Understanding Why Quality Initiatives Succeed or Fail

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.