Implementing Guidelines for Pediatric Tonsillectomies

Practice Paper: Implementing Quality Based Procedures Guidelines for Pediatric Tonsillectomies at Credit Valley Hospital

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Kathryn DePass

Trillium Health Partners, encompassing three sites- Credit Valley Hospital, Mississauga Hospital, and Queensway Health Centre, claims their hospitals are leading with outstanding performance, fiscal responsibility, and quality patient care (Trillium Health Partners, n.d.).

With the emergence of the Health System Funding Reform in 2012, drastic changes were made to hospital funding. In particular, to promote innovative and evidenced-based practice, thirty percent of hospitals’ overall funding was allocated towards Quality Based Procedures (QBP) (Provincial Council for Maternal and Child Heath & Ministry of Health and Long Term Care, 2013). QBPs are specific clusters of patient services that offer opportunities for healthcare providers to perform services based on best practice. It is suggested that when organizations adopt clinical evidenced-informed practices, quality patient care will flourish, while also increasing system efficiencies and decreasing costs (Ontario Health Association, 2013).

One of the procedures covered under QBPs is Pediatric Tonsillectomy, with or without Adenoidectomy. The Quality-Based Procedures Clinical Handbook for Paediatric Tonsillectomy with and without Adenoidectomy (2013) articulates the specific evidence-based components of care that should be provided for these patients from pre- to post-operation. The Director of Women and Children’s Health indicates that practice variation, lack of standardization, lack of evidenced-based practices, and physician resistance all contribute to the organization’s inability to enact QBP standards for this procedure since it was issued in 2014. Specifically, no standardized pre-screening tool exists to assess for complications prior to surgery. In particular, children are neither assessed nor properly diagnosed with obstructive sleep apnea syndrome (OSAS) using a sleep study, the gold standard. This assessment, however, is vital since OSAS patients have a high risk of postoperative respiratory complications (Leong & Davis, 2007).

On the day of surgery, it is not standard that patients receive a pre-operative acetaminophen loading dose for prophylactic pain management. Some anesthesiologists vocalize their discomfort with administering acetaminophen rectally, while others are not aware of the significant impact of this administration on post-operative pain management. The American Academy of Otolaryngology Clinical Practice Guideline for Tonsillectomy in Children states that rectal administration is better tolerated than oral administration and is the most effective in reducing pain and opioid requirements following surgery (Baugh et al, 2011). In addition, children with adequate acetaminophen analgesia have less post-operative nausea and vomiting.

Both the Director and Educator of Pediatrics argue that physician resistance has been a significant barrier to implement QBP standards (Cathie Boudeau, personal communication, April 27, 2015). Nonetheless, both the surgical and pediatric nurses have disclosed that they look forward to changes that encourage standardization and quality patient care. The Educator has explained that she has already began drafting a post-operative standardized PPO form, which has, surprisingly, gained significant approval by physicians. Therefore, the Educator has requested the writer focus on standardizing the pre-operative experience.

Currently, patients and families receive a Pre-Operative Information Sheet. The Educator has noted, however, that this form does not align with QBP advisement. In addition, families have vocalized that the sheet should be more comprehensive and visually appealing. In addition, a standardized pre-assessment form to screen for complications needs to drafted. Changing behaviour in regards to administration of pre-operative acetaminophen will also be considered in this project. The Quality-Based Procedures Clinical Handbook for Paediatric Tonsillectomy with and without Adenoidectomy (2013) will be used as the reference to create a Pre-Operative Information Sheet for families and patients, as well as a pre-assessment checklist to screen for complications.

In order to encourage adoption of all new changes and to change behaviour, knowledge of change management is imperative. Therefore, a literature review was conducted to guide the implementation of this project. Inclusion criteria parameters for the literature search included the years 1995 to 2015. Search terms included “organizational change”, “management of change”, and “change management.” Databases used were MEDLINE, PubMed, and CINAHL. Many articles were retrieved (about 300 hits). The search was then narrowed to focus on health care and hospitals. Roughly 145 articles were reviewed. Empirical studies were assessed for clarity of methodology, peer review, and external evaluation. Finally, the number of articles was narrowed down to 45, which met the specific criteria for change management in health care.

Change management literature draws from a wide range of disciplines, as well as theoretical and organizational perspectives, such as psychology, sociology, business policy, and social policy, creating a complex and robust body of evidence which is challenging to appraise and synthesize. Furthermore, the literature contains numerous and varying frameworks, models, evidence, and illustrations; that may describe, analyze, guide, approach, and test initiatives, programmes, and tools for change. There are no frameworks or models of change unique to healthcare organizations although several models are conducive to change efforts in these areas. Therefore, the literature that was reviewed focused on dominant change management models that are often applied to health care organizations. Furthermore, some models are used primarily for higher levels of leadership. For the purpose of this project, literature focusing on micro-level processes was selected.

Case studies, surveys, and pilot studies are the most common methodologies in change management literature. While these methodologies are considered low on the evidence hierarchy, due to the limited ability to control subjects in healthcare, these methodologies do seem the most realistic and accessible means of implementing and evaluating change. Within the literature, one of the most influential perspectives of change management originates from the “planned approach” created by Lewin in 1951, which argues that change occurs in three progressive stages: unfreezing current behaviour, moving to the new behaviour, and refreezing the new behaviour (Elrod & Tippett, 2002). For many years this three-step model has been the dominant approach to organizational change.

Critics argue, however, that planned theories are based on the assumption that organizations act under constant conditions that can be controlled and planned for. As a consequence, an alternative approach, namely an “emergent approach” was developed. This approach considers change to occur so rapidly and unpredictably that it cannot be managed from the top down. Instead, it is argued that change is a process of learning, whereby the organization responds to both internal and external changes (Barnard & Stoll, 2010). This approach speaks to the concepts of “change readiness” and “facilitation of change” which are viewed as superior to the planned approach with specific pre-planned steps for change initiatives (Todnem, 2005). Nonetheless, emergent approaches do suggest that a sequence of actions should be enacted to increase the likelihood of change being successful (Luecke, 2003). Emergent theories assume that in order to respond to change, managers of change have to have possess a in-depth understanding of the organization, its structures, strategies, people and culture. With this understanding, managers of change are able identify the most appropriate approach to change while recognizing possible facilitators and barriers (Burnes, 1996)

The literature argues that while these two approaches are often cited to be polar opposites, it is important to note that they are theoretical approaches. Therefore, the best strategy for organizations to manage change is to utilize both these approaches, in the form of frameworks or models that best meets the particular needs of the organization (Burnes, 2004).

When the variety of frameworks, models, and approaches to change management are applied to health care organizations, common trends emerge. These trends include environmental circumstances, organizational harmony, power dynamics, organizational capacity, nature of change, and process of change (Antwi & Kale, 2014). Environmental circumstances include the external conditions to the organization that forces change, such as increased competition and technological innovation (Lau, 1999). Organizational harmony illustrates an agreement among individuals and units within the organization. All members should have congruent missions and visions and be working collaboratively towards the same goal. Further, overall organizational plans, processes, and goals should also be compatible (Antwi & Kale, 2014). Power dynamics refers to the hierarchy of influence within an organization. Understanding which individuals can influence the change process is important. Change leaders should have buy-in from these individuals before undertaking a change initiative; this will increase likelihood for success (Mitchell, 2013). Organizational capacity indicates that the organization has the necessary human and financial resources to undergo change. Moreover, it is essential that the necessary skill sets and knowledge be present to allow change to occur (Bazzoli, Dynan, Burns, & Yap, 2004). Nature of change refers to the rationale behind a change initiative. Change initiatives must consider an organization’s external and internal situation. Furthermore, ample evidence must be available to justify that a proposed plan for change has the ability to solve a presented problem (Antwi & Kale, 2014). Finally, process for change is the actual step-by-step approach to implement a change. Change leaders must make certain that these steps are agreed upon by all stakeholders and evidenced to create the desired change (Antwi & Kale, 2014).

The Canadian Health Services Research Foundation (CHSRF)’s Evidence Informed Change Management Approach was chosen to be the main model to guide the project as it contains all of the mentioned concepts. In addition, it is structured around specifically targeting the needs of Canadian healthcare organizations and outlines change as it pertains to micro level contexts. The approach presents a practical model for change management and contains four stages: planning, implementing, spreading, and sustaining change (CHSRF, 2012). The planning stage of change involves understanding the context and influential forces of change while determining the organization’ ability or readiness to change. To understand the context, change managers must determine which steps and people need to be involved to implement change and garner support. Readiness and capacity for change is determined by assessing all individuals at any level of the organization and considering how they will be affected by the change. Furthermore, the capacity for the organization, for example, financially, to undergo change, needs to assessed. After the planning stage, change agents can implement change by executing their planned approach. Spreading change entails promoting change beyond its initial context and influencing the culture to introduce new customs, traditions, and ways of practicing. Lastly, sustaining change entails surveying and modifying the change process as practical experience is gained over the course of implementation.

The literature also emphasizes that the key to successful change management is strong leadership. Gill (2002) explains that effective change leaders are able to frame the change in terms of results for all involved. Further, change leaders foster and create environments that allow people to experiment with new ways of practicing. This coincides with the Leadership Competency from the Canadian Nurses Association’s Advanced Nursing Practice National Framework (2008). Learning about a patient’s experience and collaborating with other interprofessional disciplines assisted in identifying gaps in care, specifically the lack of adoption of QBP standards for Pediatric Tonsillectomies, resulting in practice that is not evidence-based and negatively impacts patient care delivery. In addition, while changing practice has been attempted in the past, the application of knowledge learned from the competition of a literature review on change management and discovery of an influential model on change, the writer can be successful in enacting a new and effective means of practicing, ultimately improving patient care. Also, the specific nature of this project’s focus, to ensure QBP standards are followed, which promotes advocating for system efficiency, quality patient care, and low cost, aligns with the leadership competency of understanding and integrating the principles of resource allocation and cost-effectiveness in all levels of decision-making (CNA, 2008).

Literature on change management is diverse and robust, with applicability to health care organizations. In this literature, it is apparent that in order to manage change specifically in healthcare, a model or approach needs to be selected to address an organization’s specific needs and current issues. Understanding the organization as a whole and the people within it is an imperative and first step in planning change. Collaborative work among change managers and targets of change will ensure readiness for change, ease of implementation, and sustainability (World Health Organization, 2010). In addition, strong leadership is a significant component of organizational change, laying the foundation to support the change through its continuum. Utilizing these concepts and knowledge will be imperative in guiding the implementation of QBP Standards for Pediatric Tonsillectomies with and without Adenoidectomies at Credit Valley Hospital.


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