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The Challenge of Change

I have been thinking about the surgical checklist study published in the New England Journal of Medicine a couple of weeks ago by two Ontario physicians.

It got me thinking about the challenge of change in the health care system and how HQO fits into the picture. One of HQO’s key roles is to support change that will lead to a higher quality health system, and this study highlighted the complexity of this task.

The study evaluated the outcome of the Ontario government’s mandating of the use of surgical checklists across Ontario’s hospitals (HQO’s Quality Compass talks about checklists here). The checklist is to be used by the operating room team before starting surgery to ensure the best possible outcomes. There was strong evidence from around the world that use of the checklist leads to better outcomes including fewer deaths.

The requirement to use the checklist was broadly communicated and hospitals reported a very high rate of compliance with the checklist. However, contrary to previous reports, in this study the introduction of checklists in Ontario does not appear to have led to fewer deaths or post-operative complications.

So what happened? There has been significant discussion about why improvement was not seen. Dr. Atul Gawande, who is an international expert in this area noted in an online post that there may have been too few operations included in the study, the cases studied not complex enough and the time frame from implementation to evaluation too short (three months).

Both Dr. Gawande and Dr. Lucian Leape (in an accompanying New England Journal of Medicine editorial) highlight that the failure to achieve results may rest with the complexity of creating change in health care – even in a defined area like the operating room. They note the need to have good data, to ensure the intervention is being used, to train teams, engage leaders and communicate the need for the change.

Reading this, I was struck by the relevance to HQO’s mandate – data analysis, evidence uptake, knowledge translation and engaging with the system to drive improvement are all tasks HQO has been charged with doing. Understanding and planning for the complexity of carrying these tasks out in a way that supports actual change in the system is going to have to be at the forefront of our thinking as we undertake the development of our organizational Strategic Plan in the coming months. We – and the health system as a whole – have to keep reminding ourselves that, as renowned quality improvement champion Don Berwick has said: “All improvement requires change, although not all changes are improvements.”


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