Table 2 Implementation strategies important for facilitation in the PICU

Tailor strategies to overcome barriers and honor preferences^a

Tailor strategies to overcome barriers and honor preferences

“I think engagement^c of the bedside providers [helps change occur]...really trying to understand how a change will affect the work and then modify the proposed change based on the information that you get from people at bedside.” (Site 3 PICU, Attending 21)

Conduct local consensus discussion^a

Achieving buy-in from leadership and bedside providers, creating ownership around change for those who use change on a daily basis

“Giving more ownership to the bedside nurses about the changes that are impacting the practice helps change to be a little bit easier.” (Site 1 Combined PICU/CVICU, Nurse 13)

Identify and prepare champions^a

Identifying champions from each discipline impacted by change

“Having people who are champions at multiple different levels of stakeholders…whoever it may be that’s going to be involved to really lead that effort helps change occur” (Site 4 PICU, Attending 36)

Change physical structure, equipment, records systems^a

Embedding change into work systems (including EMR)

I think electronic medical record is probably the one thing that can help a lot with [implementation] since there is so much of our work [that’s done there] (Site 4 PICU, Fellow 38)

Conduct educational meetings^a

Multi-professional education around change

“I think that there would have to be education [for a proposed change]. And not just for physicians, but also for nurse practitioners and for bedside nurses to understand why and where this is coming from” (Site 1 CVICU, Attending 2)

Make training dynamic^a

Creating ways to reliably inform large PICU teams about change (using multiple modes of communication)

I think it is helpful doing [education] in a multitude of ways that are kind of repeated, to capture as many people as possible. (Site 4 PICU, Attending 36)

Time-sensitive training

Just in time education around the time of change roll-out

“For nurses, [change is facilitated by] “boots on the ground” things. The huddles, just -in-time education. (, more responsive to that sort of environment. (Site 2 PICU, Attending 20)

Develop effective educational materials^a

Creating easy access to information about change, tools needed

“[a new protocol/process] would need to be in a place of easy access… in academic institutions where you’re having new rotators come through every several weeks, [you need to] make sure that there is a way to introduce it to folks” (Site 2 Combined PICU/CVICU, Resident 50)

Advance notice about change

Giving providers time to prepare for change

“[Change is hard if] it really greatly impacts our workflow and doesn't come with any preparation…If I know it’s coming, and I can personally think about how is this is going to affect my practice, and how I’m going to mitigate that issue (Site 3 PICU, Nurse 25)

Practice using change

Repeated use of change to create “muscle memory” around change (infrequently used changes are much harder to incorporate)^b

“It’s repetition [that helps change “stick”]. Whether it’s repetition of practice or just repetition of education …sometimes everybody agrees that there’s going to be a policy change but it may be six months before you encounter a situation where that change would be implemented and then nobody remembers” (Site 2 PICU, medical subspecialist 18)

Develop and organize quality monitoring systems^a/Audit and provide feedback^a

Tracking data/evaluation of the impact of change (monitoring compliance, outcomes, safety data)^b

I think reporting back…so that people know, “Hey this thing we started this nine months ago?...Here’s what happened. That’s obviously an incentive for people to feel like it made a difference” (Site 2 CVICU, Attending 28)

Remind clinicians^a

Frequent reminders about existence, importance of/rationale behind new change^b

“[change is facilitated by] Informal reminders…the way sometimes people will remind you, “All right, let’s make sure we are doing our check lists at the end of every patient,” or the way people say, “let’s remember to wash our hands in and out of every room.” (Site 2 CVICU, Fellow 29)

Conduct cyclical small tests of change^a

Iterative changes made to enhance use of change process

“[to make change “stick”] a check-in and a feedback session would probably be good, and if small changes need to be made to whatever protocol that’s established, they can be made and re-evaluated.” (Site 2 PICU, Attending 17)

Ensuring adequate resources

Obtaining adequate resources to plan, implement, and sustain change

“Resources [can be a barrier to change] as well. Most changes require some sort of time, effort, if not other financial resources to implement.” (Site 4 PICU, Attending 36)

Communicating early success

Celebrating “successes” of change

“One of the ways that we found [to help make change] most successful was celebrating our successes…we put it in the newsletter, and celebrated it.” (Site 3 PICU, Nurse 25)

Accountability

Creating accountability for change (may be from frontline staff)

“There needed to be more accountability for…how do we make sure these things get done? So, they developed this little list…you had to sign off, you had to turn it in before you left. That went on for 6 months, and then people had kind of built a habit into their practice.” (Site 2 Combined PICU/CVICU, Nurse 48)