Why Best Practices Fail to Spread


Most organizations want to get better, but most of their improvement efforts fail. Here's why.

Fam Pract Manag. 2017 Jan-Feb;24(1):17-20.

Author disclosures: no relevant financial affiliations disclosed.

The spread of “best practices” is important in today's rapidly evolving health care landscape where quality and outcomes matter more than ever. However, spread can be incredibly difficult to achieve.

One of us (Dr. Toussaint) has visited and observed 174 health care systems in 17 countries. Almost every one of these organizations has undergone significant innovative care redesign in recent years and has attempted to spread that redesign. Most have failed.

The other of us (Dr. Elmer) was a physician leader at ThedaCare Physicians in Kimberly, Wis., when the clinic was chosen to create an ambulatory care redesign, which encompassed the entire outpatient experience. It improved patients' access to care by allowing the use of smart phones for scheduling appointments and asking questions. It changed the way staff planned for upcoming appointments and included “scrubbing” the clinical chart the night before the visit to proactively understand what would happen the following day. It delivered same-day, 15-minute lab turnaround times so that providers would have at hand all lab results essential to determining the next steps in care. All patients were given an after-visit summary upon checkout that clearly documented their lab results, medication changes, follow-up appointments, and future consults. Standards were established for medical assistants to collect all vital signs, perform medication reconciliation, take an updated history, and draw blood before the provider entered the room. This enabled the provider to focus completely on the patient's issues during the visit. In short, it was a remarkable redesign, but it ultimately failed to spread.

In this article, we will explain the core elements of failure to spread and how to avoid making the same mistakes we and others have made.

Four causes of failure

Based on our experience and our observations of other health care organizations, we have identified four common reasons that improvements fail to spread.

1. A top-down approach. The most common reason for failure is using a top-down approach. The leaders write a multipage playbook based on the experience of one pilot clinic, hand it out to the physicians and staff of the remaining clinics, and tell them to implement the playbook. However, the exact standard created in one clinic rarely works in another. The patient demographics are different, the doctors have different interests and practice styles, etc. Applying a top-down, cookie-cutter approach to a complex social enterprise is folly.

Instead, organizations need to include a bottom-up aspect to their change effort; that is, give clinics a playbook not to simply copy but to “copy-improve.” For example, the best practice (or “standard work”) we developed at our clinic in Kimberly was shared with the rest of the clinics, and the phy

About the Authors

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Dr. Toussaint is CEO of Catalysis, formerly ThedaCare Center for Healthcare Value, in Appleton, Wis....

Dr. Elmer is a family physician at ThedaCare Physicians in Kimberly, Wis.

Author disclosures: no relevant financial affiliations disclosed.



show all references

1. Toussaint JS. To radically redesign health care, start with one unit. Harvard Business Review. Dec. 9, 2015. https://hbr.org/2015/12/to-radically-redesign-health-care-start-with-one-unit. Accessed Nov. 15, 2016....

2. Barnas K. ThedaCare's business performance system: sustaining continuous daily improvement through hospital management in a lean environment. Jt Comm J Qual Patient Saf. 2011;37(9):387–399.

3. Shook J. Managing to Learn: Using the A3 Management Process. Cambridge, MA: Lean Enterprise Institute; 2008.

4. Elkhorne JL. Edison – the fabulous drone. 73 Magazine. 1967;46(3):52. http://www.arimi.it/wp-content/73/03_March_1967.pdf. Accessed Nov. 15, 2016.


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