After the crisis: the maintenance model of effective change

How to get C.diff rates down and keep them there

Incidents that jeopardize patient safety are opportunities for organizational learning.  But if new guidelines and behaviours are going to be sustained, these incidents must also be seen as triggers for change. 

After a crisis, however, the normal rules of change management don’t always apply.  Experience of containing an outbreak of C.diff at Bedford Hospital Trust suggests an alternative approach. We call this the maintenance model of effective change because the actions necessary to prevent a recurrence of a crisis like this are different from the actions required to manage the crisis in the first place.

Pre-crisis

In 2006, the C.diff infection rate at Bedford Hospital was 20 to 30 new cases a month.  This rose to 47 cases in November. The infection control team held an incident meeting, and junior doctors reported the increase to senior colleagues. But managers were not aware how serious this was as there was no formal information reporting.  C.diff was a known problem, but the depth of this crisis was not immediately apparent.

Crisis

In June 2007, national league tables were published showing the incidence of HCAIs.  Bedford was in the bottom ten. An SHA support team visited in early July, issuing recommendations concerning clinical care, infection control practice, and management and governance. The support team were impressed by the open, non-defensive way in which the hospital responded to their advice, and by the speed with which plans were implemented.

Beyond crisis

The number of new cases of C.diff dropped below 15 a month in August 2007, and continued to fall. By the end of 2009, it was down to between zero and five new cases a month, a rate that has been maintained since. Success was due to the combined impact of several actions managed as an evolving programme, a six-component ‘package deal’, rather than the typical stepwise change management approach.

1. Turnaround team

As soon as the league table position was known, top managers established a cross-departmental turnaround team with clinical and managerial members who had the authority to act without permission from senior managers.

2. Appraise and prioritize

The turnaround team decided on immediate actions including improved hygiene facilities, and changing antibiotic prescribing practice (including the withdrawal of some antibiotics). Other changes, such as altering bed layouts, and depriving senior doctors and medical secretaries of their offices to create more isolation rooms, were going to take more time and resources, and require sensitive handling, but consultants and secretaries did not resist.

3. Emergency response

Managers were quick to demonstrate that the problem was understood, and that a solution was being implemented. An autocratic, ‘no questions - no negotiations’ style was adopted, highlighting the importance of the required actions, and driving the pace. The SHA were kept informed such that they remained supportive. This involved a ‘political fix’; the key external stakeholder was reassured by management’s open and non-defensive approach. But this emergency response also involved a series of ‘real’ fixes to contain and resolve the problem.

4. Systemic solution

Systemic problems need systemic solutions, including individual, team, organizational, financial, infrastructural, and other factors. Bedford introduced changes to personal hand hygiene, ward performance audits, prescribing policy and screening practices, budget allocations, bed and ward layouts, dress codes, training, practice manuals, and pharmacy-led ward rounds. Communications were authoritative, frequent, and appealed to professional values, rather than to external targets. This approach was also aware of ‘infection control fatigue’, and the ‘solution’ was constantly refined, to attract attention and maintain interest.

5. Measure and report progress

Infection rates were monitored and published with audits of ward hygiene practices.  This information often finds its way into committee minutes and board papers, and is summarized for the purposes of external audit.  At Bedford, all staff were constantly aware of how well the hospital and specific areas were performing on these key metrics. The continued lowering of infection rates provided both incentive and motivation to maintain that trajectory.

6. Plan for continuity

Performance has improved, the crisis is over, external stakeholders have left happy. So, the work of the turnaround team is over? No. At Bedford, the turnaround team continued their work, to maintain the focus on the agenda, and to sustain and improve the reduction in infection rates. The shift from the immediate emergency response to the continuing maintenance phase was critical to their success.

What works in one setting will not always work elsewhere. However, the pattern of crisis intervention at Bedford is an approach that other trusts should consider.  Bedford’s example shows that change can be implemented rapidly and be sustained through a combination of compelling evidence, autocratic management (where appropriate), a powerful cross-functional team, and innovative communications that encourage behaviour change by addressing beliefs and values.

 

Acknowledgements: The research behind this article was funded by the National Institute for Health Research Service Delivery and Organization programme, award number SDO/08/1808/238, ‘How do they manage?: a study of the realities of middle and front line management work in healthcare’.

Disclaimer: This report is based on independent research commissioned by the National Institute for Health Research. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health.