The aim of this paper is to to describe practical application of Lewin’s (1951) force field analysis change model in reducing Intensive Care Unit (ICU) patients’ length of stay (LOS) in a Tertiary Care University Hospital.

Introduction:

This paper reports on a change from 6.5 days to 4 days reduction in Intensive Care Unit (ICU) patients’ length of stay (LOS) in a Tertiary Care University Hospital. The change was embedded with systemic assessment, planning and implementing standardized strategies for all ICU long stay patients and finally evaluating the efficiency and effectiveness of ICU bed utilization with multidisciplinary team approach.

Change is inevitable for the reason that it ingrained human lives, core processes and system reforms. Day by day many changes have been observed in health care; associated with disease processes explicitly from prevention to rehabilitation, health care norms and nomenclature, infra structures modifications, policy matters, reengineering and system transformation. Different components of health care depends on one another for assembling such changes in order to produce work like from providers to payers, hospitals to suppliers, education to regulatory bodies and research to professional associations; all these are interlinked to perform function. Many of the above stated happening are planned however at times nature takes its own turn to act as a catalyst for change for example natural occurrences like tsunami, some crucial system analysis like break through reports from Institute of Medicine (IOM) on patient safety and the quality of care provided to all the health care customers. These were just simple examples of revolutions in health care taken place on an ongoing basis. Traditionally it is believed that changes are always for the betterment however at times it has been observed that this phenomenon is proven to be cynical and challenging especially when it is not made in a haphazard manner, without pursuing change management principles. Addressing the challenge of change Fetherston et.al (2009) stated that:

“Managing changing in the health care setting is always challenging, especially when it involves transforming entrenched habits grounded in professional expectations” (p.2581).

Despite change involves resources like human, material and cost and therefore whatever is proposed for change need to be evaluated for its effectiveness and efficiency, applicability, and consequences. It also depends on the team we are working with and there are times when the team building is so strong and the communication between the team is such that adopting to a new concept is very easy versus if the team members are not on same wavelength and have a lot of differences of opinions failure to reach to a simple consensus. Coch and French (1948) concluded that “rate of recovery when learning a new task is directly proportional to the amount of participation”. To improve understanding of change dynamics Armenakis and Harris (2011) recommends that “readiness for change is distinguished from resistance to change and readiness is described in terms of the organizational members’ beliefs, attitudes, and intentions”. Change agent is a very important contributor to make change happen constructively and productively. The personal and professional characteristics, interpersonal competency all these aspects are dependent to an outcome of change. Another factor involved in change process seems to be very crucial is the timeframe require for change. Is it a short term or a long run change – which is going to measure and monitor, what about the sustainability of the proposed change etc. In order to have successful change Kotter and Schlesinger (2008) recommends and put idea in practice (Appendix) and suggested that “analyze situational factors, determine the optimal speed of change, and consider methods for managing resistance” (p1, 2). According to Lippincott-Raven Publishers 1986 “Crucial to facilitating change is selecting a strategy that is likely to produce the desired change with minimal time and resistance”.

Background

In today’s health care setting, organizational change is essential for growth and development to keep up with the market competition Although health care continues to be enmeshed with ongoing challenges of cost, technologies, access to health care, human resources, quality inconsistent with an arena where error rates are too high there are multiple growing opportunities to improve client care management and service delivery components. Changes have been observed in clinical practice based on evidence based research resulting in application of new technology, diagnostics, drug regimes, treatment profile, care monitoring and finally the patient outcomes. All these are direct provision to a customer and perhaps if we look at the wider base it heavily involves all support functions available for patient care and employees of the organization. How all these are managed with patient flow and activities? Who is accountable? Change has both individual and institutional significance; and addressing its importance Watwood et al. (1997) shared that “…changes … bring opportunity for personal and institutional growth and development” (p 162). When it comes to an institutional change; it has emphasized that it should complement the philosophy, mission and vision of the organization. Therefore Heller & Arozullah (2001) identified four key factors for successful program development and achievement and those were:

“aligning the program with the strategic goals of the organization; obtaining active senior leadership commitment, including allocated resources; securing the appropriate infrastructure to facilitate integration of recommended actions into daily practice; and setting up systematic communications with all involved stakeholders” (p551)

Several challenges exists in system when it comes to a revolution however factors define by Heller & Arozullah (2001) would help in embarking change in a more structured manner.

ICU is a consolidated area of a hospital where patients with life-threatening illnesses or injuries receive round the clock specialized medical and nursing care. Intensive care is one of the hospital’s most complex and expensive medical systems. As medical care has improved, the type of patients treated in critical care units has changed from those with acute illnesses to those suffering from complications of chronic diseases. While better technology and better ways of taking care of patients has improved longevity and general health, the patients in the intensive care units of hospitals are getting sicker and globally these beds have a high demand based on the critical needs of patients and it doubles the need in an arena where these resources are very scare and inadequate This would augment medical care required, cost of care and excess use of resources when they are not required. Long stays in the intensive care unit are associated with high costs and burdens on patients and patients’ families and in turn affect society at large. Williams’s et.al (2010) states that:

“It has been estimated that between 2% and 11% of critically ill patients require a prolonged stay in ICU, accounting for 25-45% of total ICU days, and a significant proportion of resources…”(p 459)

The cost of caring for patients in ICUs in the United States has been estimated to account for 1% to 2% of the gross national product shared by (Miller et al. 2000, Seeman & David 2004) ) whereby Haugh (2003) stated that “15% to 20% of US hospital costs represents 38% of total US healthcare costs”. According to Miller et al. (2003)

“…the total number of hospitals, hospital beds, and inpatient days decreased during the years 1985 to 2000, the number of critical care beds and days in critical care increased dramatically during the same period…”

Whereby Stricker et al (20037) found that “… only 11% of patients admitted to the ICU stayed for more than 7 days, these patients used more than 50% of ICU resources”. Furthermore, in several studies (cited in Ryan et al 1997, Wong et al 1999) the mortality of patients with ICU admissions lasting 14 days or longer was estimated to be nearly 50%. Rosenberg et al. (2001) shared that “Mortality rates are higher in ICU than in any other area of the hospital due to the complexity of patients’ medical condition”. Fakhry et al (1996) found that “70% of patients with stay longer than 2 weeks reported less than 50% functional recovery”. Esserman e t al (1995) found that “32% of ICU resources were spent caring for patients who survived less than 100 days after discharge from the hospital”.

In a tertiary care university hospital where I am presently working patients were found to be stuck in the ICU and have longer stays and in the month of January 2009 it was found to be 8.4 days and subsequently in the following quarter 1 it was 6.5 days (refer appendix 1). When explored, multiple factors aroused (refer appendix 2) and therefore to address this concern a multidisciplinary team was formed. It was proposed to undertake the work of reducing patient’s length of stay in ICU and therefore it the goal was to reduce patients’ length of stay from 6.5 days to 5.5 days in the second quarter for the year 2009.

Rogers and Shoemaker (1971) framework was used to appraise the various component of the proposed change in order to identify its strengths and weaknesses. Team assessed its relative advantages to current situation and felt that it is worth spending the time and effort for the given scenario, change seems to be appropriate and compatible with existing philosophy of the clinical area, easy to be understood and applicable by all bedside staff. Moreover the project was trialable to a pilot   before going the whole way and relevant to organizational goals.

Discussion

Changes will continue as an adaptation and at times mandatory in order to survive. Lot of literature is available when it comes to the change management in health care setting. There are models available to address organizational change, system revolution, and human transformations which address many other aspects of successful implementation of reforms.

Change process follows the same course as of nursing process and problem solving approaches.

According to Christensen a & Christensen b (2007) “Lewin’s (1951) theory of transitional change is the most used form of change implementation strategies”. The change we were supposed to undertake; this theory appeared to address many aspects of it and therefore the mechanism for identifying the social system within organization for selecting, developing and implementing the strategies to serve as a solution was done by application of this model. According to course notes Lewin’s widely cited, classic model of the change process, the three changes are:

“Unfreezing, where faced with a dilemma or disconfirmation the individual becomes aware of the need to change; changing where the situation is diagnosed and new models of behaviour are explored and tested and finally, refreezing where the application of new behaviour is evaluated and adopted”. (p53)

Huber (2006) states that:

“The basic concept of the change process was outlined by Lewin… A successful change involves three elements: unfreezing, moving and refreezing”. (p810)

Fetherston et.al (2009) emphasized the importance of major change like this and endorsed that:

“Where a major change … is implemented, models such as Lewin’s (1951) model of unfreezing, changing and refreezing can be a useful guide …”

Baulcomb (2003) states that “

“This theory places emphasis on the driving and resisting forces associated with any change, and to achieve success the importance lies with ensuring that driving forces outweigh resisting forces. Driving forces tend to initiate change or keep it going whereas restraining forces act to restrain or decrease the driving forces. The intention to reach a state of equilibrium” (p277).

Unfreezing

Lewin’s change approach fall within three steps and this is the first one where the process of thawing out the system to create motivation for change. It’s like getting the team warming up to play their cards; getting everybody on the same wavelength and organizing. Huber (2006) shared that “the first stage is cognitive exposure to the change idea, diagnosis of the problem, and work to generate alternative solutions. (p811). Though it was a great challenge for the team however the process of systemic assessment and unfreeze stabilizing the team readiness was initiated for the said change. Different strategies were brain stormed in a multidisciplinary team.ICU patients’ length of stay was gathered prospectively. Potential predictors were analyzed for possible association with prolonged ICU stay. Driving and restraining forces were studied (Appendix )

Moving

Then we proceeded with the second stage of Lewin’s theory i.e., moving and changing. It involves moving a target system to a new level maintaining equilibrium; viewing the problem from a new perspective, situation is diagnosed and new models of behaviour. This stage was determine through formation of ICU long stay committee with terms of reference, notification of long stay patients stayed in ICU for more than 7days or earlier if deemed necessary to all concerned, holding meeting with primary team everyday to discuss next course of action, identification of patients difficult to wean, patient requiring early tracheotomy to maximize discharge process, initiating daily rounds by multidisciplinary team with primary team. Furthermore, introducing expected admission discharge time (EADT) to facilitate bed identification. According to Hoda (2008) “length of stay (LOS) may be influenced by the availability of appropriate high dependency units to discharge patients”. Review on daily basis the need for bed for inpatients and emergency. Admission /discharge policy was reinforced through multidisciplinary approach. Alternate accommodation in other units like CICU and CCU which has same bed accessories and uniform care provision were identified. Early tentative beds are booked in wards before rounds in order to facilitate early bed arrangement and patient transfer.

Refreezing

The final stage is refreezing. In this stage new developments are incorporated and improvements are made to stabilize the selected strategies to ensure the sustainability of the project. Daily check at unit and divisional level by bed management coordinator and ICU team. Monitoring on shift bases by charge nurses and nursing supervisors. Interventions involving palliative care, ethics consultations, and early decision about patient transfer and orders writing, family willingness and readiness and other methods to increase communication between healthcare personnel, patients, and patients’ families were helpful in decreasing length of stay in the intensive care unit. Thus, interdisciplinary communication played a vital role in improving ICU patients LOS whereby its importance is being defined by Pronovost et al (2003) and point out that “communication failures lead to increased patient harm, length of stay (LOS), and resource use…” (p71). Hence to a major extent the daily communication strategy worked out very well and the team was successful to bring about this change. ICU length of stay was 6.5 days in quarter one and it was reduce to 5.6 days in the second quarter for the year 2009 and consequently to 4.8 and 4 day in third and fourth quarter of 2009. Fetherston et.al (2009) stated that:

“When change is managed in systematic steps with adequate evaluation and communication throughout the process, it is more likely to result in successful outcomes”. (p 2582)

Evaluating the Change Project s took place and was received very positively. Following are the most important attributes I have experienced for this successful change like it was logical, efficient, and planned not haphazard

then it was based on explanation of reason for a change so that individuals understand it. After that it was very informative and staff supported change when they were involved in assessment and planning. Change agent interpersonal competency and expertise (knowledgeable) of the given task was outstanding and hence the monitoring feedback on timely basis -to ensure that all team members is on same wave length wa carried out in a very sposticated manner.