Final Change Management Plan

For your final change management  program, include the following sections:

1. Table of contents

2. Change management research and analysis (week 1)

3. Plan of intent, change management roadmap, and key performance indicators (KPI) (week  2)

4. Communications plan (week 3)

5. Ethical and cultural considerations plan that is 500-750 words and addresses the following:  a. Detail the established organizational roles to manage ethics in the change  management program.  b. Outline how awareness and social responsibility will be addressed in the change  management plan in approaching the challenges in a multicultural environment.  c. Describe how the change management plan aligns with ethical organizational  behaviors and operating values.

6. Implementation plan (week 4)

7. Written change management training plan (week 5)

8. Effectiveness plan and analysis plan (week 6)

9. Conclusions and discussion.

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Final Change Management Plan
Amanda Coffey
Professional Capstone
Dr. John Streit
May 15, 2024
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PEL/VIP specializes in cardiopulmonary staffing, consulting, and education. The mission
of this company is to create cardiopulmonary disease management programs and staff
development tools that empower healthcare providers to take control of patient outcomes.
Recently, PEL/VIP was selected to staff forty-six long-term ventilator facilities throughout the
state of Indiana. With the staffing of three of the facilities already underway, it is imperative that
the company empower its team of competent, highly skilled respiratory therapists with the
equipment and tools needed to provide safe, superior care to patients. One way to improve
quality of care while promoting patient safety is by establishing and maintaining an effective
system for reporting and investigating errors and near misses. This system is often referred to as
an incident reporting system. As always, staff and personnel of acute and long-term care
facilities licensed by the Indiana Department of Health should submit incident reports via the
IDOH Gateway Incident Reporting System (IDOH, 2024). However, PEL/VIP seeks to establish
its own error and near miss reporting system to enhance employee knowledge by providing
ongoing education and training, hereby improving the quality of patient care.
Communication failures among healthcare professionals are the leading cause of sentinel
events (JCAHO, 2024). Establishing an effective incident reporting system encourages a culture
of safety. It does this by allowing healthcare providers to learn from their mistakes without fear
of punishment. The openness this creates can lead to improved communication and teamwork, in
turn, leading to better patient care. Another benefit of an incident reporting system is that
PEL/VIP can identify patterns and systemic issues that may not be apparent in individual
situations. For instance, if multiple errors occur in medication administration, it may indicate a
need for better training or changes in procedures. Furthermore, once errors and near misses are
reported and investigated, corrective actions can be taken to prevent similar incidents in the
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future. For example, if a near miss occurred because one medication looked similar to another,
PEL/VIP could change the packaging or labeling to prevent confusion. Vincent et. al (2008)
concluded during a study published in the British Medical Journal that hospitals that encouraged
incident reporting had lower mortality rates. Ultimately, all of these benefits lead to improved
patient outcomes. When errors are reduced, patients are less likely to experience harm, leading to
better health outcomes and increased patient satisfaction.
To implement the incident reporting system, several different leadership theories can be
used. Using transformational leadership may be appropriate in this situation. Transformational
leaders encourage, inspire, and motivate employees to perform in ways that create meaningful
change (UMass, 2024). Leadership can use inspirational motivation to communicate the vision
and importance of the new system. Leadership can also use intellectual stimulation to encourage
employees to think critically and suggest improvements. One might give individualized
consideration to address each employee’s concerns and ideas.
Another leadership theory that might be used is servant leadership. Servant leadership
focuses on the leader’s role as a servant to employees, prioritizing their needs and development.
This approach can be used to create a safe and supportive environment where employees feel
comfortable reporting errors and near misses without fear of punishment.
Addressing social identities, ideologies, and personal biases can be done through
inclusive leadership, which emphasizes openness, accessibility, and availability. PEL/VIP’s
leadership needs to create an environment where diversity is valued, and everyone’s voice is
heard. This can be achieved through regular communication, feedback, and training on diversity
and inclusion.
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The change implications might include a shift in the organizational culture towards a
more open and learning-oriented environment. Employees might initially resist the change due to
fear of punishment or lack of understanding. However, with effective leadership, they can be
guided to understand and embrace the new system.
Implementation of a new incident reporting system will have significant impacts on
PEL/VIP business, staff, and patients. The change will likely improve the overall quality of
service provided by the facilities. By implementing a system for reporting and investigating
errors and near misses, PEL/VIP can identify areas of weakness and take corrective action. This
could lead to improved patient outcomes, which could enhance the company’s reputation and
potentially increase its market share. Additionally, the system could help the company avoid
costly lawsuits and penalties associated with medical errors. Staff will also be required to adapt
to new procedures and protocols. This could initially lead to resistance or confusion, but with
proper training and communication, they should be able to adjust. The new system could also
lead to increased accountability and professionalism among staff, as errors and near misses will
be closely monitored. This should improve the overall work environment and lead to higher job
satisfaction. For patients, the change should lead to safer and more reliable care. The system for
reporting and investigating errors and near misses will help ensure that mistakes are not repeated,
leading to improved patient outcomes. This could increase patient satisfaction and trust in the
company.
Consequently, there are many benefits to the implementation of a new incident reporting
system. Improved patient safety is the primary benefit. It can also be utilized as a learning tool.
By understanding the root causes of errors, PEL/VIP staff will learn how to avoid them in the
future. It will create an environment of increased transparency, fostering a culture of openness
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and accountability. This often leads to improved trust and communication among staff members.
Lastly, by preventing errors, the new system can lead to cost savings, as it should decrease the
costs of treating complications originating from errors.
In conclusion, while the system may present initial challenges, it has the potential to
significantly improve the PEL/VIP business, staff, and patient experience. The key to successful
implementation will be effective communication and training, as well as ongoing monitoring and
adjustment of the system as needed.
PEL/VIP Clinical Excellence Initiative: Implementing an Incident Reporting System
Organization’s Vision
With an effective incident reporting system (IRS), PEL/VIP will encourage an open,
learning, and always-improving culture. Employees will feel free to report mistakes and close
calls without fear of punishment because their reports will be used to find systemic problems and
stop future incidents. PEL/VIP will improve processes, training, and equipment by regularly
looking at reported incidents. This proactive approach will improve patient safety protocols and
improve care delivery in all facilities (Hamed & Konstantinidis, 2021). The system encourages
open communication and responsibility, which will help staff members work together better and
trust each other more. Reports of incidents will help respiratory experts learn new information to
help them perform better. As patient outcomes improve, PEL/VIP will become known for
providing excellent care and bringing in more clients and skilled workers. People in the industry
will look up to the company because it puts quality and safety first. Ultimately, the incident
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reporting system will turn PEL/VIP into a learning organization that is always trying to improve
for the sake of patients and staff.
Benefits of the IRS
Since this system reduces mistakes, patients will be safer and have better health
outcomes. With an IRS, Yusuf and Irwan (2021) posit that employees can improve their skills
and knowledge by getting ongoing training based on reported information. Leadership can find
and fix problems that affect the whole system, making processes run more smoothly. Setting an
example of dedication to openness and good care will boost the company’s reputation. Partners in
healthcare and government agencies will trust PEL/VIP’s proactive approach to patient safety,
thus increasing its chance of getting government grants and funding. An open learning culture
can improve morale, teamwork, and job satisfaction for everyone.
Addressing Concerns
As PEL/VIP sets up their IRS, they must be aware of and prepare for several possible
problems. One major issue is that workers might fear being punished or retaliated against for
reporting mistakes, even if they are told that no punishments will be instigated (Amaniyan et al.,
2019). To fix this, leaders need to ensure that the caregivers know about an amnesty policy for
incidents they report independently. Mutair et al. (2021) poses that creating a fair culture where
people are more interested in learning than blaming is very important. PEL/VIP should let staff
help design the reporting processes to build trust and buy-in. Another problem they might
encounter is that some skeptical employees may not believe the leadership wants to be open and
honest. Leaders can show they are human and set an excellent example by owning up to their
mistakes and telling others about them. Sharing quality metrics and real-life examples of how
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reporting stops harm from happening again can bring attention to the system’s value. Finding
change champions among respected staff and giving them the power to spread the change can
also help. If there are a lot of reported mistakes during the transition period, patients and their
families may lose faith in the institution. PEL/VIP should get ahead of this by teaching
stakeholders that more reports mean more actions can be taken to fix problems and make things
safer in the long run. It will be important to share data over time showing better patient
outcomes. It is also possible for regulatory bodies to be skeptical at first, so it is best to work
with them and let them know the new system’s goals.
Market Concepts
As an early adopter of a full incident reporting system, PEL/VIP can set itself apart in the
healthcare staffing market as a leader in improving patient quality and safety. This proactive
approach shows that the company is dedicated to learning new information all the time and
improving the way care is delivered. It lets potential clients know that PEL/VIP values openness,
responsibility, and getting better results (Yusuf & Irwan, 2021). A competitive edge is also
gained from the large amount of data and insights gathered through incident reporting and
analysis. This can help PEL/VIP train their respiratory therapists better, ensuring they have the
most up-to-date skills. They can find and fix systemic problems more quickly, which also helps
them run their business more efficiently. This commitment to putting people first creates a better
workplace and fosters employee retention.
KPI Metrics
Several key performance indicators (KPIs) can be tracked to measure the effectiveness
and adoption of the new incident reporting system. The rate of incident reports is a fundamental
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KPI; more reports at first mean that the system is being used the way it was meant to be. Rates of
adverse events, near misses, and medication errors are patient safety KPIs that can show if the
system is meeting its goal of making the institution safer. In line with patient safety, a valuable
KPI would be a patient satisfaction index to showcase how well the patients are pleased with the
institution’s measures. A good KPI indicator would be a drop in the number of aforementioned
types of incidents. Operational KPIs include tracking how long it takes to investigate incidents
and make changes based on those findings. Finally, tracking employees’ engagement, job
satisfaction, training, and turnover rates can show how the new system changes PEL/VIP’s
employer brand and ability to acquire and retain employees. Reviewing this balanced scorecard
of KPIs regularly allows for data-driven assessments and changes that will lead to long-lasting
success with the change.
KPI
Metric
Target
Reporting
Number of incidents reported per month
Increase over
baseline
Percentage of staff submitting reports
Percentage of reports with complete
information
Rate of adverse events per 1,000 patient days
>80% participation
>90% completeness
Participation
Report Quality
Patient Safety
Patient Satisfaction
Rate
Culture
Rate of near miss events per 1,000 patient
days
Overall patient satisfaction score
Decrease over
baseline
Decrease over
baseline
>=90th percentile
Employee survey: Psychological safety score
Employee survey: Trust in leadership score
>4 on 5-point scale
>4 on 5-point scale
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Operational
Talent
Average time from report to investigation
completion
Average time from investigation to corrective
action
Employee turnover rate
Time to train respiratory therapist positions