SURGICAL PERSPECTIVE
Understanding Why Quality Initiatives Succeed or Fail A Sociotechnical Systems Perspective Douglas A. Wiegmann, PhD
Efforts to implement quality improvements in surgery are notoriously problematic.1,2 One needs to look no farther than recent attempts to implement checklists, team training, and surgical briefings. These interventions have been empirically shown to improve team communication and performance.3,4 Yet numerous barriers to implementation have limited their broad adoption and use. Apparently, knowing the remedy (intervention) does not translate into knowing how to administer (implement) it.5 Or in surgical terms, knowing ‘‘what’’ procedure needs to be performed does not necessarily mean that one knows ‘‘how’’ to perform it. Surgeons serve a vital leadership role in driving quality and patient safety initiatives in the operating room. Achieving success requires both an in-depth understanding of the intervention and the complex dynamics of the elements involved in the implementation process. To aid in this endeavor, the present article describes a Model for Understanding System Transitions Associated with the Implementation of New Goals (MUSTAING). The model highlights important variables associated with implementation success. It also provides a tool for diagnosing why certain interventions may not have worked as intended so that improvements in the implementation process can be made. Finally, the model offers a general framework for guiding future implementation or ‘‘how to’’ research.
(Ann Surg 2016;263:9–11)
THE MUSTAING FRAMEWORK
M
USTAING is a model of organizational change that utilizes a sociotechnical systems approach. This approach views organizational activities as an emergent property of the dynamic interactions among multiple variables including people, tasks, technology, environment, and workplace factors.6 According to MUSTAING, organizational change involves a series of transitions across specific phases of development.7 These phases include Contemplation (considering the change), Preparation (planning the change), Transformation (making the change), Maturation (stabilizing the change), and Acculturation (sustaining the change). The extent to which an organization effectively negotiates these phases and transitions ultimately influences the impact of the intervention. Negotiating change is inherently challenging because different phases and transitions involve distinct activities that are impacted by unique sociotechnical factors. Differentiating these challenges across transitions and phases is critical to the selection of appropriate implementation strategies. From the Department of Industrial and Systems Engineering, Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin–Madison, Madison, WI. Disclosure: The author declares no conflicts of interest. Reprints: Douglas A. Wiegmann, PhD, Department of Industrial and Systems Engineering, University of Wisconsin–Madison, 3214 Mechanical Engineering Bldg, 1513 University Ave, Madison, WI 53706. E-mail: dawiegmann@ wisc.edu. Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/14/26105-0821 DOI: 10.1097/SLA.0000000000001333
Annals of Surgery Volume 263, Number 1, January 2016
As illustrated in Figure 1, organizations generally reside in a mundane, conventional state until there is a need or inspiration to change. Within health care, inspiration comes from many sources including the dissemination of research and guidelines demonstrated to improve care. Whatever the source, however, this impetus to change causes an organization to contemplate the adequacy of its conventional state. During the contemplation phase, a series of activities occur, including initial speculations about change (rumination), debates about the need for change (deliberation), and introspection on the implications of change (incubation). Several iterations of this process may occur before a final disposition is reached (resolution). Sometimes, resolution occurs very decisively whereas at other times, it may be rather vague or indecisive. A key factor that influences contemplation activities is an organization’s readiness for change.8 Readiness is characterized by a general openness to change, a positive belief in the benefits of change, and confidence in the organization’s ability to accomplish change. In contrast, barriers to readiness include a resistance to change, a cynical attitude toward change, and a lack of faith in the organization’s ability to change. Resolution of this tension between facilitators and barriers determines whether an organization experiences apprehension and retreats to its conventional state or continues to move forward. If an organization decides to press onward without resolution, perhaps because the change is mandated by an outside accrediting body, it places itself at a disadvantage and chances of success are diminished.8 Consequently, if implementation processes subsequently fail, one should examine whether issues associated with the contemplation phase were adequately resolved. The path forward from the contemplation phase involves preparation. Numerous activities occur during this process. Leaders need to be identified, teams need to be assembled, timelines need to be established, and goals need to be set. The intervention must also be carefully adapted to meld with the sociotechnical system factors in the organization. Such factors include the physical environment, tasks and workflow, tools and technology, and team dynamics that exist in the workplace. Other factors to be considered are the availability of organizational resources, including monetary and technical support, required to complete the project. Involvement of major stakeholders during the planning process is a key facilitator of success.1 Unfortunately, a major barrier is the time commitment required of all those involved. Within surgery, key individuals often include surgeons, anesthesiologists, nurses, and technicians. For these individuals, involvement in quality improvement activities is typically voluntary and often viewed by their organizations as a ‘‘collateral duty’’ that must not conflict with primary clinical responsibilities. These individuals also tend to have minimal training on how to use a sociotechnical systems approach to improve quality. Consequently, the process of planning an intervention (eg, surgical briefings or checklists) typically banks heavily on a surgical team’s adaptability to ‘‘fit one more thing’’ into their already hectic routine, rather than integrating the intervention into the natural workflow, team functions, technology systems, and www.annalsofsurgery.com | 9
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery Volume 263, Number 1, January 2016
Wiegmann
FIGURE 1. Model for Understanding System Transitions Associated with the Implementation of New Goals (MUSTAING). incentive structures supporting these team members. Whereas the latter is much more complicated, a more effective and sustainable result will emerge. Hence, if an intervention ultimately fails because of an apparent lack of commitment or ‘‘shortcuts’’ taken during the preparation process, barriers associated with organizational support, workload, and training of those involved in the planning process should be examined. Proper planning helps an organization transition from the contemplation to the transformation phase. Transformation is marked by the ‘‘rolling out’’ of an intervention (initiation). At the start, initiation may be limited in scope to identify unanticipated problems before broader implementation (eg, having a small number of surgical teams pilot a checklist). Accordingly, clear methods are needed for assessing the impact of the intervention on work processes and patient care (evaluation). Based on feedback and evaluation, the planned intervention may need to be further refined or redesigned to accommodate problems that have been discovered (adaptation). This process of initiation, evaluation, and adaptation is then repeated until satisfactory integration of the intervention into the existing work system can be obtained (resolution). However, if this process becomes too protracted or laborious, resolution may never occur. In such cases, a process of dissolution ensues that leads back to the contemplation phase, where the organization again ponders whether change is really worthwhile. Several system elements intrinsic to the transformation phase can affect its outcome.1,9 Frequently, these elements manifest as challenges (barriers) to be negotiated rather than assets (facilitators) to be leveraged. Some elements are cultural in nature and create a resistance to the intervention rather than a spirit of innovation that embraces change. Others are more political and territorial. These can produce animosity, conflict, power struggles, and opposition, rather than opportunities for building new relationships that facilitate change. Although these system elements should be addressed during the planning process, some can be difficult to proactively identify because they lie dormant until the conditions of change reveal their presence. If left unresolved, progress is severely hindered. Consequently, if the uptake of an intervention seems sluggish, one should explore whether these challenges to change have been successfully negotiated. 10 | www.annalsofsurgery.com
If transformation continues, a process of maturation begins. Maturation occurs as people in the organization no longer view the intervention as an intrusion. Rather, they accept the intervention as standard practice that reflects upon their professionalism and values. Adoption of the intervention also becomes part of peer expectations and normative activity within an organization. Unfortunately, arrested development can occur that stifles maturation and leads to regression. Factors such as turnover of key personnel responsible for championing the intervention, conflicts with competing organizational initiatives, and absence of incentive systems for adhering to the intervention are all potential barriers that need to be overcome if transformation is to reach acculturation. During the acculturation phase, an intervention loses its identify. It is no longer viewed as ‘‘new’’ or even an ‘‘intervention.’’ A classic example dates back to the early 20th century when research using video recordings in the operating room revealed considerable inefficiencies in instrument handling by surgeons that could be easily remedied by the use of a surgical ‘‘caddy.’’10 Over time, and through the informal application of the implementation principles discussed herein, surgical assistants were successfully integrated into the surgical team. Today, many surgeons would likely prefer to postpone a surgery where possible if a surgical assistant were unavailable rather than operate without one. Clearly, acculturation of the ‘‘intervention’’ has occurred and a new conventional state has been established.
CONCLUSIONS Many quality improvement interventions fail because of breakdowns in the implementation process. Surgeons play key leadership roles in driving quality initiatives in their respective operating rooms and organizations. Hence, they need to be aware of the factors that contribute to implementation success or failure. MUSTAING provides surgeons with a framework for understanding these factors and serving as effective innovators and leaders during the implementation process. Finally, not all implementation problems currently have solutions. MUSTAING provides a framework for guiding future research to identify strategies for facilitating implementation success in surgery and other health care domains. ß
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery Volume 263, Number 1, January 2016
REFERENCES 1. Dixon-Woods M, McNicol S, Martin G. Ten challenges in improving quality in healthcare: lessons from the Health Foundation’s programme evaluations and relevant literature. BMJ Qual Saf. 2012;21:876–884. 2. McCulloch P, Rathbone J, Catchpole K. Interventions to improve teamwork and communications among healthcare staff. Br J Surg. 2011;98:469–479. 3. Henrickson SE, Wadhera RK, Elbardissi AW, et al. Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. J Am Coll Surg. 2009;208:1115–1123. 4. Catchpole K, Ley E, Wiegmann D, et al. A human factors subsystem approach to trauma care. JAMA Surg. 2014;149:962–968. 5. Sundt TM. Interventions to improve surgical safety: the ‘‘how’’ is as important as the ‘‘what.’’ Ann Surg. 2011;253:855–856.
ß
2015 Wolters Kluwer Health, Inc. All rights reserved.
Implementation Research
6. Wiegmann DA, Eggman AA, Elbardissi AW, et al. Improving cardiac surgical care: a work systems approach. Appl Ergon. 2010;41:701–712. 7. Prochaska JM, Prochaska JO, Levesque DA. A transtheoretical approach to changing organizations. Adm Policy Ment Health. 2001;28:247–261. 8. Weiner BJ, Amick H, Lee SY. Conceptualization and measurement of organizational readiness for change: a review of the literature in health services research and other fields. Med Care Res Rev. 2008;65:379– 436. 9. Powell AE, Davies HTO, Bannister J, et al. Challenge of improving postoperative pain management: case studies of three acute pain services in the UK National Health Service. Br J Anaesth. 2009;102:824–831. 10. Baumgart A, Neuhauser D. Frank and Lilian Gilbreth: scientific management in the operating room. Qual Saf Health Care. 2009;18:413–415.
www.annalsofsurgery.com | 11
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Understanding Why Quality Initiatives Succeed or Fail A Sociotechnical Systems Perspective Douglas A. Wiegmann, PhD
Efforts to implement quality improvements in surgery are notoriously problematic.1,2 One needs to look no farther than recent attempts to implement checklists, team training, and surgical briefings. These interventions have been empirically shown to improve team communication and performance.3,4 Yet numerous barriers to implementation have limited their broad adoption and use. Apparently, knowing the remedy (intervention) does not translate into knowing how to administer (implement) it.5 Or in surgical terms, knowing ‘‘what’’ procedure needs to be performed does not necessarily mean that one knows ‘‘how’’ to perform it. Surgeons serve a vital leadership role in driving quality and patient safety initiatives in the operating room. Achieving success requires both an in-depth understanding of the intervention and the complex dynamics of the elements involved in the implementation process. To aid in this endeavor, the present article describes a Model for Understanding System Transitions Associated with the Implementation of New Goals (MUSTAING). The model highlights important variables associated with implementation success. It also provides a tool for diagnosing why certain interventions may not have worked as intended so that improvements in the implementation process can be made. Finally, the model offers a general framework for guiding future implementation or ‘‘how to’’ research.
(Ann Surg 2016;263:9–11)
THE MUSTAING FRAMEWORK
M
USTAING is a model of organizational change that utilizes a sociotechnical systems approach. This approach views organizational activities as an emergent property of the dynamic interactions among multiple variables including people, tasks, technology, environment, and workplace factors.6 According to MUSTAING, organizational change involves a series of transitions across specific phases of development.7 These phases include Contemplation (considering the change), Preparation (planning the change), Transformation (making the change), Maturation (stabilizing the change), and Acculturation (sustaining the change). The extent to which an organization effectively negotiates these phases and transitions ultimately influences the impact of the intervention. Negotiating change is inherently challenging because different phases and transitions involve distinct activities that are impacted by unique sociotechnical factors. Differentiating these challenges across transitions and phases is critical to the selection of appropriate implementation strategies. From the Department of Industrial and Systems Engineering, Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin–Madison, Madison, WI. Disclosure: The author declares no conflicts of interest. Reprints: Douglas A. Wiegmann, PhD, Department of Industrial and Systems Engineering, University of Wisconsin–Madison, 3214 Mechanical Engineering Bldg, 1513 University Ave, Madison, WI 53706. E-mail: dawiegmann@ wisc.edu. Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/14/26105-0821 DOI: 10.1097/SLA.0000000000001333
Annals of Surgery Volume 263, Number 1, January 2016
As illustrated in Figure 1, organizations generally reside in a mundane, conventional state until there is a need or inspiration to change. Within health care, inspiration comes from many sources including the dissemination of research and guidelines demonstrated to improve care. Whatever the source, however, this impetus to change causes an organization to contemplate the adequacy of its conventional state. During the contemplation phase, a series of activities occur, including initial speculations about change (rumination), debates about the need for change (deliberation), and introspection on the implications of change (incubation). Several iterations of this process may occur before a final disposition is reached (resolution). Sometimes, resolution occurs very decisively whereas at other times, it may be rather vague or indecisive. A key factor that influences contemplation activities is an organization’s readiness for change.8 Readiness is characterized by a general openness to change, a positive belief in the benefits of change, and confidence in the organization’s ability to accomplish change. In contrast, barriers to readiness include a resistance to change, a cynical attitude toward change, and a lack of faith in the organization’s ability to change. Resolution of this tension between facilitators and barriers determines whether an organization experiences apprehension and retreats to its conventional state or continues to move forward. If an organization decides to press onward without resolution, perhaps because the change is mandated by an outside accrediting body, it places itself at a disadvantage and chances of success are diminished.8 Consequently, if implementation processes subsequently fail, one should examine whether issues associated with the contemplation phase were adequately resolved. The path forward from the contemplation phase involves preparation. Numerous activities occur during this process. Leaders need to be identified, teams need to be assembled, timelines need to be established, and goals need to be set. The intervention must also be carefully adapted to meld with the sociotechnical system factors in the organization. Such factors include the physical environment, tasks and workflow, tools and technology, and team dynamics that exist in the workplace. Other factors to be considered are the availability of organizational resources, including monetary and technical support, required to complete the project. Involvement of major stakeholders during the planning process is a key facilitator of success.1 Unfortunately, a major barrier is the time commitment required of all those involved. Within surgery, key individuals often include surgeons, anesthesiologists, nurses, and technicians. For these individuals, involvement in quality improvement activities is typically voluntary and often viewed by their organizations as a ‘‘collateral duty’’ that must not conflict with primary clinical responsibilities. These individuals also tend to have minimal training on how to use a sociotechnical systems approach to improve quality. Consequently, the process of planning an intervention (eg, surgical briefings or checklists) typically banks heavily on a surgical team’s adaptability to ‘‘fit one more thing’’ into their already hectic routine, rather than integrating the intervention into the natural workflow, team functions, technology systems, and www.annalsofsurgery.com | 9
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery Volume 263, Number 1, January 2016
Wiegmann
FIGURE 1. Model for Understanding System Transitions Associated with the Implementation of New Goals (MUSTAING). incentive structures supporting these team members. Whereas the latter is much more complicated, a more effective and sustainable result will emerge. Hence, if an intervention ultimately fails because of an apparent lack of commitment or ‘‘shortcuts’’ taken during the preparation process, barriers associated with organizational support, workload, and training of those involved in the planning process should be examined. Proper planning helps an organization transition from the contemplation to the transformation phase. Transformation is marked by the ‘‘rolling out’’ of an intervention (initiation). At the start, initiation may be limited in scope to identify unanticipated problems before broader implementation (eg, having a small number of surgical teams pilot a checklist). Accordingly, clear methods are needed for assessing the impact of the intervention on work processes and patient care (evaluation). Based on feedback and evaluation, the planned intervention may need to be further refined or redesigned to accommodate problems that have been discovered (adaptation). This process of initiation, evaluation, and adaptation is then repeated until satisfactory integration of the intervention into the existing work system can be obtained (resolution). However, if this process becomes too protracted or laborious, resolution may never occur. In such cases, a process of dissolution ensues that leads back to the contemplation phase, where the organization again ponders whether change is really worthwhile. Several system elements intrinsic to the transformation phase can affect its outcome.1,9 Frequently, these elements manifest as challenges (barriers) to be negotiated rather than assets (facilitators) to be leveraged. Some elements are cultural in nature and create a resistance to the intervention rather than a spirit of innovation that embraces change. Others are more political and territorial. These can produce animosity, conflict, power struggles, and opposition, rather than opportunities for building new relationships that facilitate change. Although these system elements should be addressed during the planning process, some can be difficult to proactively identify because they lie dormant until the conditions of change reveal their presence. If left unresolved, progress is severely hindered. Consequently, if the uptake of an intervention seems sluggish, one should explore whether these challenges to change have been successfully negotiated. 10 | www.annalsofsurgery.com
If transformation continues, a process of maturation begins. Maturation occurs as people in the organization no longer view the intervention as an intrusion. Rather, they accept the intervention as standard practice that reflects upon their professionalism and values. Adoption of the intervention also becomes part of peer expectations and normative activity within an organization. Unfortunately, arrested development can occur that stifles maturation and leads to regression. Factors such as turnover of key personnel responsible for championing the intervention, conflicts with competing organizational initiatives, and absence of incentive systems for adhering to the intervention are all potential barriers that need to be overcome if transformation is to reach acculturation. During the acculturation phase, an intervention loses its identify. It is no longer viewed as ‘‘new’’ or even an ‘‘intervention.’’ A classic example dates back to the early 20th century when research using video recordings in the operating room revealed considerable inefficiencies in instrument handling by surgeons that could be easily remedied by the use of a surgical ‘‘caddy.’’10 Over time, and through the informal application of the implementation principles discussed herein, surgical assistants were successfully integrated into the surgical team. Today, many surgeons would likely prefer to postpone a surgery where possible if a surgical assistant were unavailable rather than operate without one. Clearly, acculturation of the ‘‘intervention’’ has occurred and a new conventional state has been established.
CONCLUSIONS Many quality improvement interventions fail because of breakdowns in the implementation process. Surgeons play key leadership roles in driving quality initiatives in their respective operating rooms and organizations. Hence, they need to be aware of the factors that contribute to implementation success or failure. MUSTAING provides surgeons with a framework for understanding these factors and serving as effective innovators and leaders during the implementation process. Finally, not all implementation problems currently have solutions. MUSTAING provides a framework for guiding future research to identify strategies for facilitating implementation success in surgery and other health care domains. ß
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery Volume 263, Number 1, January 2016
REFERENCES 1. Dixon-Woods M, McNicol S, Martin G. Ten challenges in improving quality in healthcare: lessons from the Health Foundation’s programme evaluations and relevant literature. BMJ Qual Saf. 2012;21:876–884. 2. McCulloch P, Rathbone J, Catchpole K. Interventions to improve teamwork and communications among healthcare staff. Br J Surg. 2011;98:469–479. 3. Henrickson SE, Wadhera RK, Elbardissi AW, et al. Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery. J Am Coll Surg. 2009;208:1115–1123. 4. Catchpole K, Ley E, Wiegmann D, et al. A human factors subsystem approach to trauma care. JAMA Surg. 2014;149:962–968. 5. Sundt TM. Interventions to improve surgical safety: the ‘‘how’’ is as important as the ‘‘what.’’ Ann Surg. 2011;253:855–856.
ß
2015 Wolters Kluwer Health, Inc. All rights reserved.
Implementation Research
6. Wiegmann DA, Eggman AA, Elbardissi AW, et al. Improving cardiac surgical care: a work systems approach. Appl Ergon. 2010;41:701–712. 7. Prochaska JM, Prochaska JO, Levesque DA. A transtheoretical approach to changing organizations. Adm Policy Ment Health. 2001;28:247–261. 8. Weiner BJ, Amick H, Lee SY. Conceptualization and measurement of organizational readiness for change: a review of the literature in health services research and other fields. Med Care Res Rev. 2008;65:379– 436. 9. Powell AE, Davies HTO, Bannister J, et al. Challenge of improving postoperative pain management: case studies of three acute pain services in the UK National Health Service. Br J Anaesth. 2009;102:824–831. 10. Baumgart A, Neuhauser D. Frank and Lilian Gilbreth: scientific management in the operating room. Qual Saf Health Care. 2009;18:413–415.
www.annalsofsurgery.com | 11
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
