Summary
In summary, a large-scale QI initiative comprised of 12 subprojects was implemented at our large multi-site academic health sciences centre in November 2022 with the objective of addressing WPV from a systemic perspective. The project consisted of various literature-based, community, educational, and organizational interventions that were identified and informed using the SEIPS 3.0 framework and SEIPS 101 tools.
Interpretation
Systematic Framework to Address WPV in Healthcare Institutions
The following framework was created to provide guidance on how to approach WPV in a healthcare institution. Although, there is an abundant amount of literature on WPV-related topics and interventions, in addition to frameworks for QI projects, there is limited guidance on how to address WPV in hospital settings. Therefore, we created a 13-step framework which was also used to guide our WPV QI initiative at UHN.
Step 1: Define the Problem and Find the Data
WPV quality improvement projects begin with properly defining the problem and finding reviewing the available data. Identifying the root causes of problems is critical to preventing issues from reoccurring. There are multiple problem-analysis methods to define problems such as the Ishikawa fishbone diagram or root cause analysis [25, 26]. Regardless of the method used, it is important to define the WPV problem, identify barriers, risk factors, contextual factors and facilitators of change [26, 27]. The PETT scan from the SEIPS 101 toolbox provided us with an effective method of investigating the people, environment, tools, tasks and the interactions between them in a work system to assist with defining our WPV problem [19]. The PETT scan is a checklist that encourages users to identify a comprehensive understanding of key elements interacting within the work system, as well as the barriers and facilitators of each work system component. Using these data excavation tools will assist healthcare organizations in identifying where WPV interventions are required. Utilizing SEIPS 101 tools at the commencement of a WPV QI initiative can further be helpful if healthcare institutions lack the data necessary to demonstrate an increase in WPV due to common barrier factors such as underreporting [28].
Step 2: Assemble a WPV QI team
An important preliminary step in WPV QI is assembling an effective team. An interdisciplinary team approach supports leveraging diverse perspectives, skillsets, and knowledge of team members with various backgrounds while fostering opportunities for collaboration and creativity necessary for effective WPV quality improvement [25]. When forming a QI team, it's important to consider contextual factors that have been shown to contribute to success including team diversity, physician involvement, subject matter experts, team members with a history of working together, prior experiences and skills with QI, leadership and a sound decision-making process [29, 30]. Assembling a well-rounded QI team mindful of these factors sets the foundation for a successful and collaborative QI initiative addressing WPV in healthcare.
Step 3: Listen to Frontline Staff
While it is always essential to ensure voices of frontline staff are heard, this becomes particularly crucial when addressing WPV in healthcare. WPV is a demoralizing issue contributing to undesirable patient outcomes, HCP burnout and high turnover rates, thus, making HCPs feel heard on this subject by their own organization can have a positive impact on staff engagement with the WPV QI process [31]. Performing qualitative interviews and collecting data through pulse surveys with frontline staff throughout the project is crucial. HCPs need to be heard, supported, and cared for, and prepared for the envisioned change, and ultimately, be protected within their healthcare settings, as has been discussed in a recent study in the context of the collective impact of the COVID-19 pandemic [32]. WPV-related qualitative data, complementing quantitative data, proves pivotal in addressing intricate issues and guiding WPV QI initiatives [33]. Employing a longitudinal approach supports the identification of lived experience of change, impact or lack thereof overtime [34]. Lastly, meaningful integration of both qualitative and quantitative data enhances the probability of securing key collaborators buy-in [35, 36]. By employing a mixed-methods methodology, teams can combine both quantitative and qualitative data which is often needed to pragmatically address WPV challenges.
Step 4: Key Collaborator Engagement
A critical phase in QI projects involves active engagement with key collaborators. Securing organizational leadership buy-in is a prerequisite for any project success, as it ensures the availability of resources [37]. This includes funding and protected time for team members which is crucial for success in WPV QI projects [38]. Involving leadership is pivotal in creating a cultural change that fosters supportive behaviours of WPV QI initiatives within the organization [29]. Additionally, many WPV QI initiatives, such as training, are ongoing and require ongoing funding commitment. Maintaining engagement of key collaborators is crucial to ensure that these WPV QI initiatives are sustained [39]. Research demonstrates that engaging key collaborators early, maintaining ongoing clear communication with key collaborators and involving key collaborators in project decision making are effective means of maintaining key collaborators involvement and support [40].
Step 5: Bringing Organizational Entities Together
With WPV being a systemic concern, collaboration must continue beyond the QI team. In most healthcare institution, several functional units are likely to be involved in processes related to WPV, collaborating with representatives from all functional units involved in these processes is necessary to gain comprehensive problem understanding [25]. Unfortunately, functional units in healthcare institutions often operate with silo effects that compromise efficiency and promote conflict, repeated initiatives and sometimes ineffective use of resources [41]. Silo mentality is particularly harmful to organization-wide QI initiatives such as addressing WPV [42], thus proper communication between hospital departments needs to be established from the start. In our case, when investigating functional units addressing WPV using a PETT scan, nine separate functional units involved in WPV were identified (Table 5). It was imperative that these organizational entities were brought together first before initiating change processes.
Step 6: Implement an Effective Governance Structure
Once all involved partners are identified, an effective WPV governance structure is crucial to project success [43]. This offers the leadership and management essential to prevent conflicts in project implementation, resource management, and ensure sustainability [29]. Given the size and complexity of our organization, multiple governance structures were developed in conjunction with existing departments and committees to ensure the success of a large-scale WPV QI initiative (Figure 5). The governance structure should include leadership representation from all functional units involved in WPV initiatives or related processes. A charter for rules and roles of each member should include budgeting analysis, goal alignment and prioritization, data sharing for QI, as well as the timeline of projects [44]. Furthermore, it is imperative that the governance framework has the opportunity to present to the senior most executive level of the organization to ensure securing comprehensive organizational endorsement for its initiatives [37].
Step 7: Integrate a Change Management Culture
While developing a governance structure with multiple functional units is crucial, harmonizing the project culture is necessary for the viability and effectiveness of a large-scale WPV initiative. It is imperative to acknowledge that healthcare organizations encompass multiple subcultures, that if misaligned, are capable of either bolstering or hindering initiatives aimed at improving quality [38, 45]. The cultivation and maintenance of a shared culture can align teams in their beliefs and values ultimately fostering an enhanced collaborative approach to addressing a systemic issue [45, 46]. Healthcare institutions must evaluate the existing cultural milieu within their organization, along with its alignment with strategic and leadership direction to determine whether functional units involved in addressing WPV interact constructively or destructively. An example of one model was pioneered by Spencer Stuart offering a comprehensive approach to understanding the culture landscape in one’s organization and subsequently align their strategies accordingly [45, 46].
Step 8: Assess Project viability and Monitor Progress and Engagement of Functional Units
It is imperative to assess viability and monitor project execution by a governance team for multi-level projects to reach successful outcomes [47]. A validated tool can reduce resource waste [48], which is crucial for assessing the viability of a WPV initiative. Additionally, continuous project monitoring is necessary to maintain employee engagement and commitment, factors that can be influenced by burnout [49, 50]. The Boston Consulting Group has developed an efficacious four-element model known as Duration, Integrity, Commitment and Effort (DICE), [48, 51]. This framework can highlight important determinants of program viability such as the duration of the initiative or sub-projects, the integrity and skills of the team, the commitment level of senior executives and front-line key collaborators, and the additional effort required from the workforce. As subprojects will have natural delays and competing resources, strategic resource allocation and monitoring of functional units is crucial to the continuous progression of WPV initiatives.
Step 9: Connect with the Community
In addition to placing a focus on HCPs and frontline staff, it was important to us to include patients, (chosen) family members and visitors when addressing WPV. Each group is subjected to numerous stressors during visits to a healthcare institution, a multitude of factors that impact their experience at the healthcare institution can trigger stress responses, minority stress and responsive behavior which can increase the probability of WPV events [52]. Trauma-informed care and inclusive lens is a requirement to ensure that patients, (chosen) family members and visitors can feel as safe as possible [53, 54, 55]. Engaging with patients involved in past WPV or Code White incidents provides a different and often complementing perspective of WPV events. However, there exists challenges in reaching out to patients and visitors such as patients feeling underappreciated, unheard and that the gesture is tokenistic [56]. Research has demonstrated that including patient advisors in the development of initiatives, collecting information from patients and visitors on their experiences via surveys and developing patient and visitor advisory boards are effective methods of engaging with patients, (chosen) family members and visitors [57, 58].
Step 10: Implement a Cohesive and Clear Communication Strategy
Ensuring organizational communication regarding WPV QI initiatives is imperative to project success [59]. Clear and cohesive communication from organizational leadership is essential for ensuring staff members understand the organization's direction, leading to increased HCP buy-in and engagement [60, 61]. A lack of consistency in intra-organizational communication can result in rumours and a divide between individuals or groups with knowledge and without that negatively impacts cohesiveness and organizational trust [62]. WPV QI initiatives and successes can be communicated through organization-wide newsletters, emails, websites, office computer screens, meetings, in-person handouts and leadership communication [63]. Researchers demonstrate utilizing pre-existing organization communication strategies improves effectiveness [64]. Developing a communication stream between site managers and WPV QI team members is another valuable tool that provides the opportunity for managers to provide site-specific feedback on WPV initiatives [64].
Step 11: Implement Data Monitoring and Utilize Statistics for Planning/Management Decisions
Measuring changes in regions of interest pertaining to WPV overtime is pivotal to monitoring the impact of WPV QI initiatives. However, WPV metrics at healthcare institutions often place an emphasis exclusively on outcome indicators including the frequency of documented WPV incidents [65]. These indicators are problematic as WPV is historically underreported in healthcare [7]. Consequently, healthcare institutions will require a larger set of WPV quality indicators that do not rely solely on staff reporting of incidents to successfully monitor WPV [21]. These quality indicators must include structure, process and outcome measures to capture a comprehensive and systemic perspective on WPV within an organization [8, 13, 66]. In our case example, we performed a rapid review and Delphi process to determine quality indicators that would provide the quantitative data imperative to monitoring WPV QI impact and for informing decision making [21].
Step 12: Improve Debriefing and Reporting
Enhancing debriefing and reporting protocols in healthcare institutions has been demonstrated to improve HCP well-being, and organizational culture [67, 68] both of which are pivotal to increasing HCP buy in and reporting of WPV incidents. Debriefing after WPV incidents minimizes adverse outcomes to staff and provide them with a sense of support, connectedness, and relief following the event [67, 69]. However, debriefing must not leave HCPs feeling blamed or criticized, a positive debrief checks in with staff, validates their feelings and encourages help-seeking when needed [70]. Utilizing a protocol for debriefing after WPV events enhances quality and consistency of debriefs in order to meet the support needs of HCPs [67].
The underreporting of WPV is a culturally and structurally rooted problem faced by healthcare institutions. Research has documented that as many as 88% of HCPs that experienced WPV did not report the event [71]. WPV reporting is crucial to identifying WPV trends and informing decision making processes [72]. A wide array of cultural and organizational factors contributes to underreporting (Figure 6), many of which can be addressed through an updated WPV reporting system. Staff require a convenient, accessible reporting system that minimizes added workload, provides staff with follow up messages to demonstrate a course of action was taken and provides WPV support resources to ensure that staff feel seen, heard, supported, protected, and cared for [32,73]. Education interventions and debriefs must encourage the use of WPV reporting systems to create a culture of reporting.
Step 13: Implement Comprehensive Training Plan based on HCP’s Environmental Risks
Implementing a new or updated training plan that meets the needs of their staff is a crucial step in addressing WPV in healthcare [74]. Effective WPV prevention training improves the management of WPV situations, increases staff’s sense of safety and promotes a culture of safety within the organization [75]. Training must include simulation and education programs that focus on WPV awareness, verbal and physical de-escalation, agitation management, decision making, critical thinking, crisis intervention training and conflict resolution to be effective [7, 76]. Research indicates that factors such as an employee's department, frequency of patient interactions, and concerns regarding WPV are key contributors to the likelihood of their involvement in a WPV incident [77]. Consequently, staff’s training requirements need to be determined by generating risk profiles that consider these factors rather than relying solely on professions as a determining factor of needs. Utilizing risk profiles for training will lead to interdisciplinary cohorts that will enhance staff’s understanding of other roles, interprofessional communication and teamwork [78]. In our case example at our organizations, criteria for risk level stratification were based upon an environmental assessment of each unit.
Limitations
Although this QI project aimed to address WPV within our healthcare institution through a systemic, methodological approach, there are several limitations that require acknowledgement. The primary objective of this project was to address an urgent issue in healthcare, thus creating actionable results was prioritized. This resulted in a lack of baseline data collection at the inception of the project. Additionally, QI projects lack a control group, thus increasing the difficulty of determining whether change occurred due to the interventions or other influencing or confounding factors. Furthermore, while all subprojects have been initiated, not all have reached completion which is also the nature of QI projects with several implementation cycles. It is important to note that the objective of this paper is to illustrate the development of a systemic WPV QI project, rather than its success. As well, the findings of this article may be specific to our healthcare institution with the resources and processes specific to our situation. For example, not all healthcare institutions utilize the Code White response protocol or manage WPV incidents using physical restraint systems. As a result, there is a potential for the framework provided to be not applicable for some healthcare settings. Moreover, sustainability of large-scale QI projects is difficult due to interventions, such as education and training, requiring ongoing funding and key collaborators support. Lastly, the study design lacks balancing measures to determine the impact of these interventions in other areas of our hospital organization.