D158 Task 2 Implementation Plan Example

Implementation Plan: Four Phases and Three Decision Gates for Launching Patient Blood Management on Two Inpatient Services

Student Name

Leavitt School of Health, Western Governors University

D158: Strategically Planning the Execution of a Healthcare Improvement Plan, Task 2

Course Instructor

Month Day, Year

Implementation Plan: Four Phases and Three Decision Gates for Launching Patient Blood Management on Two Inpatient Services

Overview

This plan sets out how the approved patient blood management program will be launched over 14 months on the two adult inpatient services, medicine and general surgery, in the same composite hospital. It follows the stakeholder and resource map and assigns each barrier recorded there to an owner. Work is organized in four numbered phases, each with entry conditions, the work inside it, the accountable role and a time interval, separated by decision gates with criteria set now. The executive sponsor is the chief medical officer; the operational lead is the half-time blood management nurse coordinator, hired in Phase 1.

Phase 1: Foundations (Months 1 to 3)

Entry conditions: budget released; sponsor group of chief clinical executives, surgical chief and a lead hospitalist formed. Work: hire the blood management nurse coordinator (nursing director, month 1 to 2); submit the order set and alert request through information technology governance with the sponsor's priority rating (chief medical officer, month 1); agree the savings calculation method with finance (coordinator and finance manager, month 2); build the baseline report of transfusions with the most recent hemoglobin, by service and clinician, and confirm the 12-month baseline (analyst, months 2 to 3); convene two hospitalists and one surgeon to draft alert wording and reasons to proceed (coordinator, month 3). Accountable role: executive sponsor. Dependency: the alert cannot be built until its wording and thresholds are agreed.

Gate 1 (End of Month 3)

Criteria to continue: coordinator in post; analyst hours scheduled with a build date no later than month 5; baseline report validated against blood bank issue data within 5%; alert specification signed off by the physician design group. Decider: the sponsor group. If not met: if the build date slips beyond month 5, the sponsor escalates to the hospital's information technology steering committee; the education phase is not delayed, but its timing is adjusted so that education ends within four weeks of the alert going live, since education without the tool fades quickly.

Phase 2: Build and Prepare (Months 4 to 6)

Entry conditions: Gate 1 met. Work: build and test the revised order set with a single-unit default and required indication, and the ordering alert, in the test environment (analyst, months 4 to 5); run the alert silently in the live system for four weeks, recording when it would have fired without displaying it, to check that it targets the intended orders and does not fire repeatedly for the same patient, since repeated alerts sharply reduce acceptance (Ancker et al., 2017) (analyst and coordinator, months 5 to 6); develop the one-hour nursing module and the 20-minute physician presentation (coordinator and nurse educator, months 4 to 5); present local data at hospitalist and surgery meetings through physician champions (sponsor group, month 6). Accountable role: coordinator. Dependency: silent-mode data must be reviewed before go-live.

Gate 2 (End of Month 6)

Criteria to continue to go-live: during silent mode, at least 90% of alert firings are for red cell orders on in-scope patients with hemoglobin above threshold; fewer than 10% of firings are repeats within 24 hours for the same patient; at least 80% of in-scope nurses have completed the module; both physician departments have received the presentation. Decider: the transfusion committee. If not met: fix the alert logic and repeat two weeks of silent mode; if nurse completion is low, extend the module deadline by two weeks with manager follow-up.

Phase 3: Go-Live and Early Support (Months 7 to 9)

Entry conditions: Gate 2 met. Work: activate the order set and alert on both services on the same day (analyst, month 7); the coordinator rounds on both services daily for two weeks, answers questions and collects feedback on the alert (month 7); monthly feedback reports go to each hospitalist and surgeon showing their share of transfusions above threshold compared with the service average (analyst and coordinator, from month 8); weekly review of alert override reasons and any safety concerns (coordinator and transfusion committee chair). Accountable role: coordinator, reporting monthly to the sponsor. The approach mirrors programs that paired education with real-time decision support at the point of ordering and saw substantial reductions in out-of-guideline transfusions (Goodnough et al., 2014).

Gate 3 (End of Month 9)

Criteria to move from implementation to sustainment: the share of red cell units given above threshold on the two services has fallen below 30% for two consecutive months; no increase in rapid response calls for symptomatic anemia compared with baseline; alert override rate below 60%. Decider: the sponsor group. If not met: the coordinator and physician champions review cases above threshold with the clinicians involved, adjust alert wording, and repeat targeted education; the gate is reassessed at month 11.

Phase 4: Sustainment and Spread (Months 10 to 14)

Entry conditions: Gate 3 met. Work: move feedback reports from monthly to quarterly once performance is stable; add patient blood management content to nurse and physician orientation; the transfusion committee takes over routine monitoring; prepare a proposal to extend the program to orthopedic and oncology services (coordinator, months 12 to 14). Accountable role: transfusion committee chair.

Change Management Across Phases

The plan applies established steps for leading change: a guiding coalition formed before any announcement, a clear case for urgency built from the hospital's own data, early wins made visible and new practices anchored in routine structures such as the order set and orientation (Kotter, 2012). Communication runs through trusted peers, with physician champions speaking to physicians and charge nurses to nurses.

Risks to the Timeline

Three risks could delay the plan, and each has a response. If the coordinator cannot be hired by month 2, the transfusion safety officer in the blood bank will act as interim lead for Phase 1 tasks. If a blood shortage occurs during go-live, the communication plan will separate supply-driven restrictions from the program's clinical thresholds, so clinicians do not come to see the alert as a rationing tool. If a serious adverse event is linked, rightly or wrongly, to a withheld transfusion, the transfusion committee will review the case within one week and report its findings to the sponsor group, which will decide whether any threshold or alert change is needed. Planning these responses now keeps a single problem from stopping the whole program.

References

Ancker, J. S., Edwards, A., Nosal, S., Hauser, D., Mauer, E., & Kaushal, R. (2017). Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system. BMC Medical Informatics and Decision Making, 17(1), 36. https://doi.org/10.1186/s12911-017-0430-8

Goodnough, L. T., Shieh, L., Hadhazy, E., Cheng, N., Khari, P., & Maggio, P. (2014). Improved blood utilization using real-time clinical decision support. Transfusion, 54(5), 1358-1365. https://doi.org/10.1111/trf.12445

Kotter, J. P. (2012). Leading change. Harvard Business Review Press.