Testing and Implementing Policy Initiatives

Case Study

Monia meets again with the key decision-makers – in her practice, this body is the group of directors – to present her draft, talk about the feedback she has received, and make her recommendation for the secure messaging system she thinks the practice should purchase. Considering the legal, ethical, and business efficiency information she presents, the directors decide to approve the purchase. In the meantime, the administration manager, and the three most senior practitioners in the practice will undertake a hypothetical testing meeting.

Monia shares information about the system she has recommended, and they work through each aspect of the policy discussing matters such as what training the staff will need in order to use the software, how they will communicate with other service providers who do not use the software, and so on. The realise that different teams and staff roles will use the software in slightly different ways, so Monia will need to work with managers, clinicians, and administration staff to develop procedures appropriate to each group.

The administration manager raises concerns about the increased workload for their already busy staff as the transition to secure messaging happens. Monia recognises that there will be some duplication issues while older technologies are phased out and the new ones phased in, as well as ‘teething issues’, so she approves additional hours for two casual administration workers during the first fortnight of the roll-out, to help manage additional workload.

Following the meeting, Monia contacts local services using the secure messaging system to ask for recommendations for training providers and information sources she can access to support her staff in adapting to the new system. She follows up on recommendations and receives quotes for several training options, then selects the one she considers the most comprehensive to recommend during her formal policy proposal.

Reading I

Shortly, we will consider different ways that we might present our policy initiative to a decision-making body. First, work through Reading I. As well as introducing you to the policy area that we will use in exploring presentation options, it briefly describes several current trends in organisational policy development and is an example of the kind of resource you might develop or find and share with stakeholders to help them develop their understanding of the need for a policy change. It will also set the context for the Readings that follow, both of which will be important for your assessment in this unit.

Self-Reflection

How do you think you could most strongly advocate for your policy initiative to be approved? How can you strengthen your skills in this area?

Replace Labels with Appropriate Terminology

In healthcare settings and in education of health professionals, identifying current and best-practice terminology is important for optimal patient-centered care, in curriculum development, and for knowledge translation. HCWs [healthcare workers] should keep abreast with best-practice terminology for patient-centered care. Patients might prefer language which is neutral, non-judgmental, based on facts or biology, and/or emphasizing health or health behavior. Labels such as “schizophrenics” or “the obese” may equate the person to the condition, and terms such as “non-compliant” or “non-adherence” can imply blame and judgement. Preferable terms include factual phrases such as “blood glucose is high”; words that reflect collaborative goal setting, such as “concordance” instead of “non-compliant”; and neutral descriptors such as “living with” instead of “suffering from”.

Guidelines may exist for preferred language and terminology, such as in the Aboriginal and Torres Strait Islander context in Australia. While using preferred language demonstrates respect, language is constantly shifting and evolving. Some terms once considered derogatory (such as queer, blind, deaf, and autistic) may now be positively embraced by some, and other terms (such as hermaphrodite) are no longer acceptable. Therefore, any list of appropriate terms must not be seen as perpetually appropriate.

Use Inclusive Language

Using inclusive language is a crucial pre-requisite for inclusive service, since language has the power to marginalize and exclude people through “othering”, which is exclusionary speech or behavior towards those who are deemed as different to oneself. When providing care for diverse groups, healthcare professionals must be mindful of not speaking or behaving in a way that is perceived by those who are receiving that care as othering. Formal consensus and guidelines notwithstanding, an important principle in ensuring inclusive language is respecting the power of self-identification for individuals and communities. At the heart of inclusive language is respect for all types of diversity. Terms such as “wheelchair bound” and “confined to a wheelchair” are dismissive of the Social Model of Disability; better terms include “wheelchair user” or “person who uses a wheelchair”. The term “Accessibility Action Plans” is preferred over “Disability Action Plans” due to the former’s focus on the positive rather than the negative. The lived experiences of gender-diverse people can be respected by HCWs’ use of words that patients choose in their own terms, which may include gender-neutral terms such as “chestfeed” rather than “breastfeed”, or binary terms such as female/woman if preferred to affirm one’s gender.

A case study can be made of the common conundrum between the use of person-first language (e.g., “a person with autism”) and identity-first language (“an autistic person”). Autistic adults commonly prefer identity-first language, while parents of children with autism may prefer person-first terminology. In autism, as well as in other conditions, proponents of both languages have equally strong rationale. Person-first language is argued to focus on a person’s active rather than passive role in the management of their condition. Identity-first language may inadvertently lead to labeling, which, among certain populations with experience of health marginalization, discrimination, racism, and judgement may reinforce barriers to healthcare access and perpetuate and entrench marginalization. Conversely, identity-first language has been advocated for to move away from the idea that disability is an impairment or undesirable. The use of identity-first language enables the person to claim the title and be proud of their identity, promoting autonomy, agency, and choice. Identity-first language also indicates that the condition is not detachable, but integral to the individual and their perception of the world. The person-first language may increase stigma toward disabled people, especially children with stigmatizing disabilities. Faced with this conundrum, and other cases of differing terminology preferences within a population group, HCWs are recommended to:

1. consult each person for their preference,
2. be familiar with the relevant local guidelines, and
3. acknowledge other preferences when using one language for general communication.

In writing this discussion, for example, the authors have used both types of language in different orders as an equal acknowledgment of the two preferences.

Since people may identify with and reconcile multiple identities, HCWs need to deepen their knowledge of intersectionality, which is the relationship between multiple and intersecting social identities, and how these intersections are shaped by overlapping systems of power, privilege, and oppression. Overuse of medical terminology may contribute to a hierarchical power imbalance within healthcare settings. On the other hand, avoidance of certain terms such as “heart failure” may make it difficult for the patient to understand and manage their health. Language should be inclusive and respectful, but not overly simplified, and time should be taken by HCWs for adequate explanation.

^{(Adapted from pp. 4-5)}

Case Study

In Monia’s practice, policies are ratified at monthly directors’ meetings. Once the testing and feedback process has been finished and Monia adds the new procedures into the policy draft, Monia knows she will need to present the policy and a plan for implementation at the meeting coming up in a fortnight’s time. Because the organisation cannot roll out the new secure messaging software overnight, however, Monia needs to include an addition procedure (Transition to Secure Messaging) to her policy, which specifies the timeframes and actions associated with implementation (this procedure can then be removed when the policy is reviewed and updated). The new policy includes information about:

• Information and training of staff over the next four weeks to ensure sufficient resources have been provided for a full transition to secure messaging within eight weeks.
• Notification of all clients and service providers who refer to the clinic of the adoption of the secure messaging system within the first four weeks, completed via conversations with clients who attend appointments, emails to all clients who have provided email addresses, and posters in the reception and practice areas.
• Progressive adoption of secure messaging in different divisions of the practice over the course of the four weeks following the training/resourcing and notification of change steps.
• Providing each team with a specific manager to whom they can direct any questions or concerns they have during the roll-out.
• Weekly all-staff meetings discussing the roll-out progress and addressing any issues that arise within it.

Because of her previous work with the key decision-makers, the directors are familiar with the policy initiative and broadly supportive of it, so she does not need to make a detailed presentation. Instead, she emails the final draft of her policy and plan to the directors, along with her recommendation for the training provider to be appointed. Monia also proposes that she undertake a review of the implementation twelve weeks after initial ratification, which will include a report about the implementation, any issues and their resolutions, and recommendations for changes to the policy.

The directors approve Monia’s plan and ratify the policy at their meeting. The next morning, Monia emails all staff, notifying them that the transition process will be starting and sharing the finalised policy, which she also places on the practice’s shared drive. She includes a timeline for the transition process, which she has developed into a poster, and an information-sheet for clients; these are also printed and displayed around the practice. Monia meets with the managers and senior practitioners in each of the disciplines at the practice that afternoon – they discuss the immediate steps they each need to take and arrange twice-weekly meetings for the duration of the transition period. As per her earlier agreements with the teams, she arranges for additional administration hours to be filled by their casual workers and books in training for each team with a recommended provider.

As the implementation proceeds, Monia is aware that some staff are complaining about the added time and work involved in transitioning to secure messaging, but who are not coming to her or their managers with specific concerns. Monia decides to address this directly by talking openly about the stressors of the process in an all-staff meeting, reiterating the important reasons for the change, and encouraging staff to raise concerns they have directly with her. She also presents the range of resources to support the transition that staff can make use of and reminds them of the additional administration support that will help offset the additional workload.

The implementation plan is rolled out and, while generally successful, has several challenges. Staff observe there are sometimes lags in responsiveness when they are using the system simultaneously during training activities; Monia considers the possibility that they will need to upgrade their internet plan to accommodate the increased activity. More concerningly, one of the staff members who had argued against the system being implemented became so negative that his manager approach Monia to discuss possible disciplinary action. As an administration team member, the worker will have particular responsibilities as the initial contact point for many of the practice’s communications. Yet, in addition to making “endless complaints about the extra work”, he has “called in sick” on key days, such as one of the days that the trainer would be working with the administration team, and who has not completed the introductory online training modules that all staff have been assigned and must complete before the use of the system starts. The administration manager does not think her staff member was unwell and believes he is unwilling to adapt to the new system. Monia meets with the staff member privately and, having observed his responses to her questions about his training activities, believes that the administration manager’s suspicions are correct. Monia also suspects, however, that the staff member is very anxious and, with some sensitive questioning, he discloses that he is afraid he is not capable of learning to use the new system and will lose his job. Monia arranges additional, one-to-one training for the staff member and develops a supervision plan with his manager.

As the training period ends and they start transitioning to the new system for client-related communications, all staff members make errors or find aspects of the system challenging, but Monia observes most staff willingly asking more competent team-mates what to do and identifying and correcting errors. This does cause some delays, especially in the first fortnight, while staff take longer than usual to process communications.

While the additional administration support helps that team manage without noticeable delays as they come to grips with the system, practitioners are late in starting many client appointments and Monia observes both staff and some clients becoming frustrated. Within a fortnight, however, most staff are navigating the new system well and there are signs that several areas of communication are likely to become quicker, such as the processing of incoming referrals and sharing of client updates with other service providers who use the same system.

Monia keeps notes about her observations, issues that have arisen, and ideas for improvements in future implementation processes (particularly those in relation to the other healthcare technologies she wants to roll-out within the practice). Prior to her 12-week evaluation, she gathers surveys the practice’s staff and clients for feedback. Staff are presented with an electronic survey asking them to identify their level of agreement (from ‘strongly disagree’ to ‘strongly agree’ to a series of statements about the new policy and its implementation, such as

• I understand why the practice has transitioned to a secure messaging system.
• I was provided with enough time and information to implement the Secure Messaging Policy within my work role.
• I believe that using secure messaging for client-related communications helps our practice meet our professional and ethical responsibilities.

They are asked to finish the sentence “I have found that the secure messaging system has ______________ in my work” by choosing one option from “increased efficiency”, “decreased efficiency”, or “made no change to efficiency”. The survey also asks staff for any suggestions they have about improving the policy and future policy implementations.

The staff survey responses largely accord with Monia’s observations: that there were initial frustrations but most staff, now they are adapting to it, are finding the new system useful. Several of the administration workers are particularly happy about having a single system used for the vast majority of referrals they receive and outgoing communications they send, rather than dealing with referrals coming through email, fax, letter, and phone calls. Some staff, however, raised concerns about the speed of technological change in the practice and the stress of having to learn to use a new system while continuing to do their regular work with the old system.

All clients who have provided their email addresses to the practice receive an email encouraging feedback either online or by filling in a feedback form at their next visit. Only a small proportion of clients complete the feedback surveys. Monia notices that most have noted the delays in appointments caused by additional time taken by staff learning to use the new system in practice but are generally positive about the use of the secure messaging system.

After collating her observations and the feedback results, Monia puts together the following report and emails it to the directors:

A four-week transition followed, in which communications regarding ‘batches’ of clients were transferred to the secure messaging system and most referrals were received via the secure messaging system. Practices continuing to refer via other means were identified and contacted again with information about our new referral receipt process.

Secure Messaging System – 12-Week Review

• Background: Integrating up-to-date health technologies was identified as a priorty early this year, in order to support our professional service delivery, improve efficiency, and meet community standards. A secure messaging system has been in use in our practice for eight weeks. This report reflects upon the process of policy development and implementation in relation to this system and provides recommendations for updating the policy and for future policy development, particularly in relation to the adoption of healthcare technologies.
• Policy Development Process: While reviewing our existing systems and developing the new policy, we consulted with staff, clients, and our solicitor to evaluate the legal, ethical, and practical issues associated with introduction of a secure messaging system. We identified that client-related communications were occurring on systems (e.g., fax, email) that no longer meet professional and community standards for privacy and confidentiality and decided to change to a secure messaging system. While this was broadly supported by staff and clients, many concerns were raised about the change. Strategies for addressing this resistance included information sharing via emails, meetings, and individual conversations. Hypothetical discussions identified several potential issues, which were addressed in the final policy draft, and the policy was ratified at the directors’ meeting in May, 20XX.
• Implementation: We developed an eight-week implementation plan, including a four-week period where training and resources were provided to staff and all services who have referred to us in the past year were notified of the upcoming change to our system for future referrals.

Outcome: The new system is now being used by all staff, most of whom are showing competence but with the need for further training identified by the administration team and one of the clinical groups. Over 80% of new referrals are being received through the secure messaging system and most local clinics we communicate with about shared clients are using the system to share information. In general, the new system has saved staff time by reducing the number of communication channels they need to manage and the majority of staff are satisfied that we have a more secure system in place than previously.

Issues and Recommendations:

1. During implementation, we noticed that some staff had concerns about implementation that they did not communicate to management and there was one case in which a staff member had to be counselled about their responsibilities and a plan developed for additional support to develop competence in using the new system. This showed the need to consider concerns that are not communicated, especially concerns around the use of novel technologies. For example, some staff members may be anxious about their ability to learn and use a new technology but be too embarrassed to discuss this with their team or manager.
   • Recommendation: As we progress toward introducing further healthcare technologies, we normalise concerns in our discussions with staff and reassure staff regularly that requests for extra training will be respected as showing that they are proactive in identifying and addressing issues.
   • Recommendation: Discussing training needs on an individual basis with each worker, rather than with teams or clinical areas, may reduce barriers to disclosing anxieties and additional training needs; offer one-to-one training in a private environment.
2. During the transition to the new system, the extra time required by staff to use the new system led to delays in client appointments. While the need for additional help was recognised for the administration team and this was provided by casual staff, we did not consider the possibility that delays would occur in clinical work. Some clinical staff also mentioned having to stay late at the end of their shifts to complete documentation to be shared with other service providers using the new system. (These issues were temporary.)
   • Recommendation: Prior to the introduction of a new technology, we email or send a letter to all clients and place posters in reception notifying everyone of the upcoming change and the potential for delays.
   • Recommendation: Provide ‘sandbox’ or ‘simulation’ sessions as appropriate as part of the implementation plan for future changes, e.g., simulated telehealth sessions to troubleshoot problems before implementing broader telehealth services.
3. Not all client-related communication can occur via the system, because there are services not using secure messaging systems or using systems that are not compatible with ours.
   • Recommendation: Discuss methods for increasing security in communications with stakeholders who do not have a compatible secure messaging system; potential consultants include Ms Ghai (solicitor) and AHPA.
   • Recommendation: Develop a procedure for staff to follow when communicating regarding a client with a stakeholder who does not use a compatible secure messaging system.