Utilization of Kotter's Stages and Statistical Process Control to Implement and Sustain Delirium Screening in PICU

Delirium is a preventable cause of ICU morbidity and mortality. Prior unstructured efforts to implement delirium screening in our hospital were unsuccessful. This project aimed to improve the delirium screening compliance from baseline 0% to more than 80% within 12 months (07/2019-06/2020).

We utilized Kotter's stages of transformation as guiding blocks for implementing change and undertook simultaneous efforts to decrease delirium rates. In addition, we used statistical process control to monitor screening compliance and delirium rates.

Education on delirium assessment and prevention created a sense of urgency among nursing and medical staff (Stage #1). Stakeholder analysis and a key driver diagram were presented to leadership to create a guiding coalition (Stage #2). Process mapping and failure mode and effect analysis created a vision and strategy for the project (Stage #3). Multiple methods were utilized to communicate the change vision (Stage #4) and empower broad-based action (Stage #5). We celebrated small incremental achievements or short-term wins (Stage #6) by reporting delirium compliance and rate on a control chart. We completed 5837 delirium screens on 763 patients (6689 opportunities). The median delirium screening compliance rate was 87.2% (13.4% positive screens). Small achievements produced by the project were communicated to staff, propelling future efforts to recognize and prevent delirium. This momentum was a driver for more change (Stage #7) to ensure a long-term cultural change in the unit (Stage #8).

Kotter's principle of change management, along with an emphasis on data-driven process control, may result in sustained improvement.