In her new book, Better Now, Dr. Danielle Martin — a family doctor and vice-president of medical affairs and health system solutions at Women’s College Hospital — puts forward six ideas to improve health care in Canada. In this excerpt from her book, she discusses how implementing major innovations to the health care system requires both system-level leadership and local champions:
Bernadette is a friend, someone who’s known my parents since before I was born. We’ve always called her our “aunt,” even though we’re not related by blood. A number of years ago she was admitted to a Canadian hospital for surgery intended to give her a new hip and to even out the length of her legs. One of them was significantly shorter than the other, which had caused the terrible arthritis she now had in both hips. When she woke up from the operation, she did have a new hip — but she discovered that the discrepancy between her leg lengths had doubled. The surgeons had shortened the wrong side.
At first they insisted she was wrong. She was given a protracted explanation about how her muscles had become tight over many years and that it would take a long time for them to relax (I think they were hoping she would relax, too). But eventually the team took responsibility for the error and apologized. She now wears very expensive custom shoes with a platform in one of them to make up for the now three-centimetre difference in her leg lengths.
Wrong-sided surgery happens. This is a critical incident in a hospital, one of those things that everyone agrees should never happen, and it’s on the list of personal nightmares for every surgeon and every patient. It ranks up there with injuring an organ or a blood vessel, or causing a patient a significant infection. In a way it’s worse, because those things are known complications whereas wrong-sided surgery is a totally avoidable error.
Imagine that in a hospital near you, someone learns that there’s a recurring problem: too many people like Bernadette are experiencing avoidable complications of surgery. Maybe a report comes out showing high variations in the frequency of surgical errors, and your local team ranks poorly. Or perhaps a patient like Bernadette goes to the local press.
The surgical team in your hospital calls a meeting, and someone reviews the literature to see what’s been shown to work in other settings to make care safer. They decide to implement an approach that has been successful in other places. The team measures the results associated with this change, tracking not just the frequency of surgical errors but also complications like bleeding and infection, rates of death, and patient satisfaction. Over time, they refine the model, and they watch their outcomes improve.
This is how we’ve ended up with pockets of excellent care across the country. Teams of motivated people come together to redesign care processes because they want to do better. They start with data and a plan, try something different, measure and analyze the impact of those changes, and then continue to modify and improve. They make it a point to sustain the changes. This approach works to improve the quality of patient care.
The surgical safety checklist is a good example of a solution that’s been implemented to avoid the kind of error that Bernadette experienced. The concept is simple: the surgical team follows a written checklist to make sure that each and every surgery is done according to plan.
The World Health Organization’s surgical safety checklist includes a review at three critical points: before putting the patient to sleep, prior to surgical incision, and again before leaving the operating room. Team members verify — by speaking out loud — a number of key items. They confirm the patient’s identity and the surgical procedure to be done (including which side); introduce the members of the surgical team by their name and role; and confirm that medications such as antibiotics have been given when needed. It seems so basic. “This is Bernadette Hayes; she’s here today for a hip replacement on the right side; she has no allergies; she’s received one gram of Ancef IV [Ancef is an antibiotic sometimes used to reduce the risk of infections that can occur when people have surgery].” Complete the list, and the risk of that person dying decreases by 50 per cent — or so the initial studies suggested.
If those large studies were accurate, the next logical step should be to implement surgical safety checklists across the whole health care system, or at least those parts of the system where patients are most likely to benefit. This is where we repeatedly fall down in Canadian health care. Very few health care improvement projects get implemented in a sustainable way, and spread beyond that one area of the organization.
Whose job is it to move a project like the surgical safety checklist beyond the original team? Well, no one in our health care system holds responsibility for this yet. Incentive is lacking: if I can see patients in my office on the same day they call, or my hospital can reduce the number of people who have a bad outcome in surgery, why would I worry about the wait time of the family doctor down the street or the complications in someone else’s hospital? This is why the Institute for Healthcare Improvement in the U.S, lists among its “seven spreadly sins” the idea of requiring the person or team who drove the pilot to be responsible for system-wide spread. Teams who made the local change are satisfied, and often lack the skills and the power to be responsible for the spread and scale of the innovation.
For this reason, large-scale change has to be implemented by an organization with teeth, and with a view of the whole system. That can mean the Ministry of Health, the local health authority, the provincial Hospital Association, the College of Physicians and Surgeons, the provincial health quality council, or any number of other organizations.
In July 2010, the Ontario Ministry of Health and Long-Term Care implemented a surgical safety checklist across the entire province. It mandated that hospitals publicly report their use of the checklist. Use of surgical safety checklists then became a national requirement in 2011 for any hospital wanting to receive the stamp of approval from Accreditation Canada, an organization that assesses quality in Canadian health care organizations. In other words, the full power of the scale apparatus was used to implement the tool.
Unfortunately, it didn’t work.
At least not in the way it was expected to work. A group of researchers measured whether the implementation of the surgical safety checklist had the desired effect in Ontario. They studied 101 hospitals that performed over a hundred thousand procedures in the three-month period before adoption of a surgical safety checklist and another hundred thousand after its implementation.
None of the hospitals saw a statistically significant reduction in deaths after initiating the use of surgical checklists. There was also no statistical change in post-operative complications. No significant benefit of the use of checklists was found.
The unexpected finding that surgical safety checklists did not make a big difference in Ontario reinforces the importance of rigorously evaluating changes. But of course, beyond knowing that it didn’t work, we all wanted to understand why.
When a pilot project succeeds in one environment, it’s possible that it isn’t the innovation itself but rather the special resources put in place to nurture that innovation that make the difference. Maybe when surgical safety checklists were being studied as a research intervention, the fact that teams were participating in research made them pay closer attention to their actions, causing the rate of bad outcomes to decrease.
There’s another possibility. As Health Quality Ontario CEO Dr. Joshua Tepper and others have pointed out, the surgical safety checklist was implemented as a classic scale initiative: overnight, every organization was required to do it. The techniques of spread weren’t utilized: engaging physicians and teams, building the case for change, rewarding participation, supporting culture change. If the health professionals didn’t fully engage, maybe the checklist became just another thing people did by rote. They did it, but they hadn’t done the hard work of adapting it to work in their local environments. They didn’t “own” the checklist because the scale techniques weren’t accompanied by techniques of spread.
The surgical safety checklist is a rich example of how complex it can be to move an innovation from the pilot or the research stage to a system-wide solution. Probably nearly every major change in health care requires the use of tools of both spread and scale in order to achieve its full potential. This means we need local champions, local adaptation, local impetus for change, and a push and/or support from the centre to ensure that money, rules, incentives, and mandates all point in the same direction.
Excerpted from Better Now by Danielle Martin. Copyright © 2017 Danielle Martin. Published by Penguin Canada, a division of Penguin Random House Canada Limited. Reproduced by arrangement with the Publisher. All rights reserved.