This article presents a case study of a typical challenge facing the allied health workforce. To solve it, we guide you through an approach called Easy PEASI program logic that helps to clarify the problem from the perspective of a range of stakeholders, examine different solutions, and to build a project plan that can be implemented to solve the challenges.
At the end of this article you will find a link to a downloadable Easy PEASI Program Logic Workbook.
A little disclaimer: We have chosen one example of the type of problem you are likely to see. The solutions we have provided here are not exhaustive, but are used to illustrate the types of approaches you might use. We invite you to address the issues raised in this case study from your own perspective.
Understanding contexts that enable change: The IOG Context Model (Individual – Organisational – Global)
Many people are put off trying to implement workforce changes (or indeed any change) because all they can see is the barriers. We start this model by helping you to understand your ability to drive change in your work setting in your current role. This lets you understand what resources are needed to drive change at different levels, what you can control, and those areas you may need to access support.
To do this, we look at the workforce problem from three different perspectives: The individual, the organisation and globally (IOG) (Figure 1).
- Individual: This is what you, individually, have control over in order to be able to address the problem. This can include your personal values, world views, skills, personal attributes and perspectives you might have. These could be addressed through various types of support such as training and mentorship. The individual view also includes the views of your individual stakeholders, such as patients or clients.
- Organisational: The organisational environment in which you work has a culture and shared norms that create opportunities (or barriers) to change. You need to be aware of these factors when you are trying to drive change. It is easy to become socialised into an institutional way of thinking that may need to be challenged if you want to drive change effectively.
- Global: You need to understand the wider systems and structures that shape your service and your organisation if you want to do things differently. From a workforce perspective, this can include the legislation and regulation relating to the workforce as well as health policy and funding models. You are less likely to be able to directly address these yourself, so you need to understand the way these global factors effect the context in which you want to drive change and how to influence these areas if necessary.
Figure 1 The IOG (Individual, Organisational, Global) Context Model
Easy PEASI Program Logic
Program logic is an approach that helps you unpack your workforce challenge into manageable chunks and identify workable solutions.
There are several different ways of achieving the same outcome, but we have used this tried and tested approach with over 50 allied health workforce projects, and we know it works.
Our Easy PEASI program logic approach uses five headings, Problem – Enablers– Actions – Successes – Impacts (PEASI) illustrated and explained in Figure 1.
While the program logic is presented using the headings above, we go through each topic in a slightly different order to help you gain clarity about the problem you are trying to solve.
Start by clearly defining the Problem, and looking at from the perspective of different people and groups that might be involved.
We will then look at the overall Impact you are trying to achieve at the Individual – Organisational and Global levels when you solve your problem.
Once you understand what you are trying to achieve, you can explore the Enablers, which are the individual, organisational and global contexts that help or hinder your desired outcomes.
What Activities do you need to undertake to achieve the change? Think big and think outside the box. You won’t necessarily undertake all of your identified activities, but it is a good idea to look at a wide range of options.
How will you know that your activities are moving in the right direction? Identify some clear measures of Success that demonstrate your progress towards your goal. These might also be called outputs or milestones.
Once you’ve identified all of these factors, we reconstruct them into a the Easy PEASI program logic model, like the diagram in Figure 2.
Figure 2: Easy PEASI program logic framework
Case Study of Easy PEASI Program Logic: Dietetics Workforce Shortage in a Regional Hospital.
Sacha is the Director of Dietetics in a large regional health service in Australia.
Sacha came to us with the following workforce problem (which was actually a solution first):
“I need to increase my Allied Health Assistant workforce”. She told us. “We have a new chemotherapy day unit at our regional hospital but we don’t have enough dietitians or dietitian assistants to service the new unit”.
We worked through the following steps to help Sacha identify and triage a list of problems that, in the end, allowed her to identify multiple achievable steps that needed to be taken before any workforce intervention would come close to fixing the problem….
1.1 What is the problem you think you want to address?
There is a new chemotherapy day unit and we don’t have enough dietitians to provide a sufficient service to patients.
1.2 Why is it important to address this problem? What is driving you to solve this problem?
- I want to make sure that all clients can be as well as they could possibly be and have access to dietetic input.
- I want to make sure that my staff are not stressed and stretched to provide their services to more and more clients in need.
- I want to make sure my staff are fulfilled in their roles and can maximise the impact they have on their clients.
- I can’t meet my waiting time or throughout KPIs without more staff.
1.3 What is the problem from the Individual (patient/client) and clinician perspective?
[Hint –talk your clients and gather stories of what their problem is and how it affects them. Ideally you would repeat this process with as many people as you can who have the same problem.]
- Client response – I don’t feel well after my treatment, I am losing weight and have very low energy. I don’t know how to help myself.
- I am nauseas and can’t keep a lot of food down after I have had chemo.
- AHP response – Inconsistent or no access to dietetic services whilst receiving chemotherapy
1.4: Consider who else will be affected by this problem (individuals, the organisation and globally)?
- Families of clients
- Staff on the chemotherapy unit
- Dietitian workforce
- The health service
- The community
- Government funders
Be clear about the Impacts you want to achieve with your Easy PEASI Program Logic
2.1 What is the impact you are trying to achieve from the perspective of the individual, the organisation, and globally?
For each stakeholder group, identify the best possible outcomes that could arise in the context of your problem statement. Be realistic here – for instance, a cure for cancer is an unlikely outcome of the problem you are investigating.
Table 1: Identifying impacts at Individual, Organisational and Global level
|Stakeholder||Impact||Best Possible Outcome|
|Client||I have no appetite. I am losing weight. I have really low energy. I feel terrible and sick all the time. Because I feel terrible and sick I can’t enjoy eating with my family. Because I have such low energy, I can’t go out walking or help my family around the house or enjoy the company of my friends. I feel scared because I cannot manage my condition.||Fewer symptoms and able to manage symptoms Feeling empowered to manage their condition at home|
|Families of clients||Feeling helpless to support their family member. Uncertain what food to prepare for their family member.||Better knowledge of how to support the patient. Patient not suffering.|
|Staff on the chemotherapy unit||Unable to fully deliver on their duty of care for clients.||Able to provide the best possible care within their capability. Able to focus on their specific area of practice.|
|Dietitian workforce||Stretched to meet clinical loads Dissatisfaction due to being unable to fully care for clients Feeling unable to take leave due to lack of backfill (burnout) Unable to innovate to increase efficiency due to lack of time Reduced job satisfaction||Adequate workforce supply to meet service volumes and achieve service KPIS. Satisfied staff. Time to reflect on practice and introduce innovation in care.|
|The health service||Challenges to volume and quality targets Increased likelihood of patient readmission Increased pressure on other services Lower job satisfaction resulting in attrition / retention challenges||Excellence performance benchmarks High staff retention – employer of choice Services able to adequately meet patient needs and support patient flow. Able to meet or exceed quality and volume targets.|
|The community||Increased demands on primary care / other community services Increased need for patient support in the community||Less pressure on primary care services|
|The government / funders||Poorer health outcomes of treatment, increased costs of care if readmissions increase||Sustainable health care costs Optimised community health outcomes|
2.2 Form a problem statement
Using the structure below, write a problem statement for each of the stakeholders you have identified above. Always start with your clients.
You can use a formula like this:
[Very specific person/group] NEEDS [very specific verb from client/stakeholder narratives] BECAUSE [insight from client / stakeholder narratives] results in IMPACT.
Patients who attend the chemotherapy day unit for treatment who are at high risk of weight loss and nutritional decline NEED access to nutritional support and advice on the first day of their treatment BECAUSE without good nutrition these patients have insufficient energy and nutritional status IMPACT to benefit fully from their treatment or to participate in activities that relieve the burden of their cancer diagnosis.
Dietetic staff who work on the chemotherapy day unit NEED to be able to better identify and triage high and low risk patients BECAUSE they are at risk of burning out, cannot gain sufficient professional gratification from constantly chasing up referrals and not being able to IMPACT impact those who really need it.
The health service NEEDs chemotherapy patients to not be admitted to hospital for treatment of nutritional decline BECAUSE this is a problem that can be addressed much earlier in a patient’s chemotherapy journey and the resourcing in the hospital could be IMPACT better directed to those who cannot be managed in the community.
Identify the Enablers and Barriers to change
3.1 Consider the individual, organisational and global factors that help or hinder the achievement of the outcomes outlined above?
[Hint – ask this in your interviews with clients / staff / managers]
Consider the barriers and enablers to achieving your desired outcomes from three perspectives:
- Individual: what would enable you personally to achieve the outcomes above? This might include your professional skills, personal attributes, training etc.
- Organisational: What are the organisational and environmental factors needed to achieve the outcomes above? These may be out of your personal control, but need to be present to enable change?
- Global: What are the system and structural issues that are necessary to enable the changes you require? These might include policies, legislation and changes to funding models.
It is important to understand these three perspectives, because it lets you determine where you have the ability to make a difference; to identify the resources you will need to drive changes; and perhaps identify areas that are outside your control, but could be influenced by other, perhaps more senior leaders.
We recognise that it is currently unfashionable to examine “barriers” because of the negative connotations, and that positive psychology is the favoured approach. We suggest that you look at both the barriers and enablers realistically because without an understanding of what needs to change or be stopped it can be difficult to drive effective change. You can also start by identifying the barriers or problems, then restating them as needs or solutions.
Table 2: The IOG Contexts Table
|Perspective||Enabler / Barriers / Considerations|
|Individual||Increased awareness by chemotherapy patients about when they might need to seek help and what they can do to help themselves.
Increased awareness by chemotherapy patients about what dietitians can help them with.
Dietitians want to help everyone.
|Organisational||Need a system to triage who is high and who is low risk so we can funnel resources to those who need it most urgently (and eventually to be able to delegate low risk clients to AHAs)
Increase awareness by other staff (nursing, medical) about what dietitians can do for people who at high risk of nutritional decline.
Develop clear referral system for staff to refer clients to dietitians for input if they identify high risk patients. Include the risk status of clients is on dietetic referral forms.
|Global||Adequate funding to employ more staff (this could also be organisational)
Legislation to enable introduction of changes to roles if needed
Adequate training to support the introduction of new staff if required.
4.1 Consider all possible solutions
By going through the steps above, you will have identified a number of possible solutions already.
We suggest you start with a long and ambitious list of possible solutions. We also strongly suggest that you think outside the box when you are developing your solutions. It is very easy to become institutionalised into fairly narrow ways of thinking. This is your opportunity to really consider some alternative solutions.
4.1 Crazy solution brainstorm
It is easy to only solutions through the lens of what you already know. We strongly encourage you to undertake a rapid ‘crazy’ brainstorm (ideally as part of a team), to identify potential solutions that may not seem immediately obvious.
There are several different approaches you can use for your brainstorming, and numerous online resources available. Explore different options to find the approach that suits you. For instance, a Mash Up session lets you look at possible ideas from outside your industry. In this example, you frame your question using the preface “How might we… [achieve better outcome]”, and consider another way to view the problem. A good comparator industry in health care is often hospitality, because in the hospitality industry the primary focus is on creating a positive experience for the service user (it is in health as well, but that focus can be subsumed to improving health).
Some other ideas we like include brainstorming by considering your problem from different perspectives. In this approach they ask the question “what would Abraham Lincoln do”, but you could consider a range of perspectives that might have more meaning to you – for instance, “what would your mother do?” “what if money was not an issue” “what would a teenager do” “what would [someone whose opinion you really value] do”?
4.2 Prioritise solutions
Go through your list of possible solutions and allocate them using the prioritisation framework below. Those solutions that fall into quadrants one and two are the most likely you will move forward with.
Questions to help prioritise activities
- Does the proposed activity align with existing priorities / needs?
- Does the activity have key stakeholder support at all levels?
- Is there supportive legislation / structures and systems to support the change?
- Is training required?
- Are additional resources required?
We have developed a Workforce Change Checklist which can help you determine priorities and next steps.
4.3 Pick one realistic solution / intervention within your current resources
Review, update and distribute dietetic referral guidelines for chemotherapy day unit and provide education to staff
[Provide input into the incorporation of screening tools into the electronic medical record]
5.1 If you were to implement your solution, what is a realistic and measurable outcome to demonstrate that you have been successful?
Currently we receive 10 new dietetic referrals per week for the chemotherapy day unit. The risk status of clients is not currently rated on these referral forms. A realistic measurable outcome to measure the impact of updating our referral guidelines might be to track the percentage of new referrals received per week that appropriately identify high risk patients.
Develop Your Easy PEASI Program Logic Framework
Cut and paste your problem statement from above … then add your solution and outcome statements.
Very specific person/group] NEEDS [very specific verbs from client/stakeholder narratives] BECAUSE [surprising insight from client / stakeholder narratives]
To address this we will [SOLUTION/INTERVENTION]. This will achieve [OUTCOME/DESIRED IMPACT].
Patients who attend the chemotherapy day unit for treatment who are at high risk of weight loss and nutritional decline NEED access to nutritional support and advice on the first day of their treatment BECAUSE without good nutrition these patients have insufficient energy and nutritional status to benefit fully from their treatment or to participate in activities that relieve the burden of their cancer diagnosis.
[SOLUTION/INTERVENTION]To address this we will review, update and distribute dietetic referral guidelines for chemotherapy day unit and provide education to staff about the referral guidelines. [OUTCOME/DESIRED IMPACT].This will improve the appropriate referral of high risk patients to our dietitians from 0% of all weekly referrals identified as high risk to 10% of all referrals identified as high risk patients within 6 months.
|What is the need for this change / intervention? What is the motivation behind this change / intervention? Consider: MICRO level drivers MESO level drivers MACRO level drivers||What contexts do I need to be aware of that will influence the success of this change / intervention? What do I need to action/address in order for this change / intervention to be successful? Consider: Personal environment Geographic environment Physical environment Financial environment Organisational environment Technical environment Regulatory environment||What mechanisms do I need to consider that will influence the success of this change/intervention? What do I need to action/address in order for this change/intervention to be successful? Consider: Engagement mechanisms Resource mechanisms Project & governance mechanisms||What are the key codifiable elements that will help this project to be successful? Consider : Position Descriptions Competencies Learning Materials Screening Tools Triage tools Referral pathways Care Pathways Role Definitions Processes Procedures/Policies \Systems Business case Scope of practice Delegation pathways||Given my problem, what outcome am I specifically trying to achieve? How will I know if I am successful in achieving my outcomes? Given my context & the mechanisms required for success, is my outcome realistic / achievable?|
The figure below shows the worked Easy PEASI Logic Model for the dietetics case study example in this article.
Getting started and next steps
Your Easy PEASI Program Logic is now the starting point and the guide to help you get started on your workforce change project. You should be able to identify the right people you need to engage with to commence your project and the resources you will need.
There are a number of tools and resources to help you get started on your project. The Workforce Change Checklist is one approach to help you get started.
Other tools and resources that can be of use include structured project management resources.
Download your Easy PEASI Program Logic Worksheet
You can download a copy of our Easy PEASI workbook through the link below that will guide you through the processes we have outlined above.
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