INLP Core Theory of Change
The central tenet of INLP’s change framework was that placing front-line nurses (and other clinicians) in fundamental roles in an improvement effort is necessary to achieving successful outcomes. The change framework focused on developing critical leadership skills of front-line workers, including professional self-development skills, team-based skills, organizational cultural skills, and process improvement skills.
In addition, the INLP change framework emphasized building effective teams across health care disciplines to encourage organization-wide participation in change management. Not only do multi-disciplinary teams identify more comprehensive and effective solutions, they help reduce barriers to implementation by creating ready change agents in the relevant disciplines. INLP believed that this people-focused approach was the only reliable means of delivering continuous innovation and improvement at the institutional level.
The INLP change framework led participants through an entire process of quality improvement. Through the four activities detailed below, INLP participants learned to innovate, test innovations, diffuse innovations throughout the hospital, and embed innovations in hospital policies and daily practice.
Learning Organizations
The INLP Theory of Change relies on Learning Organization Knowledge. Learning Organizations remove the root cause of problems to prevent reoccurrence. Scholars say an organization has learned when it changes its activities in response to new knowledge or insight. In order to do this, they must move from:
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First Order Problem Solving (Single Loop Learning; Reactive) to
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Second Order Problem Solving (Double Loop Learning; Preventive).
This requires a fundamental shift from away from focusing on fixing problems for immediate gratification, towards solving problems ultimately.
Unfortunately, many hospitals and healthcare settings are not successful learning organizations. While frontline workers are ideally position to provide key insight based on their continuous encounters with customer or client challenges, all too often the knowledge gained by solving these dilemmas remains with the individual, and is not passed on to those who could make a lasting difference. This happens either because their concerns are considered “petty,” or the organization is not positioned to effect change.
The core theory of change behind INLP is based on the belief that frontline clinicians are underutilized as the ideal, and ideally positioned, health care provider to turn an organization into a learning organization.
Core Elements of Change
In order to support the development of transforming each cohort of hospitals into Learning Organizations, and achieve improvements in specific quality and/or patient safety outcomes, INLP relied on the following core elements to implement system-wide change:
Multi-Hospital Collaboratives Sponsored by INLP
For each cohort of hospitals, INLP sponsored a quality improvement collaborative to enable rapid sharing and deployment of proven innovations, and shorter cycle-times for gaining measurable improvement in quality efforts. As the sponsor, INLP provided the change framework, expert knowledge, and leadership training.
Senior Executive Sponsorship
A core element of INLP was the active involvement of senior leadership. In recognition of the finding that senior leader support contributes to the sustainability of quality improvement changes, INLP required a designated senior leader at each partner hospital to sponsor the program.
Hospital-Based Project Team
Each hospital created and deployed a Core Resource Team (CRT) to serve as the project manager and governance council for the quality improvement initiative. This team was appointed by the INLP hospital leader sponsor. The team included up to 5 front line clinicians, 2 senior executives, and one data manager. For hospitals with existing quality or nursing governance councils, new responsibilities could be added to these councils to enable them to function as the Core Resource Team for the project. At the off-site meetings of the Multi-Hospital Collaboratives, the INLP leadership team trained Resource Team members to serve as the leaders of the quality improvement project in their hospital.
Unit-Based Deployment Teams
During the spread phase, INLP integrated the use of Unit-Based Deployment Teams, which enabled Resource Team members to spread their learning to and ensure the engagement of as many front-line nurses as possible in the quality improvement initiative. Each partner hospital created teams of 4 to 6 front line nurses and clinicians for each relevant unit. The Unit-Based Deployment Teams were responsible for adapting innovation to work in their specific units through the testing of ideas and process redesign. As mentioned above, Resource Team members provided all necessary training to Deployment Team members, and served as ready resources throughout the quality improvement initiative.
The INLP Change Framework
INLP provided a combination of training and technical assistance to support hospital teams in creating a strategic plan to address a critical issue of improving nursing related patient outcomes. Over the decade leading up to the inception of INLP, professional challenges for hospital nurses increased due to multiple factors. These included financial pressures, higher patient acuity, and staffing shortages. The INLP change framework stressed the importance of front-line staff making improvements at the bedside that eased these pressures, while strengthening the participant, the project team, and the satisfaction of the unit as they spent time on the quality improvement project.
The INLP Change Model (included below) focused on working with front-line staff in four areas to bring about change: The individual, the team, the organizational/unit culture and the process (or the project itself). By addressing all four aspects of the change framework, it was possible to institute sound systems in order to coordinate care, and ensure timely and accurate information. For INLP, this led to positive outcomes, including a reduction in errors, reductions in sepsis mortality, and improved care.
Common system failures include:
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Missing or incorrect information
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Missing or incorrect supplies
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Waiting for a resource, such as a human or piece of equipment
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Being pulled away and continuously interrupted because of ongoing demands.
When considered individually, these problems seem insignificant, however, they add up to wasted time, nurse burnout, cost inefficiencies and actual errors. Solving the same problems repeatedly is inefficient, frustrating, and a waste of time. It makes a worker feel like they are being unheard, and are working in an unsupportive environment.
Case Example:
One of our hospitals had a high error rate for giving meds at the wrong time. When evaluated, the problem was that the meal trays at lunch came closer to 1pm instead of Noon, so the nurses were giving insulin and other related meds later, to match the meal time. The ultimate fix included working with the dietary department to correct the times trays were delivered so that diabetic patients would continue to have safe insulin levels.
The INLP model is based on the belief that technical “know-how” related to quality improvement science is insufficient. In addition to providing training around these technical skills, an equal focus is placed on “soft” skills such as leadership development, and change management in order to promote sustainability and spread. Development of these soft skills within each of the four pillars—individuals, team, organizational culture, and process—was supported in the following ways:
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"The “individual” pillar focuses on developing awareness of one’s own preferences and on cultivating emotional intelligence, including an understanding of how one’s actions influence the work and everyone involved in it.
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The “team” pillar focuses on how high-performing teams function, complete their work, communicate, and ensure accountability.
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The “organizational culture” pillar focuses on developing “political savvy”—that is, an understanding of both formal and informal power sources within an organization, along with skills related to strategic communication, stakeholder identification, and forming allies.
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The ”process” pillar tends to be more technical in nature, focusing on evidence-based practices related to the activity to be improved, relevant data and quality improvement indicators, how to use data to predict the next test of change, and other related issues." (AHRQ, 2012)
