By Serena Agusto-Cox | News & Views

Change can be a scary prospect, and systems change may seem like an overwhelming ask. The Cardiac Rehab Change Package (CRCP), developed by AACVPR and Million Hearts^®, focuses on quality improvements that can ensure patients are not only referred and enrolled in CR, but that they also participate and graduate from these programs to lead healthier and longer lives. Haley Stolp, MPH, Health Scientist at Million Hearts^® at the Division for Heart Disease and Stroke Prevention in the U.S. Centers for Disease Control and Prevention, says systems change is about preparing and building the core foundations needed to improve outcomes.

Myths of Systems Change

When CR staff hear the word “change,” they may think they need to upend an entire program, but Stolp says, “systems change is not about starting over but about taking incremental steps to establish the infrastructure necessary to improve patient outcomes.” Systems change should uphold the goals of better patient outcomes and secondary cardiac-event prevention when modifying processes. “One of the core tenants of the change package is to test changes and engage in the cycle of plan, do, study, and act,” she adds. “Oftentimes changes don’t achieve the goal the first time.” Stolp also advises, “Be patient and work through the process.”

CR staff don’t need huge investments to foster systems change. Often, talented staff hesitate because they don’t want to start a project that they won’t have enough funding to complete. Stolp says that there are several changes CR programs can make at little to no cost, like establishing standardized referral and enrollment policies, offering group orientations, or implementing an open gym model.

Be a Champion

As champions for their patients, staff, physicians, program leads, and others also play a role as champions for systems change, paving the way for modification and removal of any barriers. “The key is to enter into the work with a willingness to consider what may be possible,” says Stolp.

One of the first steps in systems change is to designate a champion who can navigate managerial relationships, leverage existing partnerships, and engage other stakeholders in the quality improvement process as needed. “Champions can be anyone that shares the passion for CR. Sometimes the champion stands up and sees the need for improvement. Sometimes, it’s a CR professional or an exercise physiologist that sees an opportunity to make a change,” says Stolp. In some cases, a cardiologist who refers the most patients to CR could become a CR champion.

CR champions can foster conversations and influence others to identify areas for improvement and potential solutions. Jennifer Newman, RN, MSN, of Lake Regional Health System, outlines how she went about finding and leveraging a CR champion to communicate the value of CR and the opportunity for improvement to hospital administrators and department leads in her CRCP Made Easy video, Communicating the Value of Cardiac Rehabilitation to Your Hospital or Health System.

Gather Data

With a concrete goal in mind, CR program data can be helpful in exploring where adjustments may be needed to improve referrals, enrollment, adherence, and/or completion. There are resources in the CRCP to help programs access and use data for this purpose. Recently, the Michigan Cardiac Rehab Network, Baystate Health, and the Minnesota Department of Health have demonstrated the power of data in making the case for systems change.

Additionally, conversations with colleagues and partners, as well as inpatient CR liaisons and care coordinators, patients themselves, and referring physicians provide additional insights. “In some cases, reaching out to patients who declined CR program care could be a way to uncover process gaps,” Stolp advises. Informal interviews, focus groups, and surveys are other ways to gather data about CR programs and where there are opportunities for improvement.

“Systems change is about laying the foundation,” says Stolp. “Keep in mind that goals may shift under the leadership of a new champion. Goals should be flexible based on where hospitals are focusing their own efforts.” She adds that SMARTIE goals — goals that are strategic, measurable, achievable, realistic, time-bound, inclusive, and equitable — are those that can be most helpful for systems change. Teams should feel comfortable with how they arrived at their objectives, most likely from analyzing CR program data and discussions with experts regarding quality improvement opportunities.

Act Now, Don’t Wait

The time is now for embracing quality improvement in CR, especially as the opportunity to provide the same CR services remotely becomes more readily available. Educating physicians and cardiologists on the value of CR to increase referrals from acute care is a proven catalyst for change. CR champions can play this role by sharing patient testimonials and positive patient outcomes and quality improvement initiatives.

“Don’t be afraid to ask for more,” Stolp urges. “Champions may not always be comfortable asking for more from senior managers and administrators, but with data and testimonials supporting the value of CR, champions have the foundation to seek out additional resources.” Persistence is key. She explains, “You might get pushback. You may not even be put on the schedule to have a conversation. But you can always follow up later. Eventually, a ‘no’ can turn into a ‘maybe’ or a ‘yes.’”

Change is incremental, and the CRCP provides a menu of process improvements that CR Champions may consider to meet their goals. According to Stolp, “Systems change is a ramp on the freeway of quality improvement.” Start small, keep it simple, stay on the path and, if needed, begin the process again. “You could improve or save more lives, and that’s what is most important,” says Stolp.

This is the final article in a four-part series on the Million Hearts^® /AACVPR Cardiac Rehab Change Package. Read the three previous articles: The Three S’s of Cardiac Rehab Referrals; Roadmap to Recovery: Boosting CR Enrollment With Education, Communication, and Collaborative Participation; and Improve Cardiac Rehabilitation Adherence With Creative Solutions.