Recent research seems to validate the IHI's emphasis on the checklist; a study published in The New England Journal of Medicine found that the list lowered deaths rates by nearly half at eight hospitals over the course of a year. Still, such a checklist can generate pushback from caregivers used to longstanding practices and an entrenched culture. McCannon, however, says the WHO checklist is not intended to be a constraining, inflexible document.
"We find that people need to feel that they can adapt this to their own setting, so we have to be mindful of that. Some may want to add steps or change it in some way that makes sense for them," he says. "There is no cookie cutter solution, so any good improvement work will have adaptation to a local context."
The WHO checklist may ultimately become more useful as a model for hospitals to craft their own lists, says Nancy Foster, vice president of quality and patient safety for the American Hospital Association. "By the time we're able to have broad-based implementation, there won't be just one—there'll be a small cadre of these checklists."
The future of improvement
The Improvement Map represents the IHI's reaction to direct feedback the nonprofit organizations has received from providers about the guidance hospitals need in the quality improvement realm, McCannon says. "The first thing they requested in the majority of cases was what we've come to call ‘sense-making.' They said, ‘Help us make sense of all the different requirements, give us a sense of priority, and tell us what are the things we can do to lead to major improvements at a high level."
Success in this shift from the clinical specificity of 100,000 Lives and 5 Million Lives to the Improvement Map's broader goals hinges on a familiar healthcare theme: senior leaders and caregivers uniting behind a common goal. But achieving organizationwide improvement isn't as easy as merely achieving "buy-in," says Foster. "What we're all struggling with is taking strategically chosen target efforts at improving outcomes and turning that into a broader-based improvement culture. It's the right shift to make, but I don't think any of us knows how to do it perfectly. We just can't keep adding a couple of measures here, a couple of projects there. We really need to fundamentally change the way we approach quality."
For his part, McCannon says he has seen indications that such an understanding is taking hold. "From a leadership awareness standpoint, there is a real change in the sense of urgency. It's no longer possible to say it's impossible to make major improvements in patient safety and quality. But unquestionably, there is still a lot of work left to do."