Background: The orthogeriatric liaison service at Ipswich hospital, a 458-bed secondary hospital with 29 orthopaedic beds, was set up in 2015. The service works in a collaborative care model with the department of orthopaedics. Orthopaedic patients 65 years and over requiring medical review, and all patients with fragility hip fractures receive early and ongoing care from geriatricians. Since inception, various projects and quality improvement initiatives have been implemented, with opportunities to review the result over time. Reflecting on some of these projects has been crucial to learning about change implementation.
Change: Setting up the orthogeriatric service involved implementing pathways and processes to streamline and standardise care. Stakeholders from multidisciplinary teams involved in managing complex perioperative patients engaged in the process. Contribution to the Australian and New Zealand Hip Fracture Registry (ANZHFR) commenced in 2016, collecting data to benchmark performance against clinical standards. Subsequent quality improvement projects were initiated as a result. Eat Walk Engage (EWE), a multicomponent ward-based improvement program, was introduced in the orthopaedic ward in 2020. The program was readily accepted as part of usual care, with ongoing calls to expand to other units. Data from the EWE program and the ANZHFR has been pivotal in introducing other quality improvement initiatives, such as the Neck of Femur (NOF) nutritional pathway.
Learnings: Implementing changes in healthcare is often a multi-stage process. Change frameworks such as the PARiHS (Promoting Action on Research Implementation in Health Services) framework are available to guide the planning and implementation of quality improvement initiatives. They also prompt early consideration of barriers and enablers of change, making the process more efficient and reducing the risk of overlooking contextual factors. The EWE program has been a practical opportunity to learn the fundamentals and application of change management frameworks and reflect on previous projects. Champions for change, such as the NOF nurse and EWE facilitators, are crucial for success and maintaining momentum. They can engage stakeholders, providing practical support as well as mentorship. By incorporating processes for data collection and benchmarking early in the process, subsequent quality improvement projects are easily identified. This continues the cycle of change. Conversely, lack of data or quality evidence to inform clear guidelines can hinder change.