilities. As a result of the improvements, the recipients would have to perform the actions required by the protocol more often. The improvement of better documentation is a part of this process. The audit leader noted that the recipients were already familiar with the protocol. Due to this, no actions were undertaken to improve the recipients’ perception of their efficacy.
Management support
Case one’s clinical audit received management support in the form of the allocation of time to allow the supervisor and audit leader to perform the audit. No attention was given to the element of the recipients’ perception of management support and no actions were undertaken in this regard. The supervisor believed that the recipients’ perception of management support as important but, “management is always a bit of a fuzzy concept”. There is a difference between “someone in an ivory tower, who doesn't know anything about your job… and someone directly linked to the department”. He considers the support of the last group to be more important, and looks at them for positive reinforcement, believing that higher
management support “has less of a connection”. Thereby emphasizing that management support should flow from involved management.
Personal valence
The audit leader only expected an insignificant increase in workload due to increased testing. And she noted that even this might be more of a perception of the recipients than actual fact. From the interview it becomes clear that the supervisor was not aware of the actual proposed improvements. No actions were undertaken to effect the recipients’ perception of their
personal valence. Moreover, according to the supervisor, “everybody in health care, wants the best for their patient so if it’s clear that patient care improves, than this is not only a benefit for the patient but also for the care giver”, suggesting that recipients will benefit by feeling better if the care they provide is better.
Further observations
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giving a helping hand with the data extraction and analysis, “but also a bit of a supervising in a guiding role and then realizing a nice report”. On the topic of realizing improvements, the supervisor indicated that “it rapidly becomes management and department heads” that get to decide on implementation. But when the change must be implemented, the people who possess the actual skills or knowledge must not be forgotten. They can determine the viability of the improvement, for example if it can be implemented in ICT or protocol. The supervisor feels that having a “continuity of knowledge is very important”. Meaning that during the total clinical audit cycle a core person or group should be present at all stages to ensure the
presence of knowledge behind the choices made and underlying reasoning. The audit leader notes that good will and having a voice, having the authority to start a change process is important for the success of a clinical audit. But since the clinical audit is a final part of the education, the audit leader lacks the possibility to follow through. Both interviewees state that in the current clinical audit process, the ownership of the implementation process is absent.
Readiness for change: conclusion
The initially perceived clinical audit effectiveness was in line with the indicated
implementation phase reached. The interviewees were not motivated to realize improvements. Only a limited number of people were aware of the clinical audit. The actual perceptions of recipients’ readiness for change were unknown or assumed positive. The general importance of appropriateness and management support was acknowledged. As the suggested
improvements weren’t expected to require additional knowledge or skills, the recipients’ perception of change specific efficacy was assumed to be positive. The recipients’ perception of the personal valence was unknown and as the workload was not expected to significantly increase, it was not further explored. Overall little attention was given to the readiness for change dimensions and no actions were undertaken in this regard. The presentation added little to the readiness for change.
Case two
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possible” without further specification. It emerged from the interview with the supervisor that his role in supervising and providing guidance was limited. The improvement suggestions that could be found in the presentation consist of minimizing delays in inoculation and tightening the wording of the guideline.
Audit success
The audit of case two was indicated by the quality employee to be effective. In line with this, some of the improvement suggested in the clinical audit have been implemented after the presentation, such as “direct sampling of … serology” and “the lab has already been adapted”. Other improvements that depend on the electronic health record system (EHR) have been discussed and are pending. Both the supervisor and audit leader of this clinical audit saw the clinical audit as successful; indicating that implementation stage four was reached. This stage is defined as ‘improvements were adapted into daily practice and employees embrace the added value of these improvements, acting to employ them into practice’. The audit leader planned to discuss the clinical audit and its results sometime after the final presentation within the department. When the supervisor was asked if the next stage was reached, large scale implementations such as in the routinization stage, he answered “I think that that is a bit too much for this subject, yes too much. I believe it was till stage four”. The favorable circumstances in which the clinical audit was conducted might have
contributed to its implementation success. The clinical audit happened at a time when “work was already being done on the inoculation” and “where we have implemented a very large amount of changes the past eighteen months”. And the supervisor “was also the coordinator” on this topic in the department and could realize change. As such he was part of the
management. According to the audit leader, this positively influenced the success of the audit. He noted that the decision to implement was made spontaneously during the open discussion at the presentation.
Appropriateness
In this clinical audit the importance of the recipients’ feeling of appropriateness is
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everyone reflects on appropriateness in terms of advantages and disadvantages, such as time or money. And give as a general example that if “option two, is not ideal but comes close, only costs far less time or is significantly cheaper, initially you choose that one”. The initial perception of the recipients in regards to appropriateness is positive. The clinical relevance of the audit is acknowledged, the supervisor indicates that “everyone recognizes the importance of the … vaccination” and that recipients were willing to change. Due to this perception of appropriateness no actions were deemed necessary. No effort has been made to change a perceived positive attitude towards appropriateness. No mention is made on actual verification of this assumption, but the decision to implement strongly suggests appropriateness.
Change specific efficacy
The general importance of change specific efficacy is acknowledged in this clinical audit. The audit leader noted that “being able to actually do it in daily practice” is important because “having a combination of a lack of problem recognition and extra burdens on work, then obviously nothing will happen”. But in this clinical audit the initial perception of change specific efficacy was perceived as being unimportant because: “in this case it was not, it was so obvious that having an extra checkmark in the program that it was superfluous” and “because it’s quite simple”. Also it “was quite obvious and with little consequences that impacted daily practice … It was very straight forward”. The recipients’ perception of change specific efficacy received no further attention and no actions were undertaken in this respect. As summarized in the audit leaders remark that “people don't have to change their way of working. For the most part their work does not change”.
Management support
Most remarks made on management support focus on the time given to execute the clinical audit, but this can’t be seen as support for the recipients of the improvements. The
departments regularly organize ‘away days’, “which greatly helped to facilitate
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notes that his position as a coordinator helped in guiding the implementation. By doing so he showed commitment to realizing the improvements, which is a form of management support that is felt by the recipients. No further management support was shown and no other actions were undertaken as it was deemed that it was not necessary to further change the initial attitude of the recipients. In general, it is acknowledged that management support can be important, “but only if things need to be changed that require management support”. For example “if you really want to change policy, then you need the management” and if you need new equipment, “management needs to make budget and other resources available”. But “in most cases they do not need to be directly involved” since “it concerns clinical problems”.
Personal valence
Limited attention was given to personal valence. He indicated “the doctor and nurse that treat the patient at the outpatient clinic are very much willing to change, as it makes their life easier” especially since “they don’t need to do or learn anything new” and it “decreases the task complexity by reducing the number of actions necessary”. But that preparation for the change would create extra work in the short run for a group of specialists, as they participate in the building of these automated improvements. In the long run he believed that this investment of time will result in future benefits for the recipients. The audit leader believed that there would be benefits arising from minimizing the delays of inoculation noting that “it’s much easier when everybody is inoculated and protected against …, if you then have a … positive patient, it evidently becomes much easier in regards to the health risks for the employees, etc.” and “everyone knows that this is relevant”. The supervisor concurred noting that “the more patients that have been vaccinated the better this is for the one treating the patient” and believed that no extra work would be involved. Both the supervisor and audit leader undertook no actions to change the recipients’ perception of personal valence.
Further observations
The audit leader observed that “the clinical audit as part of your education… ends with determining the issues and how to improve them … But how to implement, that’s something completely different and separate”. During the interviews the term support has been
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them and provide support to do something”. So “you need to create support”, which “depends on what are the costs and benefits for someone” and that “if you can prove the benefits to everyone, progress can be made”. Besides support from the recipients support is also needed from other parties that are not directly involved in the care process in which the audit takes place.A general remark was made by the audit leader on creating the involvement of others in order to prevent the creation of an isolated project. The communication within the department has been subject to improvement during the last eighteen months, resulting in frequent meetings and communication across disciplines and including administrative employees. According to the supervisor this also helped the implementation.
Readiness for change: conclusion
The by the quality employee perceived clinical audit effectiveness was in line with the
indicated implementation phase reached. Overall little attention was given to the readiness for change dimensions. The dimension change specific efficacy was deemed to be unimportant while the others were either positive or assumed to be positive. The actions during the final presentation seem to confirm these assumptions, as a spontaneous decision to implement was made. Attention was given and action was undertaken by the supervisor on management support. On the other dimensions no actions were undertaken to influence the recipients’ attitudes. With the exception of personal valence, the general importance of the dimensions was acknowledged. The suggested improvements were expected to have little impact on change specific efficacy and personal valence. The department was undergoing many improvements during the last year which contributed to a general positive attitude towards readiness for change.
Case three
The audit of case three was aimed at evaluating the quality of documentation of a treatment process and the reasons why patients were given this specific care. National and local
guidelines exist on when and how to provide and how to document this care. The topic of this audit was chosen by the audit leader as she believed it had relevance, noting that if
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when providing it. He cites personal experiences as part of his motivation. The suggested improvements were: the improvement of accessibility to sources such as the protocol or a summary on the care aspects; additions to the training of residents on documenting the process and lastly the creation of a care pathway and its related templates and checklists.
Audit success
The clinical audit of case three was indicated by the quality employee to be one of the
effective clinical audits. But according to the supervisor and the audit leader, the clinical audit of case three did not lead to the implementation of any improvements. The supervisor stated that the audit led to nothing, and that not even the initiation stage was reached. He indicated that he did not follow up on the recommendations, noting a lack of power to enforce them and argued for a formalized improvement program that includes the implementation of the clinical audit improvements. The audit leader believed the initiation stage was reached, as the people involved were made aware of the content, value and urgency of the clinical audit. In her opinion, “it was not a bad audit”. The audit leader stated on the final presentation that “within twenty minutes your done and then, if you take no action, nothing will happen which reinforces the feeling that it is just a checkmark to be gained as part of the education”. She believed that “no one is responsible” for the implementation. The interviewees’ answers seem to indicate that they rate the implementation success at the time of the presentation. The statement of the audit leader that “if you take no action, nothing will happen” is later nullified by her own actions. She paid significant attention to this topic during three months department supervision. Currently she has an educational role in this area of care within the UMCG. This allowed her to give attention to the importance of the audit topic. The realized improvements are primarily the result of her personal actions. These actions “were all ad-hoc … without an actual plan”. The audit leader indicated that she felt motivated to carry the improvements forward in her new role, but clearly did not perceive this as a result of the clinical audit as “that’s because I do it myself, but there’s no formal implementation phase”. The quality employee on the other hand saw the end result; the improvements were implemented and the automation of the care pathway has been introduced. As such, the clinical audit achieved stage four and was successful.
Appropriateness
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is if they can document it properly and you have to do that anyway”. The audit leader
discussed the improvements with her colleagues and noted that “I talk with them every day”. She noted that with this kind of treatment, the common perception was “that when its
documented that poorly, that this then creates the suggestion that people don't really know what the indications are” to start the treatment. No further actions were undertaken to change the attitude of the recipients. The supervisor acknowledged the importance noting that, “if it’s not perceived as being appropriate then you can forget it happening”. He believed that the improvements would be perceived as appropriate, but he did not actually check this. Nor did he undertake any actions to change the recipients’ perception.
Change specific efficacy
On the topic of change specific efficacy of the recipients the audit leader indicated that she “did not really look at it”. No actions were under taken as “it’s just proper documentation and not even that much more”, “it’s not difficult, it’s more being aware of it” and
understanding the reasons. The supervisor also didn’t know how the recipients felt on this topic, but notes that perhaps “you should give people the chance to put their own stamp on it, so that they find a comfortable working procedure”. Thus placing more emphasis on
documenting than on the form in which it takes place. Overall little attention was given to the change specific efficacy of the recipients and no actions were undertaken.
Management support
Both the supervisor and audit leader indicated that there was no management support in relation to the implementation of the improvements. The supervisor noted that he “did not know anything about” the perception of the recipients. He reasoned that some subjects “definitely need management support and others, like this one, do not”. The audit leader indicated that she “believed the recipients are not given enough support” and “this limits the time available for these kinds of improvement processes in general but also the
familiarization with respect to content that accompanies this”. In this, she referred to
management on the work floor. No actions were undertaken by the audit leader or supervisor on the recipients’ perception of management support.
Personal valence
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with almost every resident, and you try to convince them that it’s easy …. but it doesn't
happen”. When asked if he was aware of how the recipients felt on this topic he indicated that he did not know and also did not undertake any actions to change it. The audit leader believed that there would be only a minor short term disadvantage for the recipients, as they would have to read the protocol and consider when to apply it. But she believed it would create “certainty in regards to the actions they perform because then they know what they are doing”. This was important because “it has a large impact, especially for starting doctors” when improperly handled since it relates to patient mortality. She undertook action to highlight these benefits and noted “they certainly recognize it”. But the impact of these actions is minor as she was hindered by an “ocean of other work”. The actions benefited some “individuals, but on the whole, I do not know as there are regularly new people arriving”.
Further observations
The audit leader felt a lack of personal influence which affected the attention given to readiness for change. When asked if she undertook actions with regard to change specific efficacy or management support she indicated that she “did not really look at it”. She expressed that she was “at the bottom of the ladder, so I have limited influence” and “many more important others are claiming priority”. It was the belief of the audit leader that as she gains more experience and seniority she would be better able to influence her professional surroundings. The audit leader reflected upon the clinical audit as a requirement for the
educational program by noting: “I believe that no one has an implementation stage unless you indicated you would do this or the department takes it over” and “if you don't take action, nothing further will be done, which enhances the feeling that it’s just an educational milestone”. She notes, “there is no plan, no support and no owner … it just disappears”. “I’m not a passerby, but nine out of ten are. Therefore it (the audit results) should remain with a regular team”. This suggests a problem with the follow up on the improvements.
Readiness for change: conclusion
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appropriateness and management support was recognized. The suggested improvements were expected to require no additional training or skills and therefore to have little impact on the perception of change specific efficacy. Little attention was given to change specific efficacy and management support and no actions were undertaken. Some attention was given to appropriateness and personal valence and in both dimensions actions were undertaken.
Overall some attention was given to readiness for change. Notably, the personal motivation of the audit leader to realize change was very high.
Case four
The audit leader initiated the clinical audit as a mandatory part of his education. He chose this topic as it seemed to be a good topic for an audit and because he asked himself “are we doing it in a consequent manner”. The audit attempts to provide insight into the use and outcomes of certain tests. These tests are performed on patients that are admitted through the emergency care as indicated by protocol and are used to help determine the optimal treatment. The audit contained three related aspects. Is the test used consequently, what results do these tests provide and are these results used to adjust the provided antibiotic treatment? The audit leader didn't know how his colleagues felt about this topic. After settling on the audit topic, the audit leader “eventually found someone that had an affinity for this topic” to act as his supervisor. The supervisor acknowledged that the topic was in his eyes “very clinically relevant”. The clinical relevance comes from the importance of knowing which infection to treat, since this allows for a better selection of the optimal treatment method. He felt supervising this topic was proper since he was involved in diagnosing and treating these patients. The
improvements formulated during the audit concerned suggestions to increase the percentage of patients that are tested and to adjust policy regarding the use of the test on immune compromised patients.
Audit success
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stage one and two are done, and at the most we made minor inroads into stage three”. According to the supervisor a behavioral change was needed, but “how do you realize this?”. He further notes that “no feedback has been given to the employees of the emergency care as far as I know” on the results of the audit. This is confirmed by the audit leader. On realizing these improvements the supervisor noted that he “lacked the time to create a whole program” and did not know if any follow up had happened elsewhere.
Appropriateness
The audit leader noted that it is “quite hard to create a nice good clinical audit … that actually is useful to everyone”. On this clinical audit he noted, “I think that other people might have considered the question: ‘why has a test been performed or why not?’”, but “it’s not the largest clinical problem”, “were not doing it quite that bad”. The audit leader thereby gave the impression that recipients wouldn't consider the clinical audit improvements to be appropriate, as the benefits might be too small or the problem too insignificant. This view on benefits was seemingly held by the supervisor as well, as this wouldn't give rise to great changes. But when asked if the recipients would view his improvements as appropriate, the audit leader answered: “Well not exactly … they found it interesting and insightful, being happy to see the our current performance and results” but that while he “believed it was perceived as useful, I don't know to what extend this would lead to more tests”. The test could lead to a more specific use of antibiotics, on which some specialists remarked “I don’t dare to” while others were more positive. The audit leader noted “there are often good reasons to deviate from protocol”. The supervisor believed that it would be seen as appropriate but notes that there had been no feedback from the recipients. Both audit leader and supervisor
confirmed that no actions were undertaken to change the recipients’ attitude. But the audit leader notes that in hindsight more attention should have been given to assess and change the recipients’ perception.
Change specific efficacy
In general change specific efficacy was seen as relevant. The supervisor noted that
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that there were some problems with the actual transfer of the sample to the lab, this is not connected to change specific efficacy. The problem occurred due to forgetfulness, not because the skills and capabilities were lacking.
Management support
In the opinion of the audit leader management support is generally needed; “if you want to change something on the work floor, you need management”. Also in general, the supervisor added that “it is important for people to feel sufficiently supported”. Both he and the
supervisor stated that the recipients mostly perceive their immediate supervisors as
management. Both the supervisor and audit leader indicated a lack of management support that related to the recipients. But the audit leader didn't see this as a problem since “you need it if you want to change something”. He thereby implied that there was no need to explore recipients’ feelings on this topic. The supervisor noted “if we change things … then we often go to the head nurse, attending physician or department supervisor … and not to the highest medical director”. But since “there has not been an improvement process initiated, you can hardly say that there has been a lack of management support”. Both the audit leader and the supervisor undertook no actions to influence the perception of the recipients.
Personal valence
According to the audit leader, the majority of needed tests were performed and he expected no additional workload from performing additional tests. Moreover, he noted that he couldn’t “imagine someone saying: I won’t do that because it's a disadvantage for me or something like that”. The supervisor concurred, noting that things might be different if significantly more effort was required, but this was not the case here. According to the audit leader, the potential benefits of performing the tests wouldn't be experienced by the personnel that work in the emergency care department. “You can’t see the effects of your work, as the patient either gets transferred or goes home and you lose sight of him”. The audit leader believed that the applying the protocol could benefit the specialists that give the treatment, especially the less experienced ones. It gives them more information and thereby increases their assuredness when making treatment decisions. No actions were undertaken by either the supervisor or audit leader to explore or change the attitude of the recipients towards personal valence.
Further observations
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reflected on the readiness for change and culture of the department by saying “so you want something, then often the reaction is ‘yeah, but we have always done it this way’, so we won’t change with the whole department”. When asked about an implementation plan he answered: “that's not within the scope of the audit, is it? … you suggest your improvements and that's where the audit stops”. The supervisor agreed, saying “I think this happens to many audits, that’s about were the audit stops … Currently it’s more of an exercise for residents in the first part of a clinical audit, but the last part, well there it stagnates”. He further indicated that some kind of improvement process based on the clinical audit recommendations is desired. He believed that the lead educator internal medicine and member of the clinical audit
commission would like to see this happen. According to the audit leader, if something needs to be implemented higher management needs to take up the cause. And that “realizing changes in work routines encounters many barriers … and there should be intrinsic motivation from local management”. The audit leader further expressed that even with the support of his supervisor a regular resident would be unable to realize change when
management support is lacking. They can take an advisory role, explaining the reasoning and importance, but implementation will require management.
Readiness for change: conclusion
The initially perceived clinical audit effectiveness was in line with the indicated
29 Case overview
Readiness for change: Unsuccessful cases
Case Implementation stage Appropriateness Change specific efficacy Management support Personal valence
Case 1 Audit leader One Perception: assumed positive Attention given: little
• General importance recognized • Based on earlier experience Actions undertaken: No
Perception: unknown, assumed positive Attention given: little
• Recipient believed to be capable • Little impact on tasks
Actions undertaken: No
Perception: unknown Attention given: little
• General importance recognized • Local management more important Actions undertaken: No
Perception: unknown Attention given: little
• Everyone wants the best for the patient • Insignificant increase in workload Actions undertaken: No Supervisor One Quality employee Less effective Stage reached: One
Case 4 Audit leader Two Perception: negative Attention given: little • Might not be appropriate • Appropriate? Well not exactly Actions undertaken: No
• Hindsight: needed more attention
Perception: assumed positive Attention given: little
• General importance recognized • Recipients need no additional skills • Only have to send a sample to the lab Actions undertaken: No
Perception: deemed unimportant Attention given: little
• General importance recognized • You need it if you want to change Actions undertaken: No
Perception: unknown, assumed positive Attention given: little
• No additional workload
• Benefits not felt locally (patient transfer) • Increases assuredness in decision-making Actions undertaken: No Supervisor Two Quality employee Less effective Stage reached: Two
Readiness for change: Successful cases
Case Implementation stage Appropriateness Change specific efficacy Management support Personal valence
Case 2 Audit leader Four Perception: positive Attention given: little
• General importance recognized • everyone recognizes the importance Actions undertaken: No
Perception: deemed unimportant Attention given: little
• General importance recognized • Minor adjustment, quite simple Actions undertaken: No
Perception: positive Attention given: some
• General importance recognized Actions undertaken: Yes
• Away day (communication platform) • Supervisor showing commitment
Perception: assumed positive Attention given: little
• Makes the recipients life easier
• On the short term extra work for specialists Actions undertaken: No
Supervisor Four Quality
employee Effective Stage reached: Four
Case 3 Audit leader One Perception: positive Attention given: some
• General importance recognized • Something they have to do anyway Actions undertaken: yes
Discussed improvements
Perception: unknown, assumed positive Attention given: little
• Expected everyone would be capable • Just proper documentation& awareness Actions undertaken: No
Perception: unknown, deemed to be of low importance
Attention given: little
• General importance recognized Actions undertaken: No
Recipients need more support
Perception: assumed positive Attention given: some
• Little extra work but gives certainty in actions • Convincing recipients of benefits is hard • Also to avoid legal liability
Actions undertaken: Yes Highlighting benefits to recipients Supervisor Zero
Quality
employee Effective
Stage reached: Four
30 Cross-case analysis
The cross-case analysis compares the four cases with each other to see if any patterns in the data can be distinguished. In all the cases the clinical audit was performed by a resident as a project that is part of his or her education.The objective was to teach the resident to set up a clinical audit. All cases were supervised by medical personnel with extensive experience, with the exception of case one in which a nearly graduated resident with experience supervised. In each case the subject of the clinical audit was chosen by the residents. All clinical audits were presented in a twenty minute final presentation, thereby informing other specialist of their existence and the proposed improvements. All audit leaders saw this presentation as the end of their clinical audit. They didn’t consider the implementation of suggested improvements to be part of their clinical audit.
Clinical audit success
The clinical audits were assessed on the implementation stage reached. Table 3 “Case overview” gives a summary of the entirety of the cases and the dimensions of readiness for change. Based on the results, two categories of clinical audit can be distinguished. Those that achieved implementation of improvements and those that did not. According to the
implementation stages, implementation is achieved when stage three or higher is reached. The unsuccessful cases were cases one and four. Case two was successful. Based on the answers given by the audit leader, case three can reached stage four of implementation, making it the second successful case.
Analysis
In all cases the perception of appropriateness is regarded as being of great importance. In case three it is even argued that without it, change wouldn't happen. Case four scored negative on appropriateness. In hindsight the audit leader believed that they should have paid more attention to appropriateness, thereby acknowledging its importance. A common theme
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change. According to the interviewees, change specific efficacy and personal valence didn’t negatively influence the readiness for change.
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DISCUSSION
This research was based on theoretical replication where cases were selected with strong different outcomes, also known as polar types. Two groups of cases are distinguished, those that implemented improvements and those that did not. The purpose of this research was to investigate “How the implementation of improvements resulting from local clinical audits is influenced by the readiness for change of the recipients involved?”.
Summary of results
As can be seen in the cross-case analysis, not all readiness for change dimensions seem to influence the implementation success in equal measure. In all researched cases, the improvements that are suggested are minor changes of existing care processes. In this circumstance, change specific efficacy and personal valence are perceived to be of lesser importance. Recognition of appropriateness seems to be a necessary condition without which change won’t happen. Management support from management on the work floor also seems to be important, whereas higher management seems to be unimportant as “it concerns clinical problems”. Communication and motivation of the audit leaders and supervisors are also important influences on the implementation success.
Interpretations and propositions
Further exploration of the results shows that the audit leaders and their supervisors indicated that the actual implementation of the suggested improvements was not part of their clinical audit. They noted that for them the clinical audit ends with the presentation of the suggested improvements. This is in accordance with the educational goal and steps that are described in the article of Jalving, Kromme, Gans and Lefrandt (2014). This article describes the
educational program of clinical audits within the UMCG. Appendix D “Clinical audit in four months” shows this process. Nonetheless some clinical audits achieved implementation. As there is no formal process that leads to the implementation of improvements, an informal process must exist.
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Ingols, 2016, p.21). Tuning is a low intensity change process with low difficulty that falls under the responsibility of middle management (Cawsey, Deszca & Ingols, 2016).
Gill (2002, p.307) notes that “while change must be well managed, it also requires effective leadership to be successfully introduced and sustained”. On leadership Cawsey, Deszca and Ingols (2016, p.xvi) note that “middle managers need to be key change leaders”. Birken et al., (2016) see the role of the middle management as the one that diffuses and synthesizes
information, mediate between day-to-day activities and strategy, and sells the innovation implementation. This is in accordance with Jones, Jimmieson and Griffiths (2005), who observed that communication and employee involvement, are amongst the factors that are empirically linked to readiness for change.
The middle management that can take the role off change leaders is amongst the recipients that need to be convinced of the value of implementation. As the process “Clinical audit in four months” ends with the final presentation of the results, it can be argued that “finding a change leader” in middle management should be the next step. Not successfully managing this step will likely result in an unsuccessful clinical audit. Local middle management is responsible for providing the optimal care possible. Changes that don’t benefit the given care will not be seen as appropriate by them and they will not be willing to invest in these changes. This explains the significance of appropriateness. It also explains the effect of management support in readiness for change, as middle management is a primary source for change leaders. In the case two the audit leader found a supervisor that was also willing and able to fulfill the change leader role, while in case three the audit leader became the change leader in her new role. The final presentation may also play role in finding a change leaders, as it presents the clinical audit to potential change leaders. Or as the audit leader of case one argued, it would have helped the follow up if more members of the quality commission and care givers had been present.
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work floor. In the change message of the successful cases the dimension of personal valence seems to be of lesser importance even though it is assumed to be a positive factor. It’s absent in the communication, or the impact of the communication on the recipient was minor. On the whole more communication is present in the successful cases, which seems to support the presence of a change message. As no change leader is present in the unsuccessful cases, no change message is communicated to the recipients on the work floor. If cases were
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CONCLUSION
The goal of this research was to answer the question “How is the implementation of improvements resulting from local clinical audits influenced by the attention given to the readiness for change of the recipients involved?”.
The conclusions of this research apply to clinical audits that attempt to realize small changes of limited influence that refines or “tune” existing processes further. Not all dimensions of readiness for change influence the success of such clinical audit improvements in an equal manner. The readiness for change dimension “change specific efficacy” has little impact on the implementation success as personal is likely to be sufficiently educated and experienced to handle minor changes. The handover of suggested improvements to a change leader is an important step during the clinical audit implementation. When there is no formal procedure to guide this step, finding a change leader is mainly influenced by the readiness for change dimension of appropriateness. Not finding a change leader is likely to cause an unsuccessful implementation. The importance of the readiness for change dimension personal valence is limited and will express itself along with the other dimensions of readiness for change in the change message that is used by the change leader to convince the recipient of the change on the work floor. Management support provided by middle management is observed to be important. This is likely because the change leader is often someone from middle
management. The conclusions derived from this research tentatively indicates that at least parts of the change management literature is applicable to local clinical audits and this knowledge could be beneficial in creating further understanding of the reasons behind the success and failure of clinical audits.
Theoretical implications
36 Managerial implications
In the current setup of clinical audits within the UMCG, the suggested improvements don’t always get implemented. This constitutes a potential waste. Burgess (2011, p. 8-9) states that “measurement on its own is not enough … even if the intention is for audit to improve patient care, very often that change to improve practice does not happen – the cycle is not
completed”. In those cases were a change leader was found, success followed. It can be put forward that a formal handover process step should be created in order to facilitate the
appointment of change leaders in order to realize the potential completion of the clinical audit cycle. As implementations can take a long time, this might be preferable to expanding the educational audit to a full clinical audit. An educational point can also be made. The students learn to set up a clinical audit, but at the same time, they are not taught the importance of readiness for change that goes with implementing change (Shea et al., 2014). It can be argued that an educational clinical audit should therefor also entail an inventory of readiness for change attitudes amongst those involved.
Limitations
Several limitations apply to this research. The most important one is that it took place in only one hospital, the UMCG. This showed in the way the clinical audit process was adapted for educational use. This limits the generalizability of this research somewhat. During the interviews there was limited time available in which all questions had to be asked, this reduced the depth of information and prevented follow-up questions. No second interviews were possible in the timeframe of the research. As a consequence, the data gathered partially lacked clarification and the reasons behind the answers. Another important limitation is that no recipients on the work floor (e.g. nurses) were interviewed, this prevented verification of the recipients perception as stated in the interviews. Originally, interviews were also planned with the recipients in order to get their view on readiness for change, thereby strengthening the data. But this proved to be unfeasible, partly because of time constraints and partly because it was indicated that recipients that knew of the audits were hard to find.
Further research
