Explaining Matching Michigan: an ethnographic study of a patient safety program
Open accessAbstract
BACKGROUND: Quality and safety improvement initiatives in healthcare often display two disconcerting effects. The first is a failure to outperform the secular trend. The second is the decline effect, where an initially promising intervention appears not to deliver equally successful results when attempts are made to replicate it in new settings. Matching Michigan, a patient safety program aimed at decreasing central line infections in over 200 intensive care units (ICUs) in England, may be an example of both. We aimed to explain why these apparent effects may have occurred. METHODS: We conducted interviews with 98 staff and non-participant observation on 19 ICUs; 17 of these units were participating in Matching Michigan. We undertook further telephone interviews with 29 staff who attended program training events and we analyzed relevant documents. RESULTS: One Matching Michigan unit transformed its practices and culture in response to the program; five boosted existing efforts, and 11 made little change. Matching Michigan's impact may have been limited by features of program design and execution; it was not an exact replica of the original project. Outer and inner contexts strongly modified the program's effects. The outer context included previous efforts to tackle central line infections superimposed on national infection control policies that were perceived by some as top-down and punitive. This undermined engagement in the program and made it difficult to persuade participants that the program was necessary. Individual ICUs' histories and local context were also highly consequential: their past experience of quality improvement, the extent to which they were able to develop high quality data collection and feedback systems, and the success of local leaders in developing consensus and coalition all influenced the program's impact on local practices. CONCLUSIONS: Improved implementation of procedural good practice may occur through many different routes, of which program participation is only one. The 'phenotype' of compliance may therefore arise through different 'genotypes.' When designing and delivering interventions to improve quality and safety, risks of decline effects and difficulties in demonstrating added value over the secular trend might be averted by improved understanding of program mechanisms and contexts of implementation.
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Initiatives to improve quality and safety in healthcare frequently result in limited changes for the better or no meaningful changes at all.
“Initiatives to improve quality and safety in healthcare all too frequently result in limited changes for the better or no meaningful changes at all, and the few that are successful are often hard to sustain or replicate in new contexts.1”
From Demystifying theory and its use in improvement (2015) · cites this paper as [1]
The few successful improvement initiatives are often hard to sustain or replicate in new contexts.
“Initiatives to improve quality and safety in healthcare all too frequently result in limited changes for the better or no meaningful changes at all, and the few that are successful are often hard to sustain or replicate in new contexts.1”
From Demystifying theory and its use in improvement (2015) · cites this paper as [1]
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BackgroundA qualitative study of speaking out about patient safety concerns in intensive care units
Tarrant, C., Leslie, M., Bion, J., & Dixon‐Woods, M. (2017) · Social Science & Medicine · doi:10.1016/j.socscimed.2017.09.036 · Cited by 61 · see citing works
“This paper reports data from an ethnographic study of a national programme (Dixon-Woods et al., 2013) to reduce central venous catheter bloodstream infections (CVC-BSIs) in intensive care unit (Bion et al.”
BackgroundSelf-citationBradley, E. H., Brewster, A. L., McNatt, Z., Linnander, E. L., Cherlin, E. J., Fosburgh, H., Ting, H. H., & Curry, L. A. (2017) · BMJ Quality & Safety · doi:10.1136/bmjqs-2017-006574 · Cited by 56 · see citing works
Tank, T. 2. G. I.-T., Zingg, W., Storr, J., Park, B. J., Ahmad, R., Tarrant, C., Castro‐Sánchez, E., Tomczyk, S. M., Kilpatrick, C., Allegranzi, B., et al. (2019) · Antimicrobial Resistance and Infection Control · doi:10.1186/s13756-019-0527-1 · Cited by 58 · see citing works
Self-citationWhite, M. C., Peven, K., Clancy, O., Okonkwo, I., Bakolis, I., Russ, S., Leather, A. J. M., & Sevdalis, N. (2020) · Annals of Surgery · doi:10.1097/sla.0000000000003944 · Cited by 53 · see citing works
“In 2013, a similar null outcome was reported for the ‘‘Matching Michigan’’ national improvement which aimed to reduce central venous catheter infections across 223 UK intensive care units.(73,74) Both examples used an intervention with a strong evidence base, but failed to effectively implement the intervention at sca…”
ResultOvercoming the obstacles of implementing infection prevention and control guidelines
Birgand, G., Johansson, A. F., Szilágyi, E., & Lucet, J. C. (2015) · Clinical Microbiology and Infection · doi:10.1016/j.cmi.2015.09.005 · Cited by 51 · see citing works
“Based on the principle that HCAI surveillance should form the cornerstone of IPC, these networks are necessary for helping to implement guidelines at the local level and reduce HCAI rates [18].”
BackgroundInfluentialModels for Intensive Care Training. A European Perspective
Bion, J., & Rothen, H. U. (2014) · American Journal of Respiratory and Critical Care Medicine · doi:10.1164/rccm.201311-2058cp · Cited by 51 · see citing works
Self-citationPresseau, J., Byrne-Davis, L. M. T., Hotham, S., Lorencatto, F., Potthoff, S., Atkinson, L., Bull, E. R., Dima, A. L., van Dongen, A., French, D., et al. (2021) · Health Psychology Review · doi:10.1080/17437199.2020.1866638 · Cited by 51 · see citing works
“Improving patient care is not easy and when successful can result in small changes that are hard to maintain and replicate (Dixon-Woods et al., 2013).”
BackgroundFrom spreading to embedding innovation in health care: Implications for theory and practice
Scarbrough, H., & Kyratsis, Y. (2021) · Health Care Management Review · doi:10.1097/hmr.0000000000000323 · Cited by 53 · see citing works
“Comparative analysis of the U.S. and U.K. cases is revealing (Dixon-Woods et al., 2011, 2013).”
BackgroundMethodInfluentialUnrestricted drinking before surgery: an iterative quality improvement study
Rüggeberg, A., & Nickel, E. A. (2022) · Anaesthesia · doi:10.1111/anae.15855 · Cited by 50 · see citing works
“It may be perceived as ``what you have done so far may be wrong ́ ́ or ``people do not appreciate what you have been doing for the last years ́ ́ [17].”
BackgroundInfluentialStapley, E., Sharples, E., Lachman, P. I., Lakhanpaul, M., Wolpert, M., & Deighton, J. (2017) · International Journal for Quality in Health Care · doi:10.1093/intqhc/mzx162 · Cited by 52 · see citing works
“3 translate easily into other contexts [9].”
Portela, M. C., Lima, S. M. L., Martins, M. S., & Travassos, C. (2016) · Cadernos de Saúde Pública · doi:10.1590/0102-311x00105815 · Cited by 64 · see citing works
Brewster, L., Aveling, E., Martin, G. P., Tarrant, C., & Dixon‐Woods, M. (2015) · BMJ Quality & Safety · doi:10.1136/bmjqs-2014-003732 · Cited by 48 · see citing works
“33 In accordance with the rationale behind the concordat approach, we do not advocate that other collaborations simply adopt this example of a concordat ‘ as is ’ .”
BackgroundSelf-citationBreckenridge, J. P., Gray, N., Toma, M., Ashmore, S., Glassborow, R., Stark, C. R., & Renfrew, M. J. (2019) · BMJ Open Quality · doi:10.1136/bmjoq-2018-000553 · Cited by 49 · see citing works
“InTroducTIon Initiating and sustaining effective change in healthcare is a continuing challenge, with even the most successful improvements often being difficult to sustain or replicate in other contexts.(1) Key figures in improvement science have emphasised the importance of learning from the psychological, social an…”
BackgroundBrewster, L., Tarrant, C., & Dixon‐Woods, M. (2016) · Journal of Hospital Infection · doi:10.1016/j.jhin.2016.01.021 · Cited by 46 · see citing works
Self-citationColeman, K. J., Magnan, S. J., Neely, C., Solberg, L. I., Beck, A. L., Trevis, J., Heim, C., Williams, M., Katzelnick, D. J., Unützer, J., et al. (2016) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2016.05.007 · Cited by 43 · see citing works
Lane-Fall, M. B., L., J. L. P., Massa, S., Collard, M. L., Peifer, H. G., Taranti, L. J. D., Linehan, M., Fleisher, L. A., & Barg, F. K. (2018) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/j.jcjq.2018.02.004 · Cited by 44 · see citing works
The Positive Deviance Approach
Baxter, R., & Lawton, R. (2022) · Cambridge University Press eBooks · doi:10.1017/9781009237130 · Cited by 44 · see citing works
Yanchus, N. J., Ohler, L., Crowe, E., Teclaw, R. F., & Osatuke, K. (2017) · Journal of research in nursing · doi:10.1177/1744987117710305 · Cited by 41 · see citing works
“Overall, environmental, behavioural and organisational contexts of care delivery are broadly acknowledged to influence both the quality and safety of the care delivered (Berenholtz et al., 2014; Dixon-Woods et al., 2013; Edmondson et al., 2016; Kalisch et al., 2007).”
BackgroundTaylor, N. J., Healey, E., Morrow, A., Greening, S., Wakefield, C. E., Warwick, L., Williams, R., & Tucker, K. (2020) · Implementation Science Communications · doi:10.1186/s43058-020-00054-0 · Cited by 41 · see citing works
“and generalisability of interventions problematic [2].”
Bonaconsa, C., Mbamalu, O. N., Mendelson, M., Boutall, A., Warden, C., Rayamajhi, S., Pennel, T. C., Hampton, M. I., Joubert, I., Tarrant, C., et al. (2021) · BMJ Quality & Safety · doi:10.1136/bmjqs-2020-012372 · Cited by 39 · see citing works
Self-citationEliminating Infections in the ICU: CLABSI
Latif, A., Halim, M. S., & Pronovost, P. J. (2015) · Current Infectious Disease Reports · doi:10.1007/s11908-015-0491-8 · Cited by 42 · see citing works
Approaches to Spread, Scale-Up, and Sustainability
Papoutsi, C., Greenhalgh, T., & Marjanovic, S. (2024) · Cambridge University Press eBooks · doi:10.1017/9781009326049 · Cited by 37 · see citing works
Tarrant, C., O’Donnell, B., Martin, G. P., Bion, J., Hunter, A., & Rooney, K. (2016) · Implementation Science · doi:10.1186/s13012-016-0518-z · Cited by 41 · see citing works
“One problem is often a lack of understanding of how interventions actually work and what is required to make them work [29, 30].”
BackgroundSelf-citationA mixed-methods study of challenges experienced by clinical teams in measuring improvement
Woodcock, T. M., Liberati, E. G., & Dixon‐Woods, M. (2019) · BMJ Quality & Safety · doi:10.1136/bmjqs-2018-009048 · Cited by 39 · see citing works
Self-citationStokes, T., Tumilty, E., Doolan‐Noble, F., & Gauld, R. D. C. (2018) · BMJ Open · doi:10.1136/bmjopen-2018-025094 · Cited by 38 · see citing works
“Others have similarly shown the importance of the local context in determining whether local implementation works or fails when rolling out a national quality improvement programme in secondary care.(24) We therefore consider that the implication of our work for future implementers of HealthPathways and similar comple…”
BackgroundMiddleton, S., Lydtin, A., Comerford, D., Cadilhac, D. A.-M., McElduff, P., Dale, S., Hill, K. M., Longworth, M., Ward, J., Cheung, N. W., et al. (2016) · BMJ Open · doi:10.1136/bmjopen-2016-011568 · Cited by 38 · see citing works
“While central venous catheter bloodstream infections dropped in the UK ICUs, the Matching Michigan study was not an exact replica of the original Michigan Keystone project, particularly in terms of implementation of the intervention.(16) As reported elsewhere,(17) our team previously developed a successful implementat…”
ResultCommissioning mental health services
Kisely, S. R. (1997) · Journal of Epidemiology & Community Health · doi:10.1136/jech.51.3.342-b · Cited by 40 · see citing works
Sendlhofer, G., Lumenta, D. B., Leitgeb, K., Kober, B., Jantscher, L., Schanbacher, M., Berghold, A., Pregartner, G., Brunner, G. A., Tax, C., et al. (2016) · PLoS ONE · doi:10.1371/journal.pone.0149212 · Cited by 37 · see citing works
“Nevertheless, in order to prove team performance with respect to SSC-usage, audits in an OR are needed to further investigate the possible disconnection between physical completion of the SSC and actual compliance to checklist items.”
BackgroundInfluentialSheard, L., Marsh, C., Mills, T., Peacock, R., Langley, J., Partridge, R., Gwilt, I., & Lawton, R. (2019) · Health Services and Delivery Research · doi:10.3310/hsdr07360 · Cited by 35 · see citing works
de Mheen, P. J. M., & van Bodegom‐Vos, L. (2015) · BMJ Quality & Safety · doi:10.1136/bmjqs-2014-003787 · Cited by 36 · see citing works
Szymczak, J. E. (2018) · BMJ Quality & Safety · doi:10.1136/bmjqs-2018-008512 · Cited by 35 · see citing works
Leadership and management for infection prevention and control: what do we have and what do we need?
Gould, D. J., Gallagher, R., & Allen, D. A. (2016) · Journal of Hospital Infection · doi:10.1016/j.jhin.2016.07.005 · Cited by 34 · see citing works
Opportunities for system level improvement in antibiotic use across the surgical pathway
Charani, E., Ahmad, R., Tarrant, C., Birgand, G., Leather, A. J. M., Mendelson, M., Moonesinghe, R., Sevdalis, N., Singh, S. K., & Holmes, A. H. (2017) · International Journal of Infectious Diseases · doi:10.1016/j.ijid.2017.04.020 · Cited by 34 · see citing works
Self-citationSubbe, C. P., Tellier, G., & Barach, P. R. (2021) · BMJ Open · doi:10.1136/bmjopen-2020-047446 · Cited by 36 · see citing works
Mann, C., Shaw, A. R. G., Guthrie, B., Wye, L., Man, M., Hollinghurst, S. P., Brookes, S. T., Bower, P., Mercer, S. W., & Salisbury, C. (2016) · BMJ Open · doi:10.1136/bmjopen-2016-011260 · Cited by 32 · see citing works
“If there is a clear trend towards initiatives that are very similar to 3D, any improvements in care resulting from 3D may be matched by those that occur as a result of ‘secular trends’.(29) It is also expected that the various components of the intervention may not be uniformly implemented across practices, in part du…”
BackgroundClinical Communities at Johns Hopkins Medicine: An Emerging Approach to Quality Improvement
Gould, L. J., Wachter, P., Aboumatar, H. J., Blanding, R. J., Brotman, D. J., Bullard, J. E., Gilmore, M. M., Golden, S. H., Howell, E. E., Ishii, L. E., et al. (2015) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/s1553-7250(15)41050-5 · Cited by 33 · see citing works
de Neef, M., Bakker, L., Dijkstra, S., Raymakers-Janssen, P. A. M. A., Vileito, A., & Ista, E. (2019) · Pediatric Critical Care Medicine · doi:10.1097/pcc.0000000000001862 · Cited by 33 · see citing works
Ziemann, A., Brown, L., Sadler, E., Ocloo, J. E., Boaz, A., & Sandall, J. (2019) · Systematic Reviews · doi:10.1186/s13643-019-1180-8 · Cited by 34 · see citing works
Emergent barriers to the lean healthcare journey: baronies, tribalism and scepticism
Leite, H., Williams, S., Radnor, Z., & Bateman, N. (2022) · Production Planning & Control · doi:10.1080/09537287.2022.2054386 · Cited by 36 · see citing works
“Dixon-Woods et al. (2013) argue that this challenge often brings some disconcerting effects, such as failure to outperform the secular trend and the decline effect when improvements do not deliver equal, successful results during replication in the new context.”
BackgroundResultAveling, E., Martin, G. P., Herbert, G., & Armstrong, N. (2016) · Social Science & Medicine · doi:10.1016/j.socscimed.2016.11.026 · Cited by 32 · see citing works
“Even where interventions prove successful in one context, attempts to replicate positive impacts elsewhere are variable in their results (Dixon-Woods et al., 2013), and often disappointing (Lomas, 2005).”
BackgroundHowells, K., Burrows, M., Amp, M., Brennan, R., Yeung, W.-L., Jackson, S., Dickinson, J., Draper, J., Campbell, S., Ashcroft, D. M., et al. (2021) · International Journal for Equity in Health · doi:10.1186/s12939-020-01364-4 · Cited by 32 · see citing works
Sheard, L., Marsh, C., O'Hara, J. K., Armitage, G., Wright, J., & Lawton, R. (2017) · BMJ Open · doi:10.1136/bmjopen-2016-014558 · Cited by 32 · see citing works
Papoutsi, C., Poots, A. J., Clements, J. T. C., Wyrko, Z., Offord, N., & Reed, J. E. (2017) · Age and Ageing · doi:10.1093/ageing/afx194 · Cited by 32 · see citing works
“However, their use has not always been met with success and transferability across settings has been questioned [7, 8].”
BackgroundMorton, K., MacNeill, S., Sanderson, E., Dixon, P., King, A. J. L., Jenkins, S., Metcalfe, C. D., Shaw, A., Chalder, M., Benger, J. R., et al. (2019) · BMJ Open Respiratory Research · doi:10.1136/bmjresp-2019-000425 · Cited by 31 · see citing works
White, M. C., Daya, L., Karel, F. K. B., White, G., Abid, S., Fitzgerald, A., Mballa, G. A. E., Sevdalis, N., & Leather, A. J. M. (2019) · Anesthesia & Analgesia · doi:10.1213/ane.0000000000004586 · Cited by 30 · see citing works
“Surgical count completed 132 (41)a 51 (16)a 52 (16)a 35 (11)a 48 (15)a 6 (2)a 102 (56)b 60 (33)b 13 (7)b 4 (2)b 3 (2)b 1 (1)b”
InfluentialSegurança do Paciente: criando organizações de saúde seguras
Sousa, P. J. D. S., & Mendes, W. (2014) · Editora FIOCRUZ eBooks · doi:10.7476/9788575415948 · Cited by 32 · see citing works
Collaborative, O. B. O. T. C. C., Subbe, C. P., Kellett, J. G., Barach, P. R., Chaloner, C., Cleaver, H., Cooksley, T., Korsten, E. H. H. M., Croke, E., Davis, E. R., et al. (2017) · BMC Health Services Research · doi:10.1186/s12913-017-2288-y · Cited by 29 · see citing works
“Medical checklists are more likely to follow a predictable course if they make clinical sense to providers, have clearly defined endpoints [38] and actively engage the teams using them [39].”
Segurança do paciente: criando organizações de saúde seguras
Sousa, P., & Mendes, W. (2019) · Editora FIOCRUZ eBooks · doi:10.7476/9788575416426 · Cited by 48 · see citing works
Gould, D. J., Hale, R., Waters, E., & Allen, D. A. (2016) · Journal of Hospital Infection · doi:10.1016/j.jhin.2016.09.015 · Cited by 29 · see citing works
Shojania, K. G., & de Mheen, P. J. M. (2015) · BMJ Quality & Safety · doi:10.1136/bmjqs-2015-004461 · Cited by 28 · see citing works
Haynes, A. S., Brennan, S., Redman, S., Williamson, A. B., Makkar, S. R., Gallego, G., & Butow, P. N. (2017) · Health Research Policy and Systems · doi:10.1186/s12961-017-0234-4 · Cited by 28 · see citing works
“This may be especially important for interventions where participants have involvement in the tailoring and/or delivery of an intervention, since their attitudes towards its content, form and goals are likely to have profound impacts on what is delivered and how it is received [19, 20].”
BackgroundTroughton, R., Mariano, V., Campbell, A., Hettiaratchy, S. P., Holmes, A. H., & Birgand, G. (2019) · Antimicrobial Resistance and Infection Control · doi:10.1186/s13756-019-0565-8 · Cited by 28 · see citing works
Central-line-associated bloodstream infection burden among Dutch neonatal intensive care units
Jansen, S. J., Broer, S. D. L., Hemels, M. A. C., Visser, D. H., Antonius, T. A. J., Heijting, I., Bergman, K. A., Termote, J. U. M., Hütten, M. C., van der Sluijs, J. P. F., et al. (2023) · Journal of Hospital Infection · doi:10.1016/j.jhin.2023.11.020 · Cited by 27 · see citing works
“Mock before you block”: an in‐built action‐check to prevent wrong‐side anaesthetic nerve blocks
Pandit, J. J., Matthews, J., & Pandit, M. (2016) · Anaesthesia · doi:10.1111/anae.13664 · Cited by 27 · see citing works
- Authors
- Dixon-Woods, M., Leslie, M., Tarrant, C., & Bion, J.
- Affiliations
- Johns Hopkins University (US)
- University of Leicester (GB)
- Queen Elizabeth Hospital Birmingham (GB)
- Venue
- Implementation Science
- Published
- 2013-06-20
- Volume
- 8
- Issue
- 1
- Pages
- 70-70
- ISSN
- 1748-5908 (ISSN-L)
- PMC
- PMC3704826
- OpenAlex
- W2153352637
- Cited by
- 291
- References
- 28
- Citations by year
- 2026: 3 · 2025: 4 · 2024: 18 · 2023: 21 · 2022: 23 · 2021: 18 · 2020: 25 · 2019: 57 · 2018: 21 · 2017: 25 · 2016: 29 · 2015: 30 · 2014: 12 · 2013: 4
- FWCI
- 45.28
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Implementation Science (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Figshare (submittedVersion, cc-by)
- Leicester Research Archive (University of Leicester) (submittedVersion, cc-by)
- Funders
- Wellcome Trust (097899, 097899/A/11/Z)
- Topics
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Health Sciences › Health Professions › Health Information Management › Healthcare Quality and Management
- Keywords
- patient safety programs, central line-associated bloodstream infection, intensive care unit, quality improvement, decline effect, secular trends, program implementation, context effects, infection control, employee engagement, local leadership, intervention replication
- MeSH terms
- Anthropology, Cultural, Catheterization, Central Venous, Critical Care, Cross Infection, England, Humans, Infection Control, Catheter-Related Infections, Quality Improvement, Patient Safety
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