[This article was originally published in Longwoods Review, Volume 4, Number 2.]

Gosfield and Reinertsen's paper poses a number of interesting questions that merit examination in the Canadian context. They propose that the widespread adoption of the six streams of evidence-based practices included in the 100,000 Lives Campaign changes the standard to which hospitals will be held liable, regardless of whether they have enrolled in the campaign. They suggest that hospitals now have a legal incentive to ensure adoption of these practices. They propose that, instead of viewing the potential litigation as a threat, hospitals and healthcare leaders should understand and harness these legal forces to help them drive these changes. They go as far as suggesting that malpractice liability could be a positive force for reducing needless deaths.

This may be true in the context of a highly litigious American environment, but what about the Canadian setting? Safer Healthcare Now! is based on the 100,000 Lives Campaign. Across the country, hospitals and health regions are adopting one or more of the six streams of the campaign. Some organizations, including those already enrolled in the national ICU collaborative, had a head start and are well on their way in adopting these and other practices to improve patient safety, with promising preliminary results. Other organizations had a slower start and are still struggling to build the internal capacity to adopt and sustain these changes. The pace at which these patient safety practices are being adopted is influenced by many factors, including the existing quality culture within the organization, commitment from the CEO, other senior leaders and boards, and the presence of strong clinical leadership, especially among physicians.  

It is interesting to note the difference in the Canadian and American campaigns. When Don Berwick announced the campaign in December 2004, he stated, "some is not a number, soon is not a time." The campaign was notable for its specificity - 100,000 needless deaths avoided by 0900 hours on June 14, 2006. American hospitals enrolled in the campaign started to use hospital standardized mortality data (HSMD) as the Big Dot by which to measure hospital performance. The campaign began to gain significant momentum when the early adopters started to publicize their results in terms of lives saved.  

In perhaps characteristic Canadian fashion, Safer Healthcare Now! adopted a much softer approach. No specific targets were set in terms of lives saved, and the campaign goal was more generally focused on enhancing patient safety. To the credit of the Canadian Institute for Health Information, standardized hospital mortality data are now available. Some organizations are starting to incorporate this measure into their performance dashboard and to use the data to focus quality improvement efforts. 

Although considerable progress has been made, we have a very long way to go. Even where there is corporate commitment, implementing changes in clinical practice is challenging. Gosfield and Reinertsen suggest that one of the reasons why the campaign strategies could now be perceived as new standards is because none of the planks requires major capital investments or information system redesigns in order to be implemented. They use the example that reconciling medications at each transition point in a patient's care can be done with simple nursing processes, not expensive computer systems. This vastly understates the change management that is required in making these changes, particularly in large complex health regions that involve multiple sites and the full continuum of care. It is no coincidence that adoption of rapid response teams has the lowest level of uptake in the Safer Healthcare Now! campaign. The reality is that these teams require an initial investment in staff. Many cash-starved hospitals and health regions are struggling to free up these resources, even though they can anticipate a payback in both patient safety and cost of care.

These differences notwithstanding, the bar is moving. One example is the incorporation of medication reconciliation in the patient safety practices now required by the Canadian Council on Health Services Accreditation (CCHSA). As CCHSA further develops new patient safety standards and patient safety indicators, there will be increasing pressure for health organizations to change clinical practice and to demonstrate compliance with these new expectations.  

This begs the question, when does a standard become a standard? In my opinion, at this point, we have not yet reached the Tipping Point where there has been sufficient adoption of the campaign strategies to view them as new standards. But that time is coming - we will eventually see these practices reflected in the practice guidelines of various professional groups and accrediting bodies. Many of us are not waiting until then and are already defining new expectations within our organizations. The motivation for doing this is not risk management, at least not in terms of avoiding litigation. It is about continuously improving the quality of our care and adopting practices where the evidence shows we can do things better. In my own organization, when recently reviewing a patient incident where a hospital-acquired infection contributed to the patient's negative outcome, the issue of our infection control practices relative to one of the Safer Healthcare Now! bundles was part of our discussion, even though we have not yet enrolled in that part of the campaign.  

We cannot ignore the fact that, even in the Canadian context, the fear of litigation exists. Like other Canadian health regions, we are trying hard to engage physicians in patient safety initiatives. Part of our change management strategy needs to address the resistance to "cookbook medicine" expressed by some physicians. Many of our physicians are passionate champions of patient safety, although sometimes the advice they get from their legal counsel could serve as a deterrent (for example, to participating in multidisciplinary reviews of critical incidents). In this environment, playing the "litigation card" could backfire and actually serve as a deterrent for them to be involved.

In conclusion, I agree that the 100,000 Lives Campaign and Safer Healthcare Now! are raising the bar and are influencing the standards of practice. I believe they have heightened awareness of patient safety and provided a focus for changes in practice that will significantly reduce the number of needless deaths. They will lead the way for other areas of evidence-based practice changes. They have helped us understand that hospital standardized mortality rates are a meaningful large system measure of quality.

The campaigns are making a difference. Organizations that are not adopting at least some of these practices need to be able to justify why. In the American system, the fear of litigation may help accelerate these changes. In the Canadian environment, I hope that this will not be the motivator, but if that's what it takes to save lives, so be it.  

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