Making it happen
Evonne Curran
Nurse Consultant
Unknown but limited ingredients
Variable talent
Time limit
Goal: Make the best possible output with the above
At the end of the day..... It would
be good to say..
• I can show that because of me
(xxxxxxxxxxxx )
– Is now performed more safely
– Has improved the patient experience
– Has reduced risks to the organisation
– Has resulted in fewer infections
– Has resulted in less waste (money,
time, resources)
LAND MINES
Lack of vision
Lack of information
Lack of inclusion
Lack of strategic thinking
Lack of strategic alignment
Participation as an end
Lack of productive conflict
Untested assumptions
Lack of alignment
Lack of communication and accommodation
Focus on results – not the steps to the results
http://www.rexroundtables.com/showbriefs-yplansfail.php
Risk assessment
Very high
High
Moderate
Low
Devasting
Severe
Moderate
Minor
Potential benefits assessment
Very likely
Reduce harm / risks
Improve pt experience
Reduce costs
Faesible
Likely
Low likelihood Undetectable
Potential topics - what is important
to
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You
Your IPCT
Those at the front line
The antimicrobial pharmacist
Those who hold the purse strings
The patients
The HAI executive lead
What makes hospital infections
• Invasive Devices
– Urinary Catheter
– PVCs
• Norovirus
• Antibiotics
• Contaminated equipment
• Failure to comply with SICPs
Topic Review
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The problem?
How big is it?
What is driving the problem?
What is achievable?
Benefit Assessment?
Urinary catheters
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We use too many of them!
We keep them in too long
We don’t know about alternatives
By pass defence mechanism
Perfect culture medium
Alternatives – not accessible
– Scales to weigh urine
– Female slipper pans
– Suitable inco pads
Habits
• Habits emerge because the brain is constantly looking
for ways to save effort (system 1 / 2 thinking)
• When a habit emerges the brain stops fully participating
in decision making.
– The order you wash in the morning
• Unless you deliberately fight a habit – find new routines
– the habit will unfold automatically
• Habits work on cues
• Habits are driven by ‘cravings’
• Willpower becomes a habit when certain behaviours are
chosen ahead of time – routine followed when cue
arrives
The Power of Habit – why we do what we do and how to change,
Duhigg
Q How man animals of each kind
did Moses take on to the ark?
Habits in healthcare just as in life
• Serve us well
• Allow us to do things swiftly and
consistently
• But… from time to time we need to
break old habits and create new ones
Habit Loop
Action
Buy and drink coffee, eat muffin or sub
Cue
Reward
Job done
Smell of coffee,
Smell of cinnamon
Smell of Subway
Feel satisfied (and guilty)
Craving: taste, effect of drinking coffee (not hunger)?
Habit Loop
Action
Indwelling foley catheter
Cue
Reward
Job done
Urinary retention
Fluid balance measurement
required
No longer in retention
Urine measured
Craving: to do something good / technical / solve a problem
Habit Loop
• For success
– Need a new habit
• Need to know and have access to alternatives
– Accurate fluid balance does not always need a
catheter – scales and a bottle
– Uro-sheaths reduce infection risk
– Intermittent catheters
– Need to believe that it can be achieved
• Some one else has done it – group therapy
• Data to show it works
• Data to show it matters
How do we change habits
• Need to learn new habits that overpower
the current habit behaviours
• Find new routines and rewards from cues
• Works for (some but not all) alcoholics
• The ingredient that made a reworked habit
into a permanent behaviour – Belief
• What is our (habit) reaction to:
“we are going to introduce a new initiative
to……. “
New Habit Loop
Action
Engage with patient to
consider best possible
option for patient
Cue
Reward
Job done
Urinary retention
Fluid balance measurement
required
Patient centred care
& catheter avoidance
Our craving needs to be to achieve PCC
Social Marketing
• A process that applies marketing
principles and techniques to create,
communicate, and deliver value in
order to influence target audiences
behaviours that benefit society (public
health, safety, the environment and
communities)
Kolter et al (2006)
If not social marketing what else?
• Education & Data feedback
– Use of rational facts to persuade people
to adopt a different behaviour
• Coercion
– Forces people to adopt a behaviour
under threat of penalty for not doing so
Social marketing
Is
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A social behaviour change strategy
Most effective when it activates people
Targeted towards those who have a reason to care
Strategic and requires efficient use of resources
Integrated and works on a plan
Social marketing in healthcare, Radha Aras
4ps of Social Marketing
• Product: Desired behaviours
– Reduction in urinary catheter usage with an increase in
safer alternatives
– Increase in patient involvement in decision making
– Optimisation of clinical decision making
• Price: Cost associated with the behaviour changes
– Price of CA-UTI (physical and psychological)
– Effort – resource required
• Place: Make it convenient – to translate the motivation
into action. Intervene at the point of decision making
• Promotion: Make the new habit acceptable, easy, and
desirable to the audiences
Social marketing in healthcare, Radha Aras
Lets now look at a plan to join our
habit knowledge with our social
marketing knowledge
To modify a habit you need to answer
these questions
• Location: where are people when the cue
happens / decisions are made / first acts?
• Time: does it happen at a particular time?
• Emotional state: what state are people in
when the cue arises?
• Other people: who else is around to help
with decision making?
• Immediate preceding action: what happens
just before the decision?
Before you start
• Identify and prioritise barriers
– Don’t have easy access to alternatives
– Don’t know what to use when
– Don’t consider remove ASACI
• What will over come barriers
– Get help from continence support
– From whoever has the budget
– Alternatives and placement of alternatives
– Training
• Pilot
• (We still need education and data)
Clear message catheters are
dangerous
STOP
Before you
catheterise….
Reason to believe:
Limiting urinary catheters is doable
and better for patients
• 7mth pre period; 4 mth intervention period
• Limit criteria set: urinary tract obstruction, hourly
output measurement, etc.
• Measured
– CAUTI
– Urinary catheter
– Nursing experience
• UC usage decreased by 42%,CAUTI by 57% nursing
satisfaction improved
Rothfeld et al AJIC 2010 38 568-71
What we do in nursing
• Are learned behaviours
• Habits run by – cue, action, reward
• To bring about safer action
– Need different habits (that involve
patients more)
– Need education on safest alternatives for
patients to optimise clinical decision
making
– Need easy access to the safest
alternatives
– Need data that shows we provide optimal
care
Habit and social marketing
• Social marketing can help deliver the
message
– Alternatives to catheterisation are
suitable and safer in many cases
– Here are the alternatives to
catheterisation
• This messaging will make the case for new
habits (create the belief) and make it easier
for new habits to become established
Need to find out – what are the
attitudes to the process to be
changed
• Is it a settled way of thinking or feeling,
typically reflected in our behaviour?
• Or are we ready to break a habit?
Potential benefits assessment
Very likely
Reduce harm / risks
Improve pt experience
Reduce costs
Faesible
Likely
Low likelihood Undetectable
Lets do one together
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The problem?
How big is it?
What is driving the problem?
What is achievable?
Benefit Assessment?