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Healthcare has a really hard time changing. Time and time again, we see delays in putting evidence into practice. In outpatient medicine, we frequently miss quality targets for care with high-quality evidence rankings.1–3 In hospital medicine, we routinely discharge patients without needed secondary prevention.3,4 In intensive care medicine, we continue to fail to provide lifesaving, lung-protective ventilation.5 Why is this? Healthcare providers are not actively trying to deliver bad care. Doctors and nurses are not actively choosing to fail their patients. Frequently, what may be missing is an implementation path forward.6,7

This chapter will focus on two major topics: how to effectively function as a healthcare leader, and how to incorporate the insights of implementation science. These two areas are fundamentally tied together, although they often are taught separately. As healthcare delivery scientists, we are called both to identify the tools of change and, in some cases, the path forward to lead that change. Encouraging change, creating urgency, and inspiring colleagues all will require the building blocks of teams from Chapter 6 to lead a group of people. Implementation science provides us the tools to see a path forward. In this chapter, we add three well-established theories of implementation science to your growing toolkit and consider how to use these methods to lead change.


Leading change in healthcare can be exhausting and frustrating. We believe that there are three major ways that we stumble, which we will discuss here, although we would caution the reader that this is not a comprehensive list.

Culture Change Is Usually the Outcome of Successful Change, Not the Intervention

When the culture of a health system is problematic, patients, families, and clinicians all suffer. Outcomes are worse, care is less safe, and staff are less engaged.8,9 This leads many to believe that the best way to improve the quality of care is to try to intervene to improve the culture. While that makes intuitive sense, empirically it turns out that attempts to improve safety culture have been a less-effective-than-hoped-for intervention.10,11 In our experience, intervening to change clinicians’ behavior (e.g., standardizing practice with evidence-based pathways) often results in culture change. The culture that surrounds us is not fixed. It changes when forces act on it and reframe the experience of the actors contained within it; by definition, change in an existing culture is an outcome.12 Culture change, itself, is almost never the intervention–it is the outcome of successful quality and patient safety improvement.

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Plans to change the culture often fail. Culture change is usually the outcome, not the intervention.

Consider the following example. Over ten years ago, a culture existed at a Boston teaching hospital that discouraged junior trainees from seeking help from their more senior residents or from the attending physician of ...

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