by Carol J. Peden, M.B., Ch.B., M.D., M.P.H.
If you’re reading this piece it is likely that you have reached the point of action, and you want to do something about perioperative brain health. You have read the literature, hopefully you have watched our moving patient stories, and you want to ensure that you and your colleagues minimize postoperative cognitive dysfunction (POCD) confusion and delirium for your patients. The question is how do you turn your energy and engagement into action?
Here are my top 10 tips for making clinical change happen, gained over many years of designing and leading QI programs in anesthesiology, intensive care and surgery around the world. Be aware that leading change can be hard and resilience is required, however, achieving improvement is very rewarding.
You will need to convince colleagues that confusion and delirium are issues at your institution, not just at research or academic institutions. Getting data for improvement is not the same as acquiring data for research; you need just enough data for improvement to inform you of the current state and create a baseline. You may choose to sample patients, for example, by reviewing the notes for the last month of patients over a certain age (e.g., 65 years) for use of sedatives and antipsychotics, or performing a short prospective audit to provide the information to engage your stakeholders (and by this, I mean everyone who comes into contact with the patient – nurses, surgeons, therapists).
Start talking to everyone about what you have found, get engagement and buy in, get interns and residents involved, get the nurses talking about what they can do. Successful improvement programs do not run on their own nor on the energy and drive of a few individuals. This is a very important problem and you need to create that recognition and a burning platform for change. Tell patients’ stories to make the data real. Did you see the patients’ stories on this site? If so, you will know what an impact they have. Tell the story of a patient who suffered delirium at your institution—make it about what happened in your hospital to a patient in your care.
The evidence that postoperative delirium is one of the commonest postoperative complications has been out there for a while, but most organizations are not actively tackling it. Take time to talk to different staff groups and understand the issues preventing improvement: is it lack of knowledge, failure of recognition, fear of giving anti-psychotic drugs? Understand the issues in your organization through discussion and analysis of your data, and formulate ideas for change. If you can, I would suggest getting as many of the relevant stakeholders in the room, mapping a typical “at-risk” patient pathway (see some resources on Lean and patient shadowing) and identifying where the interventions we are suggesting in this campaign could be applied.
Understanding your system sounds complicated and derives from Deming’s “System of Profound Knowledge,” but essentially this means there are four interacting components of the system that you need to consider: psychology, understanding the system, understanding the variation, and a theory of knowledge.
First is the psychology of the people—why will people want to help you to change the incidence of postoperative cognitive dysfunction? Doctors in training may wish to participate in a project that they can present or write up; surgeons may be interested in the fact that improvements will make their patients and families happier and reduce length of stay; and anesthesiologists will wish to improve their patient’s experience and reduce the number of times they are called to the PACU to deal with a delirious patient.
Second is understanding the system. How do the system components the patient will pass through interact? How can these interactions help and hinder the project? For example, do the order sets facilitate a “brain health”–friendly anesthetic for at-risk patients? Are there system prompts to be aware this patient is at-risk? Consider your improvement ideas from a system perspective—how will key information be communicated across many different teams? How will essential pieces of property such as glasses or hearing aids be with the patient at key times?
Thirdly, understand the variation in what you are studying. Are there some days of the week or weeks where more patients are delirious than others? If so, ask why. Are there some types of surgeries that seem to be worse for postoperative cognitive dysfunction? Understand what is going on in your organization to see where you can make improvements.
Finally, the theory of knowledge is about creating a hypothesis for your system about what might make improvement happen, such as avoiding all benzodiazepines in patients 65 years and older. Test this hypothesis and observe what happens, and gain knowledge about whether this plan can work in your organization and for your patients. Essentially you will work through the Plan-Do-Study-Act (PDSA) cycles central to all improvement projects to gain knowledge about what works for your patients in your organization.
The best aims that achieve real improvement are SMART—specific, measurable, achievable, relevant and time bound; visit the Minnesota Department of Health website for more detail. An example of a good aim statement for the perioperative brain health initiative in a participating hospital might be “We will have reduced the number of our patients 65 years old older undergoing surgery who suffer postoperative delirium by 50 percent by December 1, 2018.” Contrast that aim statement with one such as “We plan to work on reducing post-operative delirium.” The first statement much more clearly communicates that results are expected by December 1, 2018: it sets a goal of a defined amount of improvement and more clearly defines the patient population. However, both statements require further clarity about how postoperative delirium is classified, how it is detected, and how and when it will be measured.
Communicate your aim statement to everyone in the organization and make it visible. Go to your senior management team and tell them the facts about delirium and POCD, and get their help to support the project.
We have included resources to common change management tools such as Lean or the Model for Improvement. Please use them as they are very useful and will help guide you through your improvement work. If you have a quality improvement department ask for their help. Use tools such as a driver diagram or segmentation to help make the project more manageable and to help engage different teams and define their roles. For example, a brain health improvement project could be broken up or segmented into preoperative actions, intraoperative actions and postoperative management. Within each area there are small and distinct projects that can be worked on. For example, preoperatively one project may be to improve screening of patients, another group could work on better information for patients and families. Dividing the work and the change concepts this way can help make the project seem less daunting and can allow different teams to work in different areas while aligning to the common goal. The Model for Improvement used by the Institute for Healthcare Improvement and the improvement approach with which I have the most experience asks three questions key to your work: What are we trying to accomplish? How will we know whether a change is an improvement? What changes can we make that will result in improvement?
Patients are becoming more aware of the incidence of postoperative confusion and delirium. Families may be concerned that it has happened to a relative before and they do not want it to happen again. One well-known orthopedic hospital with an active project in reducing delirium is telling potential patients about their success, and the local community is talking very positively about it—older patients are choosing to go there. The film clips on this website demonstrate the power of using the patient’s voice. Consider forming a patient advisory council for your delirium reduction project, get patients and their families input on your ideas, and ask for their suggestions.
This project is unlikely to be successful if it is solely dependent on anesthesiology input. We can make significant changes by modifying our sedative and anesthesia management for at-risk patients, but for this program to be very effective we will need to engage with nursing and surgical colleagues, as well as ambulatory clinic staff. All colleagues in the multidisciplinary team need to understand our aim, what we are trying to accomplish, what changes we are trying to make happen, and how we will measure our success. Our project will be much more successful if we engage with colleagues early on (see Top Tip Three) and harness their ideas and input. The use of visible prompts and measurement charts, such as run charts demonstrating improvement over time, can be very inspirational for teams, and can act as a focus for discussion on what is going well and what could be improved. Team members should feel empowered and be given the chance to come up with better ideas or new suggestions as the project evolves; this would fall in line with the learning step in the improvement process.
Improvement work is tough. I have found food, especially cakes, to be a great improvement aide. It is amazing what a small token of support and fun can do to enhance a project! Ensure that you call out the progress that is being made, encourage more junior team members to discuss their successes, and write up these progresses and successes or present them at meetings. Create a sense of fun and regularly provide feedback and show the data. Do not underestimate the power of healthy competition, especially amongst doctors. Sharing data and progress between different units is a way to accelerate learning and spreading good ideas. Ask patients or families to share how they have seen improvement or how they have had a different experience of surgery since your changes. Make everyone proud to be part of the team that achieved these changes!
Once you have started to see progress and a reduction in postoperative cognitive dysfunction and delirium, do not let up. Ensure you understand what has achieved the change. Be careful that success has not been due to the hard work of a small number of individuals: the progress must sustain if they move on. Also consider whether your new processes will work at nights and weekends, as well as during routine hours. You must keep measuring. You may be able to decrease measurement in key parts of the process, but do not assume that without some measurement and accountability improvement will be sustained! See the IHI White Paper on Sustaining Improvement.
Good luck and please send us your successes for this website to encourage other teams [email protected]
