Change Plan for SBAR Implementation Change Proposal

Change Plan for SBAR Implementation

Change Proposal - Healthcare

Change Proposal

Change Issue

The benefits of the SBAR are apparent to the nursing staff in the Labor, Deliver, Recovery, and Postpartum Unit of St. Johns Hospital Birth Center. All nursing staff receives training in SBAR and it has been implemented -- successfully -- for a few months at a time. However, nursing staff soon return to the historical ways of communicating about patient care, which has predominantly been by giving a verbal report.

Benefits of SBAR. SBAR stands for Situation-Background-Assessment-Recommendation and it is a framework for communication about patients' conditions that is used by members of a healthcare team. The following discussion is from the Institute for Healthcare Improvement (2011) website. The benefits to using SBAR by hospital staff are: (a) It is an easy-to-use, easy-to-remember mechanism; (b) it is a concrete way to frame conversations that fosters effective and timely communication; (c) it permits information to be easily accessed and recorded with fidelity, particularly important for communicating about patients with critical care issues or that require immediate attention and action by members of the healthcare team; (d) it helps healthcare team members to stay focused on the standards and expectations for patient communication; and (e) it fosters a "culture of patient safety" and supports the development of effective teamwork ("Institute for Healthcare Improvement," 2011).

Implementation variables. A number of discrete variables have been found to be related to the implementation of SBAR. Some of these variables have emerged as hearsay and observation by supervising staff. To gain a firm picture of the key drivers for failed implementation of the SBAR, a survey will be given to a stratified, randomly-selected sample of the hospital staff. Anecdotal information about failed information will be used as an aide to the construction of the survey. The following variables, for example, have been noted to be related to failed implementation of SBAR: (a) Details about patient care, patient histories, and treatments are being missed; (b) shift reports tend to be too long and convoluted to be used as effective communication tools; (c) socializing is intermixed with the verbal reports about patients, which results in important patient information being missed or mis-communicated during the pass-down conversation.

Change Model

Peter Drucker (1993) argued that the organizational form assumed by healthcare agencies is the most complex of all human organizational structures. The confluence of different professional roles and stakeholders with conflicting time horizons, motivations, goals, and perspectives contribute to this intractable complexity (Golden, 2006). A four-stage change model (Golden, 2006) is proposed as a way of bringing the implementation of SBAR to acceptable levels within the desired hospital unit. Golden's (2006) four stages are briefly described below. [Note: The majority of the language and phraseology is Golden's.]

Stage One: Determine the desired end state. During this stage, needs assessments and environmental scans are used to identify a performance gap between the current status in the organization and the level to which the organization aspires.

Stage Two: Assess readiness for change. Once objectives have been clarified, a situational analysis will be carried out to identify if stakeholders recognize the need for change; the degree of competition for resources and the attention of leaders and management; if new capabilities to close the performance gap have been identified; and if the organizational history biases stakeholders against the change process -- a situation that is an opportunity for leaders to learn how to ameliorate that influence and to prevent the same sort of outcome.

Stage Three: Broaden support and organizational redesign. The change effort needs to move out from behind the scenes to center stage and, in the process of doing so, must enlist through its evangelism the support of champions and must work on the indicated redesign of the organization.

Stage Four: Reinforce and sustain change. The effort in this stage is designed to maintain progress made in the three previous stages. The tasks include performance monitoring, showcasing success, rewarding implementers and supporters, recognizing and analyzing losses or failures, reconsidering objectives against new information and opportunities, and fine-tuning any realigned systems.

Organizational barriers to change. Healthcare organizations are characterized by several attributes that make planned change difficult to execute. As Drucker pointed out, healthcare organizations consist of disparate groups of stakeholders. In addition, the workers in a healthcare setting tend to work in an ad hoc autonomous manner, yet the influence of their decisions and practice is both wide and deep on the overall hospital operations and fiscal situation. Further, several missions occur simultaneously in the hospital setting, including to provide healthcare to community members, to be a going concern, and to be function as a primary employer in the community setting. Finally, healthcare organizations may not be good at collecting and analyzing information that is necessary for the management of an effective change process. The Shared Governance Committee recognizes the need for shorter shift change reports, for a decrease in repetitive information in the reports, and for elimination of miscommunication or omitted patient information.

Individual barriers to change. In order for change to take place and be sustained in complex environments, it is necessary for top-down leadership to visibly communicate the need for the change and to clearly articulate the constraints and rewards associated with the mandatory implementation of the change. At the same time, healthcare leaders must convey a culture focused on safety and openness -- the goal of the change process must not be interpreted by staff as one the employs reprimand and reprisal, otherwise breeches will not be reported and will not surface in a manner that triggers appropriate corrective responses and quality improvement. Of particular interest is the fact that most of the birth center staff are veteran nurses who tend to be resistant to the requirements of the change. Management pushes for implementation on the one hand, but does not monitor or follow up on the other, and neglects to update and customize the SBAR tool according to the unit's specific needs.