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Can Doctors change? Lessons to consider when implementing enhanced recovery pathways in orthopaedics

2010 March 24
by webmaster

Managing change is difficult in all walks of life, and nowhere more so than the National Health Service (NHS) within the United Kingdom. Introducing different ways of working is challenging for a variety of reasons, but the key to sustained behavioural change is clinical engagement. This is well recognised and difficult to achieve but there may be ways to help stack the odds in your favour.

One area where problems can occur is in the gap between knowing and doing. Whilst the argument and case for change may make perfect sense, and you have full clinical sign up to making it happen, if when the clinicians get back to the clinic the procedures don’t support this change, and there is no one managing or co-coordinating the change, it won’t be long before everyone has reverted to how it has always been.

A simple example of this can be found in an article published recently in The Royal Collage of Surgeons of England Bulletin (Ann R Coll Surg Engl 2010; 92:86-98). The paper examined the content and structure of orthopaedic clinic letters. Written guidelines and the circulation of best practice failed to improve both the structure and content of letters. It was concluded by the authors that the way to embed change would be to utilise a computerised template that would ensure the recording of important data and appropriate structure.

I am not so sure that this is the right conclusion on why the change didn’t work. It is easy for the lack of technology to be cited as the problem but this was more likely to be a case of how change was implemented rather than the need for an extra and more complicated computerised step in the process.

Over the years I have seen many IT innovations designed to improve practice and efficiency, but medical staff has taken few up universally. Computerised templates are often an additional step, over complicated, and laborious. Doctors’ ignore them.  In my own hospital online ordering of MRI scans was made compulsory last year.  The clinicians tried, found it slow, and full of glitches so most clinicians in the department do not use the system. An improvement? I don’t think so.

So how do you implement change successfully if additional technology is not the answer? In my experience it is all about how the change is implemented. We have seen this in our own Rapid Improvement projects and Enhanced Recovery programmes, but others also understand it.  Last night I was reading Atul Gawande’s book “The Checklist Manifesto”. He is the surgeon who produced a 90 second checklist to be used prior to surgery that has reduced deaths and complications by a third in hospitals around the world that use it.

He describes the Keystone Initiative for successful implementation of change. Appoint a Facilitator in the unit. In our example above looking at clinic letters, this could be a nurse working in outpatients. She is there to encourage, educate and collect data.

Regular meetings between the nurse, head of department, lead clinician and an executive of boardroom level are set up. The executive (only needed for major change initiatives) is there as there are some problems that only they can solve. For example, agreeing to one off expenditure necessary to make the change happen.

Using this methodology of facilitating change, new programmes can be rolled out in weeks with 100% compliance.  Then you can design your computer template.

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