Trauma performance improvement is a chain of activities that stretches from event identification and review to corrective action and loop closure. Like any chain, however, trauma PI is only as strong as its weakest link. In many cases, the weak link is implementation of the corrective action.
Many PI projects fall short because program leaders are unable to implement a new process or guideline. The solution itself may be sound, but provider performance does not change. What is the key to making a change “stick” in a trauma center? One proven methodology is the Kotter model.
The Kotter change model was developed by Harvard Business School professor John Kotter. It is an eight-step process for helping any team understand, embrace and adopt a new way of doing things. In my experience, the Kotter model is an effective tool for managing the people issues that can stand in the way of implementing a corrective action in trauma PI.
Recently, my team at a Level II trauma center in New Jersey used the Kotter model to improve our care for geriatric trauma patients. In this PI project, our opportunity for improvement was a high undertriage rate for geriatric patients. Our corrective action was to incorporate the Revised Trauma Score for Triage (T-RTS) in our ED process. We used the Kotter model to help our team understand the importance of this change, embrace a modified triage process, and embed it in their way of doing things.
In this article, I will use our recent T-RTS project to illustrate how to use the Kotter model to implement a corrective action plan. First, one note: Kotter’s eight steps are phrased in different ways by different experts. The wording I use below reflects a basic approach that works well in trauma PI.
Step 1. Establish a sense of urgency
The first step of the Kotter model is to make a strong case for the proposed change in policy or practice. When trauma team members perceive the danger of not changing — or understand the opportunity inherent in a change for the better — they are more willing to embrace a new way of doing things.
For our geriatric trauma initiative, our sense of urgency was supplied by the data. A retrospective chart review showed that the undertriage rate for geriatric trauma patients was approximately 20%.
For our team, “1 in 5 older patients are not getting the care they need” was an urgent wake-up call that we needed to change our activation process.
To develop our corrective action plan, the team scoured the literature for appropriate activation criteria. As I noted above, our ultimate decision was to incorporate the Revised Trauma Score for Triage (T-RTS) into our triage process for geriatric trauma patients. Our foundation was the original T-RTS (Champion, 1989) modified to increase the systolic blood pressure threshold to < 110 mmHg (Brown, 2015).
Step 2. Create a guiding coalition
Any change in healthcare affects many different stakeholders. This is true of even relatively simple process changes. To implement a corrective action, it is important to assemble a leadership team that represents the needs and views of every stakeholder. Even if you think you already know the solution to a problem, it is important to hear from other voices. Stakeholder input is often key to identifying hidden obstacles to implementation.
The leadership team for our T-RTS project consisted of the trauma medical director, the trauma program manager, the trauma PI coordinator, the ED medical director and the ED nursing director. This leadership group came together for a project kick-off meeting in September 2020. We reviewed the opportunity, agreed on the proposed corrective action, and created a vision and strategy (see Step 3 below) for implementation.
A strong guiding coalition provides the knowledge and skills necessary to mobilize change. It can also provide the credibility and influence needed to overcome organizational barriers to implementing a corrective action.
To secure senior leadership support, we also briefed the hospital’s chief nursing officer on our initiative. This step is important for any nursing implementation, and it is critical for initiatives that could have a budget impact.
Step 3. Develop a vision and strategy
One of the guiding coalition’s most important jobs is to finalize the vision and the implementation strategy. A strong vision provides a collective sense of what a desirable future looks like, in clear and measurable terms that all stakeholders can stand behind (Clark, 2010). An effective strategy is a practical plan for moving the organization from its current state to its desired future.
For our PI project, the vision focused on the simplicity and effectiveness of incorporating the T-RTS into geriatric triage. Triage nurses would use physiological parameters that they were already collecting (systolic blood pressure, respiratory rate and Glasgow coma score) to employ a validated tool (the T-RTS) to make better triage decisions for geriatric patients.
Our strategy was relatively straightforward. Since triage nurses would not have to collect any new data or add a new assessment, there was no need for acquire new tools or provide extensive education. The strategy was simply to communicate the change vision (see Step 4 below), introduce the new practice, measure performance and follow up as needed. Since we had an easily quantifiable process measure (T-RTS completion rate) and outcome measure (undertriage rate), tracking staff performance and providing feedback would be very doable.
Step 4. Communicate the change vision
Change in any form is hard to implement, but the situation in healthcare is particularly challenging. On one hand, healthcare providers are often entrenched in the status quo. On the other hand, changes are made frequently in healthcare, which eventually exhausts staff.
To break through these impediments, it is important to engage staff in the corrective action by clearly communicating the vision for change. One useful approach is to develop a 30-second “elevator pitch” that concisely expresses the shared vision and strategy. Our elevator pitch was:
“We recognize that we have a significant level of undertriage in our geriatric trauma population. In fact, our current geriatric undertriage rate is approximately 20%. This is caused by several factors, including the high workload of the triage nursing staff and the social challenges of communicating with the elderly. We propose to overcome these challenges and improve our care by implementing the Revised Trauma Score for Triage in our triage process. The T-RTS is a validated tool that will empower triage nurses to make better activation decisions more easily.”
We used the elevator pitch to introduce triage nurses to the corrective action and help the entire triage team stay focused on the project as we rolled it out. We also used the pitch when communicating with the CNO about our T-RTS implementation. The short format is essential to connecting with busy executives and other clinical leaders.
Step 5. Remove obstacles to change
Barriers to change can take several forms — existing hospital policies, competing incentives and uncooperative individuals to name just a few. In many cases, staff simply lack the tools to implement a particular change. Removing these obstacles is critical to a successful implementation.
For our geriatric triage project, one of our biggest obstacles was nursing workload. Our trauma center includes the third busiest emergency department in the U.S., so our triage team regularly contends with high volumes. In addition, physical and social barriers to communicating with the elderly were a consideration. Another major obstacle was the COVID-19 pandemic itself. Contact restrictions limited our ability to meet with triage nurses. The pandemic also led to a change in the injury mechanisms that nurses were encountering, forcing them to adjust their focus.
We overcame obstacles to contact by holding the initial staff meeting in a remote format. We also worked to streamline the educational component of this implementation to avoid adding to the workload for triage nurses. The corrective action itself helped overcome many communication barriers — triage nurses could use objective measures to assess elderly patients for trauma activation, reducing the need to ask probing questions.
In addition, we gave the implementation extra time. Normally, we might see an initiative like this as a 4-week project. In this case, we gave ourselves an 8-week runway to get staff comfortable with the change, monitor performance and make adjustments as needed.
Step 6. Generate short-term wins
Full implementation of a corrective action can be a long process. Early successes energize team members to stick with a change and see the implementation through to completion.
After launching our T-RTS initiative, the trauma administrative team provided triage nurses with 24-hour case progression feedback on a daily basis. This allowed us to reinforce the need for change without casting blame. It also allowed us to identify several early “wins” — geriatric patients who were correctly triaged for a trauma activation and who went on to receive needed interventions.
As part of the feedback process, we regularly shared performance charts that showed the team’s progress. This supported a collegial sense of competition between shifts, which further energized team performance.
The entire process led to fast progress. Thanks to the professionalism and flexibility of our triage nursing team, our center was able to reduce its geriatric undertriage rate from 20% to approximately 7% in less than 2 months.
Step 7. Build on the change
Change leaders should always look for ways to build on their current initiative.
First, it is important to memorialize the process by updating any standard operating procedures to reflect the new way of doing things. In addition, carefully document any lessons learned. For our team, one important takeaway was the value of making rapid improvements through small process changes.
Second, consider how your trauma program might use the momentum of success to launch a new change initiative. Our team has decided to build on the success of our geriatric triage initiative by applying the same rapid improvement model to a registry documentation challenge. Thanks to the goodwill we earned through our T-RTS implementation, we already have buy-in from key stakeholders.
Step 8. Anchor the change in culture
Don’t declare victory too early. Kotter said that if change leaders declare success prematurely, team members can lose their sense of urgency and relapse to the previous way of doing things. Trauma teams thrive in creating organization from chaos, so project leaders must continue to monitor performance and work with staff to hone the process.
This step should be intuitive for any PI leader trained in the Trauma Outcomes & Performance Improvement Course (TOPIC) philosophy and accustomed to the loop closure requirements of the American College of Surgeons.
To monitor our T-RTS project, we leveraged our trauma center’s normal PI process. The trauma program leadership team reviews all trauma activations during our weekly team synch meeting. We then validate our overtriage and undertriage events and rates. This process allows us to monitor T-RTS utilization and geriatric triage outcomes, make real-time improvements, maintain open dialogue with triage nurses, and ensure our corrective action has appropriately impacted the problem.
More models to choose from
The Kotter change model is not the only effective framework for implementing a corrective action. Other options include the Lewin model (unfreezing, moving, refreezing) and the ADKAR model (awareness, desire, knowledge, ability, reinforcement).
All of these change models are flexible, and trauma PI leaders may find that a blend of techniques will provide the best solution to a particular implementation challenge. But starting with an established change theory increases the likelihood of success, reduces “re-work”, and decreases the risk of financial loss and staff burnout from ill-fated change attempts.
Tracylain Evans, DNP, MBA, MPH, RN, EMT/P, TCRN, CEN is the trauma program manager at St. Joseph’s University Medical Center in Patterson, New Jersey.
Brown JB, Gestring ML, Forsythe RM, Stassen NA, Billiar TR, Peitzman AB, Sperry JL. (2015). Systolic blood pressure criteria in the National Trauma Triage Protocol for geriatric trauma: 110 is the new 90. Journal of Trauma and Acute Care Surgery, 78(2), 352–359.
Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. (1989). A revision of the trauma score. Journal of Trauma, 29(5), 623–629.
Clark C. (2010). From incivility to civility: Transforming the culture. Reflections on Nursing Leadership, 36(3).
Kotter JP. (1996). Leading Change. Boston, MA: Harvard Business School Press.