Abstract
This is the first paper describing the unit level champion role in order to implement the Collaborative Care framework as an evidence-based practice in the province of Alberta. The clear selection criteria of Unit Lead, funding (.2 FTE) that allows for the dedication of the role, support with various education, coaching from the project management team, and community of practices were suggested as important factors for successful utilization of Unit Leads to implement quality improvement initiatives in a large scale. Future initiatives may consider using a peer-leader champion as a change agent who is committed to the change initiative, credible and personally connected to the unit staff, possesses knowledge about the organizational culture, and develops a unit-tailored strategy via performance monitoring data to fully implement an evidence-based practice for quality care.
Background
Patient care in hospital has become increasingly complex in Canada. Accordingly, Alberta Health Services (AHS) recognized a need to change the current model of care delivery to achieve their mission; to provide a patient-focused, quality-driven health system that is accessible and sustainable for all Albertans (www.albertahealthservices.ca). The Collaborative Care Program is a framework designed to provide patient-centred care, to support highly effective teams, and to yield effective system based measures for quality improvement. 1 AHS selected Collaborative Care as the way forward and designated the Collaborative Care program team (CoACT team) to oversee a province wide implementation.
AHS is the largest provincial health authority in Canada and serves 4.3 million residents with more than 850 hospitals, community clinics, and continuing care facilities. 2 AHS, similar to many healthcare organizations, is challenged with achieving the organizational goal of introducing evidence-based initiatives to create efficiencies in providing quality care and sustaining such changes. In order to implement the changes necessary across such a vast geographical area and adapt to subtle and overt differences across the zones and sectors, a purposeful implementation strategy was needed such as using a peer champion. There is inherent recognition that use of champions is not a novel idea in the literature as a way for leading and sustaining evidence-based practices.3,4 Champions are considered effective communicators, receptive to change, and able to establish positive relationships throughout the organization and demonstrate genuine deep-rooted enthusiasm for the initiative at hand.5,6
Yet, little is known about how champions are identified and supported to achieve the outcomes of the initiative being implemented. A systematic review by Woo and colleagues showed that although all the included studies suggested that implementing nurse or other care provider champions in their quality improvement initiatives were important facilitators of success, how the champions were selected and trained in their role is either missing or not described in any detail. 7 A recent study described an overview of an Evidence-Based Practice (EBP) change champion program and evaluated participants’ perceived usefulness of the program and understanding of EBP. 8 However, this was a pilot program and lacking the information of how nurse champions are utilized in the implementation of EBP in a large setting.
Purpose
This paper provides a narrative description of how a Unit Lead champion role was developed to support the implementation of the Collaborative Care framework in Alberta. Further, this paper demonstrates how this peer leader role was developed, supported, and used to generate the unit level change necessary to address system level outcomes.
Program overview
Collaborative Care as defined by AHS aims to (1) identify care practices and processes that place the needs of patients and families first, (2) enables high-performing, Collaborative Care teams, (3) promotes a culture of curiosity, inquiry, collaboration, and learning for continuous quality improvement, and (4) uses a partnership acceleration network to facilitate the change (see Figure 1).
9
Collaborative Care was originated from three initiatives: Path to Home, Workforce Model Transformation and Care Transformation, all of which were aimed to change how health care teams work together, across the system, to ensure that no matter where Albertans access care, their experience is at the centre of everything we do. In order to focus the effort and reduce the burden on frontline staff, the three initiatives have integrated to carry forward as one cohesive program as “Collaborative Care.” Since its launch in September 2014, Collaborative Care has been implemented across the province over 200 individual nursing units across various practice settings including medical, surgical, mental health, and continuing care. The CoACT program team is the provincial resource that supports the implementation of the Collaborative Care framework which consists of staff with various expertise in program management, analytics, and a variety of clinical knowledge. As implementation began for Collaborative Care, the need for more specialized implementation support was identified quickly to meet the scale and achieve the successes expected of this program. Referred to in the literature as champions, these individuals demonstrate a promising approach to supporting change and implementing evidence into practice.10,11 Staff resistance and buy-in can be difficult barriers to overcome, using in house staff to support change is viewed to be an effective method to address these challenges to change management.
12
CoACT Collaborative Care design with elements.
The CoACT team embraced the notion of local level leadership through the development and utilization of over 500 unit level champions to date referred to as Unit Leads. In order to meet the objectives set out by the CoACT team, a grassroots approach was needed to determine the who and the what of the Unit Lead role. Not only would a new role emerge but defining how to select the right individuals and support them to be competent was novel work for this program.
The Unit Lead role was developed using point-of-care staff from the inpatient units to support the implementation of Collaborative Care is a hallmark aspect to this role. The priority focus and direction of Unit Lead work was to address gaps in implementation that were occurring prior to the enlistment of Unit Leads such as barriers to addressing resistance in a timely manner; capability and reach to support unit staff in real time in a setting of shift work, and coaching through change. The overarching goal was to train and establish a peer within the unit to support the start of change, implementation, and on-going sustainment once the model was fully implemented. The CoACT program team developed a clearly defined approach to selection, training, and professional development required of the Unit Lead position to successfully support change at the local level.
Selection and funding
Unit Lead selection criteria.
aAdapted from Votova et al. 13
In an effort to preserve the peer-to-peer relationship the Unit Lead was not seconded nor moved into a project associated position, they maintained their unit position and continued to provide bedside patient care but were allocated time from that position to assist with implementation. Financial support (an average of .2 FTE of their current wage) was paid to the unit to offset the costs of the Unit Lead’s time and enable dedicated hours for the Unit Lead to engage in what is classified as Unit Lead duties. This work could include participation in professional development education sessions, involvement in implementation planning activities, or supporting the dissemination of education to their peers and other health provider colleagues.
Education and support
Unit Leads’ demographic information and understanding of the role and perceived support on taking a Unit Lead role.
The CoACT program team consistently supported the Unit Leads via regular meetings in order to generate awareness of Collaborative Care among their peers and provide content specific education for the progression of implementation. The CoACT Team generated enthusiasm at the initiation stage and provided Unit Leads with the opportunity to assist with developing action plans based on unit specific insights to help achieve a program plan that best suited the unit. Based on the combined efforts of this partnership of program experts and local level leader, a supportive environment was created for Unit Leads to ensure local adaptation of Collaborative Care to their setting. A successful relationship between Unit Leads and the CoACT Team is reflected in the survey such that 89% of respondents indicated that they knew who to reach out to if they were struggling with their role. In addition, the majority of respondents felt supported by their staff in their Unit Lead role (see Table 2).
Data literacy through audit and performance monitoring
Another aspect to the role of Unit Lead being fundamental to demonstrating success as well as opportunity for improvement was the monitoring and evaluation of performance. 16 The CoACT Team educated Unit Leads on performing audits and utilizing audit data for performance monitoring and improvements on patient experience and leading practices. The ability to demonstrate data literacy and translate that knowledge into improvement opportunities was identified as a valuable skill to support other quality improvement initiatives.
Unit Lead community of practice
Support for the Unit Lead role came from the program team as content experts as well as peer to peer to support the sharing of ideas and experiences through the CoACT Unit Lead Community of Practice (CoP). A CoP is a group of people who meet regularly to share common interests, passions, and challenges by sharing experiences and learn from each other. 17 The Unit Lead CoPs were chosen as critical pathways for information sharing by connecting Unit Leads working in geographic isolation with modest resource requirements. 2 The Unit Lead CoPs varied in frequency from weekly to once per month providing additional learning opportunities for members to explore ways to address local challenges and solutions in implementing Collaborative Care. The Unit Lead CoPs provided an informal support structure that offered Unit Lead’s connection to others doing similar work and allow for the sharing and reflection of experiences.
Lesson learned
This is the first paper describing the implementation of Collaborative Care framework as an evidence-based practice by utilizing the unit level champion role. Anecdotal information indicates the use of a champion type role to support implementation of a significant behaviour change across a large geographic area to be invaluable. The Unit Lead role allowed for an increased speed of adoption due to the large numbers of staff supporting the Collaborative Care messaging. The peer relationship further added to the credibility of the practice changes being implemented.
Providing minimal financial support (.2 FTE) enabled a Unit Lead to dedicate their time in implementing Collaborative Care with various activities and engaging with the point of care staff. Additionally, keeping the Unit Lead as part of regular staff served the unit to continue to function without disruption on the loss of a staff member but also embedded a content expert in the staffing mix to provide support real time and after the CoACT program team’s hands-on support on implementation of Collaborative Care was completed. Last, setting up clear selection criteria, ensuring role clarity, and training by change management experts were critical for Unit Leads to manage typical barriers to change such as resistance.
Unit Leads described personal gains from taking on the Unit Lead role. As Unit Leads were educated on change management and leading teams among other leadership courses and opportunities presented as a Unit Lead, some ended their roles early to pursue offerings of job advancement. While the Unit Lead orientation and support was not meant to be a career advancing mechanism, it has been shown over time to have allowed emerging leaders to hone in on this opportunity in order to advance their careers in health leadership. Namely, this group was able to develop LEADS capabilities: leads self; engage others; achieve results; develop coalitions; and systems transformation 13 —which is the end goal of the Collaborative Care team. This is reflected in the survey results (see Table 2) as many Unit Leads were considering taking clinical leadership roles in the future.
College and Association of Registered Nurses of Alberta framed “leadership” as one of their entry-level competencies for the practice of registered nurses, yet most nurses do not have the opportunity to use this core competence in their daily practice. 18 Being a Unit Lead provided point-of-care staff opportunities to improve their leadership competency and invigorate others in providing quality and safe care to all patients. Continuous support on setting them up for success was the rationale for professional development support in coaching, education, and communities of practice, which was critical in improving their competence and confidence in taking this leadership role. Participating in Quality Councils, Unit Leads were able to raise their voices on how to improve quality of patient care.
Limitations
While the direct costs of Unit Leads are known, no analysis has been completed at this time to compare costs and outcomes due to a number of confounding variables with implementation. Future publications may consider a cost-benefit analysis to highlight the value for dollar of having a Unit Lead support implementation of quality improvement initiatives. Second, due to the initial purpose of the study being quality improvement, neither testing the hypotheses from the study nor examination of the causal relationship of the utilization of the Unit Lead role on Collaborative Care implementation was performed. Future research may consider setting up a rigorous design to examine the causal relation of Unit Lead role on the implementation of EBP and improvement on leadership skills based on LEADS framework. Last, a small cohort size of the survey respondents was a limitation. This may be because nurses often take positions on other units, take educational or maternal leaves of absences, which make it necessary to select a new Unit Lead. As a result, the reach to all previous Unit Leads was complicated by the normal churn of nursing units. In future, utilizing this survey as an exit survey may help to increase the number of respondents.
Conclusion
CoACT Unit Leads performed a crucial role in leading practice changes as a champion for improved patient care and team functioning. Thoughtful consideration is required when appointing a Unit Lead, who is professionally competent in taking the Unit Lead role, is open to adapt a new way of thinking, and well-respected by the staff. Beyond the support of Unit Leads in practice, unit level leadership and above could support this role by visibly recognizing the value they bring to supporting change by reducing the likelihood of being reassigned to nursing duties rather than protecting Unit Lead time. Additional considerations for organizational leadership is the inherent value associated with supporting point of care staff to be engaged with strategic priorities, often the drivers of quality improvement initiatives. Unit Leads will continue to be an important role for the continued implementation of Collaborative Care. As educated change agents they can further be utilized to support other quality improvement initiatives within AHS.
