Building a Quality Program Around Delirium
At ADS, we share a passion for improving care for delirium. However, more than passion about caring for patients with delirium is required to develop a quality improvement program for delirium. In this blog, we will detail crucial implementation steps of a delirium program.
Step 1: Become the “Expert”
The development of a strong understanding of the problem and previous attempts to address it will inform the next steps and help you to avoid repeating other’s mistakes.
The term “Expert” is in quotes because the meaning can vary greatly among hospitals. For some health systems, expert refers to a person that has been awarded many grants and published dozens of articles. However, this background is not necessary to implement a quality improvement program.
The most important feature of being the expert is the ability to share knowledge about delirium, including risk factors, causes, diagnostic strategies, prevention, and treatment. The program leader must feel comfortable discussing delirium with those who will implement the program as well as conveying the value of the program to stakeholders. Attending the American Delirium Society Annual Meeting will offer much of this knowledge (particularly the preconference sessions), as well as, bringing the “Expert” into contact with “Experts” from other health systems. At ADS, the conference planning committees have tried to maximize the opportunities for networking
Step 2: Assemble a team
A good project leader will recognize that help is needed and enlist it. There are different factors that drive people to teams and the project can tap into these factors (innovation, visibility, improve care, promotion, etc). As the leader, it is helpful to have a discussion about these motivators. The team needs to also have credibility among the broader clinical providers so that positive findings can quickly be shared and expanded. For example, building an experienced interdisciplinary team will generate more “buzz” with positive findings and the effort of the team.
Step 3: Offer an Alternative to the Status Quo
It is difficult to imagine a harder task than convincing a busy healthcare professional to voluntarily complete additional assessment without having an action or understood purpose behind it. Assessing for the sake of assessing is demoralizing and will limit the project. Offer an intervention; even if the intervention is providing a pair of earplugs for the patient. The intervention item can be used to justify the assessment. Another strategy would be to replace an assessment. For example, the falls, pressure ulcer, and delirium risk tools include some measure of cognitive assessment. Standardizing the cognitive assessment across these three risk tools streamlines the effort of the clinical team and may represent a significant advance (i.e. more predictive, easier, interventions, etc).
Step 4: Listen
In the early stages of a quality improvement program, the leader’s ears are attuned to the input of others. As time passes and the protocol solidifies, there is a tension that develops between what one is doing and experiencing. The leader must continue to listen, because the people in the field have firsthand knowledge of the challenges of implementation. In this stage, it is important to acknowledge resistance to change yet hold to the principles of the program. Having an alternative to the status quo allows you to acknowledge the resistance and offer possible solutions.
In the process of listening, you will collect stories from staff and patients about their experience with your program and delirium. Collecting these stories either through writing de-identified information or obtaining the patient’s consent to formally record the story provides you with an incredibly powerful resource as you present your work to stakeholders and other clinical team members.
Step 5: Identify and Invest in Stakeholders
Imagine that your delirium program is successfully improving the care of patients, but the first fiscal crunch eliminates all non-essential programs, including yours. At that point, you are in a panic trying to get an audience with decision makers. By identifying key stakeholders early and investing their interests in your successful implementation, you afford your program the best chance at sustainability. Stakeholders may come at all levels of an organization from CEOs to patients. The more stakeholders, the higher visibility of your program, the more pressure to demonstrate positive outcomes, and the more chance that your program will continue during difficult times.
At the American Delirium Society meetings, “Experts” from many health systems present their clinical delirium programs annually. As the mission of ADS is to “….minimize the short-term and long-term impact of delirium on patients,” we invite you to comment on the above steps or describe other steps that were not presented here. We need to learn from each other if we are to alleviate the suffering associated with delirium.
- Jim Rudolph, MD