MOVING

 

Once the competing forces have been unfrozen, moving toward a new set of behaviors is the second step in the change process. Lewin advised, “any attempt to predict or identify a specific outcome from planned change is very difficult because of the complexity of the forces concerned." Achieving the desired behavior is a process of trial and error, and requires consistent evaluation of change efforts.

 

Moving the RNs toward a new set of behaviors was accomplished by conducting facilitated workshops with the RNs to redefine quality and prescribe a home visit model. The first step in the moving process was to facilitate a Nominal Group Technique (NGT) exercise to guide the entire staff through the process of defining what we titled The Exceptional Patient Experience for Hospice Patients and Family. Using the NGT, the group identified 4 major focus areas and numerous subsets that define the Exceptional Patient Experience. Each subset item was then scored according to the number of votes received in the NGT process. After scoring each item, the group placed them under one or more complementary major focus areas. I sorted the subsets by score to demonstrate the relative importance of each to the major focus area and to the other subsets. (See Table 1) I then worked with the staff to develop a Quality Values Statement that defines the Exceptional Patient Experience, using the results of the NGT exercise (see Figure 1).

 

 

The next challenge was to determine how to provide the Exceptional Patient Experience in 60 minutes or less. The Center for Medicare and Medicaid Services (CMS) recommends up to 90 minutes per RN visit of the Hospice Patient. This includes travel time, the actual visit, and documentation. In order to adhere to this recommendation, and maintain a 12-patient caseload while providing the Exceptional Patient Experience, RNs need to follow a Standardized Patient Visit Model. (see Figure 2).

 

Since the Standardized Patient Visit Model represented an additional behavior change for the RNs, I suggested they complete a series of time studies over several weeks as a means to facilitate the additional unfreezing of their established behavior patterns, allowing them to compare actual time spent with patients with the expected time under the new model (See Table 2).  Based on the results of the time study, the RNs could see that they needed to trim their average home visit times by only 20 minutes.

 

During subsequent meetings and analysis of the time studies, the group decided to further modify the Home Visit Model to better reflect actual home visit activities and times (See Figure 3)

 

The outputs from these workshops were (a) a new quality values statement that accurately reflects the values of the RNs, and (b) a structured Home Visit Model that standardizes the average home visit experience within a 60-minute time frame, and a staffing model (see Figure 4) for administration to use in their labor planning. Although the workshops were integral to moving the RNs toward adopting a new set of behaviors, as Lewin cautioned, the complexity of the opposing forces results in additional challenges to fully achieving the new behaviors.