Implementation success requires frontline staff participation during change development.
Not all proven, evidence-based healthcare practices are successfully implemented and sustained. In the 150 years since Ignaz Semmelweis was committed to an asylum, in part for suggesting to his colleagues that they could reduce maternal mortality by following midwives’ practice of washing hands, hospitals have posted sign after sign reminding staff about hand hygiene. However, the Centers for Disease Control and Prevention estimates that adherence with this basic safety practice is less than 50%. Many hospitals have successfully implemented checklists to drive central line-associated bloodstream infection rates to zero, but other hospitals trying to implement this same practice continue to have substantial infection rates. More complex processes, such as medicine reconciliation, frequently fail to improve despite dissemination of tested systems.
What makes implementing and sustaining changes known to improve care so hard to accomplish? The literature on implementation identifies many contributing factors that undermine success, including external payment or regulation incentives that discourage good practice, lack of institutional commitment, a culture that doesn’t value or prioritize patient safety or care quality, perceived cost, and poor leadership.
A core problem not frequently noted is that evidence-based practices are developed and tested and their success demonstrated as stand-alone processes by champions of improving that one dimension of care. They’re then promoted for adoption “because they work.” Implementation is an afterthought, or perhaps more optimistically, a later developmental stage.
In the evaluation of Robert Wood Johnson’s Transforming Care at the Bedside initiative, we asked some of the hospitals that participated which proven innovations had been sustained in practice and which had not. Many had not, and the common explanation was that the staff couldn’t fit them into the unit’s regular workflow.
That experience highlights two issues for successful implementation. First, implementation can’t be a second stage or an afterthought. How a practice will be incorporated into workflow must be considered from the start, and it should be part of the design and testing of all evidence-based practices.
Second, to successfully discover how practices can be implemented within the workflow, frontline staff must be involved from the beginning. Healthcare and nursing care are complex. Patricia Ebright, trying to describe the complexity of nurses’ work, spoke of each patient having a set of activities—some procedural and some analytic and conceptual—that need to be accomplished during a shift. Nurses manage sets for multiple patients and these activities change dynamically as new orders come in or a patient’s condition changes.
Without an understanding of this complex workflow, new practices won’t be designed sustainably. No one understands the workflow and environment in the way frontline staff do. They can’t be viewed as the recipients of the wisdom of the practice developers. Rather, they must actively participate in shaping improvements.
Without the involvement and commitment of frontline staff, implementation of “proven” evidence-based practices will routinely fail. Leadership needs to truly support engagement of these staff in making and sustaining change by providing time and resources. With this support, frontline staff can take on the challenge of improving the work as part of the work.
Jack Needleman is a member of the American Nurse Journal editorial advisory board. He’s Fred W. and Pamela K. Wasserman Professor and chair of the department of health policy and management at the UCLA Fielding School of Public Health in Los Angeles, California.