Cristina Nunes, MD, is a dedicated team leader of 10 different sectors at the Hospital of Bragança who participated in the STOP Infeção (Infections) Collaborative in Portugal. Under her direction, the team in Northern Portugal significantly reduced Central Line-Associated Bloodstream Infections (CLABSI), Catheter-Associated Urinary Tract Infections (CA-UTI), and Ventilator-Associated Pneumonia (VAP) over two years.
How did Dr. Nunes’ leadership contribute to dramatic improvements? Her attention to the human side of change can be understood by specifically focusing on three components of the Psychology of Change framework:
- Unleashing intrinsic motivation
- Adapting in action
- Distributive power structures
Unleash Intrinsic Motivation
Before the STOP Infeção (Infections) Collaborative, the Hospital of Bragança teams had worked hard to reduce CLABSI, CA-UTIs, and VAP, but hard work is not enough. Dr. Nunes knew she needed to release the team members’ individual and collective commitment to make care better for patients and she understood that being present was essential. “Never once did [our leadership team] miss the walkarounds for each of the teams we were supervising,” Dr. Nunes noted. “There was an intentional valorization of each [person] that gave the team members and frontline staff autonomy.” She encouraged commitment from the teams through frequent visits, online virtual support, and by providing ad-hoc coaching as teams tested changes.
Dr. Nunes understood that — when trying to shift a system — her approach needed to be staff-centered in addition to patient-centered. Understanding each professional as a human being meant acknowledging that people want to feel supported while making such large changes. By humanizing their experiences, their needs, and their success, Dr. Nunes also helped her teams tap into their intrinsic motivation to prevent harm to their patients.
Adapt in Action
Adapting in action means learning about change by taking action. For Dr. Nunes, this meant building the skills of Hospital of Bragança leaders. Dr. Nunes coached them every step of the way and taught them to do the same for their staff, helping them to feel comfortable testing changes in a team environment.
Her guidance was essential for teams as they later faced inevitable challenges as a team. These included doubts about their change ideas, balancing their regular work with their improvement projects, and trusting each other enough to build an efficient team. Dr. Nunes’ coaching helped the team adapt and navigate change. “At the beginning of the Collaborative, I brought them communication tools to help them become independent and allowed for ownership of projects,” Dr. Nunes reported. Dr. Nunes always made sure that every team members’ voice was heard and appreciated as each team tested, failed and succeeded together. Through her coaching, she helped teams to endure hardship and fail forward, always supporting them through their successes and failures.
Dr. Nunes had strong support from IHI and the Portuguese government throughout the collaborative that helped her to thrive as a leader. In turn, she co-created change with her staff and teams. She shared knowledge and opportunities to lead, and created opportunities to hear and value ideas from many departments and individuals.
Change can be challenging, especially when it means letting go of old practices and setting ambitious aims. Dr. Nunes’ personal perseverance and belief in the importance of reducing infections were essential to her organization’s success, but any leader can learn from how her attention to the human side of change led to inspiring results.
Santiago Nariño is an IHI project coordinator.
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