Improving Patient Care

The Implementation of Change in Health Care

Michel Wensing, Richard Grol, Jeremy M. Grimshaw, Michel Wensing, Richard Grol, Jeremy Grimshaw

• Publisher: Wiley-Blackwell
• Year: 2020
• ISBN:
  9781119488606
• Edition: 3
• Topic: Medicine
• Subtopic: Clinical Medicine

Strategies for successfully updating and improving health care organizations of all kinds

Health care is always evolving and improving. However, the rapid speed of medical advancement can make the adoption of new technologies and practices a challenging process – particularly in large organizations and complex networks. Any projected impact upon quality and outcomes of care must be carefully evaluated so that changes may be implemented in the most efficacious and efficient manner possible.

Improving Patient Care equips professionals and policymakers with the knowledge required to successfully optimize health care practice. By integrating scientific evidence and practical experience, the text presents a cohesive and proven model for practice change and innovation, complete with analysis of innovation, target group and setting; selection and application of strategies; and evaluation of process, outcomes and costs. This new third edition also includes:

• Newly written chapters on clinical performance feedback, patient engagement, patient safety, evaluation designs, and methods for process evaluation
• Increased emphasis on the role of contextual influences in implementation and improvement
• New research examples from across the world and updated scientific literature throughout

Designed to help promote safer and more efficient, patient-centered care and better outcomes, Improving Patient Care is an essential resource for healthcare providers, quality assessors, and students of health services research, health management, and health policy.

Part I
Principles of the Implementation of Change

1
Implementation of Change in Healthcare: A Complex Problem

Richard Grol^1,2 and Michel Wensing^3,4,5

¹ Radboud University, Nijmegen, The Netherlands

² Maastricht University, Maastricht, The Netherlands

³ Faculty of Medicine, University of Heidelberg, Heidelberg, Germany

⁴ Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany

⁵ Department IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands

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SUMMARY

• Substantial numbers of patients do not receive high‐quality care: care that is accessible, safe, effective, patient centered, well‐coordinated, and efficient.
• Changes in practice are often required to improve patient care and prevention. It may also demand changes in healthcare organizations and healthcare systems to facilitate practice changes.
• Different approaches to the implementation of change in patient care can be observed, each based on different assumptions and theories of human and organizational behavior.
• A combination of structured guidance (“top‐down”) and participation of target populations and stakeholders (“bottom‐up”) is often needed to achieve real and sustainable changes in practice.
• Different innovations and proposals for change demand different implementation strategies.

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1.1 Introduction

The number of new insights, procedures, programs, and technologies that have become available as a result of careful development and/or scientific research is enormous. For instance, the number of clinical trials added to Medline, a large database of journals in the field of medicine, is gigantic. Subsets of this database – systematic literature analyses of clinical research studies or that portion of the literature capturing clinical guidelines – are growing at significant rates. For many problems and questions that emerge in healthcare practice and policy, a search in the research literature would identify many relevant publications.

As a consequence, knowledge about optimal patient care quickly becomes obsolete, affected by both scientific and social developments. An example of quality problems in modern times is presented in Box 1.1. A great deal of knowledge that one absorbs over the years of training to become a doctor, nurse, or paramedic is obsolete by the time training is completed. This is not a new observation (see Box 1.2). It reflects the importance of health professionals' ability to scan, absorb, and use the medical literature, described in subsequent chapters (Candy 2000). The legitimate concerns about the validity and relevance of published research and technologies (leading to “research waste”) imply a need for careful selection of items for implementation into practice.

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Box 1.1 Unsafe Cardiac Surgery: The Radboud Cardiac Surgery Case

In September 2005, details about the mortality rates at the Cardiac Surgery department of the Radboud University Nijmegen Medical Center got into the newspapers. The post‐surgery mortality rate in 2004 was 6.7%, compared to 2.7% in other cardiac centers in the Netherlands. This situation initiated a process which led to major improvements in clinical practice within a few years. The Board of Directors initially denied the problem, stating that the high mortality rates were caused by the patient case mix. However, after the situation had been intensively analyzed, by both an internal committee and an external committee (appointed by the Health Care Inspectorate), the conclusion was reached that in fact these high mortality rates reflected serious problems. The high mortality and complication rates could not be attributed to more seriously ill patients (in fact, the situation was quite the opposite). Instead it was discovered that staff did not work according to prevailing clinical research evidence and protocols; there was little or no cooperation between the disciplines involved (for example, everyone used his/her own patient record); departments did not collaborate with each other; there were conflicts among cardiac surgeons; the management of the department had lost control of the situation; and little effort was invested in quality improvement. The Board of Directors of the hospital was aware of the problem, but left it to the physicians to solve it. For a long time, the national Inspectorate relied on the department's explanations.

These findings led the Inspectorate to close the department. The Board of Directors was dismissed. The management of the medical staff and the head of the department resigned. Meanwhile, many patients looked for treatment elsewhere, resulting in many empty beds. This initiated a reorganization of the Radboud University Nijmegen Medical Center in general and the cardiac surgery department in particular. The reorganization led to operations being restarted after six months. A year later, the department's mortality and complication rates were far below the national average (around 1%). The question is: What was the real cause of this change? Several hypotheses can be formulated:

• Transparency: publicizing the data and validating them provided both the public at large and the medical center with an insight into the fact that a real problem did exist. Good objective data on performance can contribute to the sense of urgency that something really needs to be done. This information prompted the Inspectorate as well as the patients to take measures.
• National Inspectorate: the decision of the Inspectorate to close the center and to demand radical changes put the organization under great pressure to implement improvements in a quick and thorough way.
• Leadership: the new management of the department, the medical staff, and the medical center made high quality and patient safety into an absolute priority and supervised the implementation of many changes to achieve this, including, among other actions, a revised and more intensive internal audit method.
• Organization of care processes: the surgical process was redesigned with the help of all disciplines involved, daily consultation on the patients as well as a joint medical file were introduced, and cooperation with the aim of a safer surgical process became a core objective.
• Competency and motivation of professionals: less than competent or dysfunctional surge...