There are different levels of participation in creating change. The first level is the active working team that is responsible to carry out the daily planning, documenting, communications, education, monitoring, and evaluation of activities needed to bring about successful change. The working team must be multidisciplinary, with representation from all departments involved in the change processes — doctors, nurses, pharmacists, respiratory therapists, and other staff with roles in the specific change process, such as clerks and technicians. Team members should be knowledgeable about the specific aims, the current local work processes, the associated literature, and any environmental issues that will be impacted by these changes.
The second level is the leadership group or person who helps remove barriers, provides resources, monitors global progress, and gives suggestions from an institutional perspective. Teams need someone with enough authority in the organization to overcome barriers that arise. The leadership needs to understand both the implications of the proposed change for various parts of the system and the more remote consequences such a change might trigger. This person must allocate the time and resources the team needs to achieve its aim.
The third level is the extended providers, including all who have an interest in the change. Procedures are needed to include them in the process by keeping them informed, providing a hassle-free mechanism to receive their feedback, and assuring them that their responses are respected and will influence the changes. This helps give them some ownership and facilitates implementation and utilization of the new processes.
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Example 1:
Aim: Diagnose respiratory failure due to pneumonia in the emergency department and initiate mechanical ventilator support.
Core team: The overall core team must be interdisciplinary and must include, at a minimum:
- ED physician
- Triage nurse
- Staff nurse
- Respiratory therapist
- Admissions clerk
Additional team members may include:
- Critical care medicine (CCM) physician
- House officer
- ICU charge nurse
- Infectious disease physician
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Example 2:
Aim: Apply appropriate ventilatory strategies for patients with acute respiratory distress (ARDS) in the ICU.
Core team: The overall core team must be interdisciplinary and must include, at a minimum:
- CCM physician
- Respiratory therapist
- Staff nurse
- Pharmacist
Additional team members may include:
- Private attending physician
- Surgeon
- ED physician
- Blood gas technician
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Example 3: Effective Leadership Team
Aim: ED and CCM will join together to implement best possible care for septic patients using the known evidence that fits their institution.
Core leadership team: The overall leadership team must be interdisciplinary and must include, at a minimum:
- Administrator over ED and CCM
- Critical care medicine physician
- ED physician
- CCM nurse manager
- ED nurse manager
- ED charge/triage nurse
- CCM charge nurse
Additional team members may include:
- Pharmacist
- Respiratory therapist supervisor
- Process improvement facilitator
- Laboratory supervisor
- Technicians from ED
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