Reducing Hospital Elopement Through Organizational Change

Introduction: Elopement as an Organizational Problem

The modern world demands organizational change. Hospitals in particular need change to address the growing problem of elopement — the intentional leaving of a medical facility by a patient who is aware they do not have permission to do so. Organizational change to solve this problem can come from several areas, some of which may involve new leadership or new methods to assess changes throughout the day. New leadership can drive organizational change through plans that alter the way staff behave and think with regard to incidents like elopement and how to manage such potential occurrences.

Identifying At-Risk Patients and Common Elopement Patterns

The first step toward implementing any organizational change aimed at reducing elopement is to understand which types of patients are most likely to elope. Patients with Alzheimer's disease or dementia are most likely to elope. If staff are informed at the beginning of a patient's stay that the patient may be at risk for elopement, better monitoring and precautions — such as locking the door at night — may prevent or at least reduce the likelihood of elopement.

In an exploratory, qualitative study, Aud (2004) describes the conditions, environmental hazards, and injuries involved in 62 elopement incidents. These elopements occurred in long-term care facilities housing elderly residents with dementia. Content analysis of the incident data identified recurring patterns that encompassed:

1. A lack of effective precautions to prevent elopement when residents had indicated an intent to elope, had repeatedly attempted to elope, or had a history of elopement;
2. A lack of awareness by staff of resident location; and
3. Ineffective use of alarm devices intended to alert staff to elopement attempts (Aud, 2004, p. 361).

For elopement rates to decline, working alarm devices must be installed and tested periodically to confirm proper function. Effective precautions must be implemented, and staff awareness of elopement risk — and of which patient population is most vulnerable — must be raised. Implementation and monitoring of an organizational change can be a critical and often difficult task. Difficulty sometimes arises from an inherent resistance to change and a belief that the old way is stable and sufficient. Other times it stems from a lack of motivation or communication needed to carry out objectives. However, tools are available to make change in a medical or hospital setting less difficult.

The Change Monitor as an Organizational Tool

Dr. Kilian Bennebroek Gravenhorst, in an interview, discussed a measurement tool called the Change Monitor. The Change Monitor is an organizational intervention tool intended for use by organizations with well-developed teams and an awareness of organizational matters. Its purpose is "to help you assess your organization's capacity for the changes being implemented and what action to take as a result. Unlike other change management measurement tools, the Change Monitor™ takes a more integrative approach" (Savage, 2012, p. 1).

The Change Monitor software eliminates much of the difficulty involved in identifying problematic areas that need correction, allowing staff to focus on their regular duties rather than on tasks normally handled by the software. The instrument examines workflow data, identifies complications, and alerts employees to new changes or issues. Employees then communicate relevant information to the organizational team. This process accelerates corrective action, promoting better management and communication within the organization.

If staff were to attempt to adapt to a new method of handling patients — or in the case of long-term care facilities, residents — without any supporting tools or methods, confusion could result. Confusion often leads to anger, miscommunication, and disruption of nursing care. Use of the Change Monitor may reduce that confusion and alleviate negative consequences brought on by the implementation process.

Kurt Lewin's Three-Stage Change Management Theory

Another model, Kurt Lewin's Change Management Theory, can be used in conjunction with the Change Monitor. Lewin's Change Management Theory is a "time-tested, easily applied field theory that is often considered the epitome of change models, suitable for personal, group and organizational change" (Kaminski, 2011, p. 1). Lewin was a Gestalt social psychologist widely recognized as the "forefather of social change theories," as numerous modern models are at least partly grounded in his work. Together, this theory and the Change Monitor give staff the tools needed to better handle the changes they face. As previously noted, people often find change difficult and prefer stability. These tools offer a smoother transition.

To understand the Change Management Theory, it is important to discuss its three stages. "The first stage involves finding a method of making it possible for people to let go of an old pattern that was counterproductive in some way. This is the stage where the desire to change occurs, or at least the recognition that change is needed" (Kaminski, 2011, p. 1). Common examples of this first stage include transitioning from a paper-based system to an electronic one, since computers are faster and more efficient for storing and retrieving information.

The second stage involves a process of modification. This includes changes in opinions, approaches, and behaviors — or all three — that allow for a sense of liberation and the opportunity for greater productivity than the old methods allowed. Throughout this stage, those involved in the change are persuaded that the new way is better and that the old way is obsolete.

The third and final stage consists of "establishing the change as a new habit or process, so that it now becomes the 'standard operating procedure' or status quo. Without some process of refreezing, it is easy to backslide into the old ways of doing things" (Kaminski, 2011, p. 1). During this stage, it is especially important to provide rewards and support to those who are struggling with the changes.

Conclusion

Several theories have been used to support organizational change: "Systems theory, organisational development, social worlds theory, and complexity theory each has a practical contribution to make to our understanding of how indicators work in prompting quality improvements and why they sometimes don't" (Rhydderch, Elwyn, Marshall, & Grol, 2004, p. 213). One theory from this list — organizational development — aims to improve the effectiveness and knowledge of people within the organization. If people within an organization understand not only the changes that need to be implemented, but also how to cope with those changes, there will be less resistance and a greater likelihood of success.

If staff are informed in meetings about what to do, how to do it, and where to direct questions, this prevents second-guessing and builds confidence in carrying out their responsibilities. Developing an organization's collective knowledge not only improves communication but also reduces fear of the unknown. Applied to the problem of elopement, this knowledge-centered approach — combined with practical tools like the Change Monitor and the structured framework of Lewin's Change Management Theory — provides a realistic and comprehensive pathway toward safer, more responsive care for at-risk patients.

References

Aud, M. A. (2004). Dangerous wandering: Elopements of older adults with dementia from long-term care facilities. American Journal of Alzheimer's Disease and Other Dementias, 19(6), 361. doi:10.1177/153331750401900602

Gupta, A. (2013). Business strategy implementation and strategic management: An analytical study. International Journal of Management and Development Studies, 2(6), 11–16.

Kaminski, J. (2011). Theory applied to informatics — Lewin's Change Theory. Canadian Journal of Nursing Informatics, 6(1), 1.

Rhydderch, M., Elwyn, G., Marshall, M. N., & Grol, R. P. (2004). Organisational change theory and the use of indicators in general practice. Quality & Safety in Health Care, 13(3), 213. doi:10.1136/qshc.2003.006536

Savage, D. (2012). The Change Monitor | Think Transition. Retrieved May 30, 2014, from