Theresa Patenaude was nervous. She was walking into an important meeting with her colleagues – including some she hadn’t met yet. And she was wearing a hospital gown.
It was part of her pledge to wear a hospital gown for one day for Alberta’s Change Day – an initiative that asks health care workers and others to think of one positive change they can make to the system. “When Change Day was introduced, I thought I should look at every strategy through the eyes of my patients,” says Patenaude, a registered nurse and project director with Integrated Quality Management at Alberta Health Services. “To make that more concrete, I made a pledge that I would wear a patient gown to get that sense of vulnerability.”
Her unique outfit is one of the 3,000 pledges already made for Alberta’s first Change Day, which culminates with a celebration on April 4. The initiative asks health care workers, patients and the general public to make a promise to improve their health or the health care system. Practitioners have pledged to remember to introduce themselves to patients or to shadow another doctor for a day, and the public have vowed to walk more or to help prevent bullying.
The movement began as a grassroots push in the UK in 2013, and it has since spread to 17 countries including Canada, where Change Day has occurred in Saskatchewan, BC and now Alberta. There are rumours that next year it may go national.
“Change Day captures people’s own passions and spirits in an environment where sometimes it feels like there are so many structures and so many mandates,” says Marlies van Dijk, a nurse who is leading Alberta’s Change Day. “This is a different signal that says yes, you have good ideas, and we want to hear them.”
The beginnings of Change Day
Change Day was started in the UK by a group of doctors who were looking for a way to push back against a top-down system and empower health care workers to make changes. “It began as a discussion around how we could get junior doctors involved in quality improvement,” says Damian Roland, a pediatrician who was part of that first group. It was a success, collecting 189,000 pledges in its first year and growing to 500,000 in 2014.
Change Day was launched at a time when NHS workers were stressed by financial pressures and public criticism about the system. But those problems may have helped fuel its success. “[Change Day] provided an opportunity to transform people’s anger or frustration into constructive action,” reads a report about it.
Roland has made some of the most memorable pledges. The first year, he tasted some of the medicines he prescribed to his patients (and took a video of his reaction to a particularly unpleasant one). Last year, he lay on a spinal board for an hour with his head in blocks. Both tests, he says, changed his practice.
Support services manager Marc Yerrell created a website to recycle unused furniture in his hospital. And a group spent a day asking the public, “If you could make a change to your local NHS, what would it be?” Many people – 3,500 – pledged to smile more while at work.
Change Day also works to increase the visibility of group quality improvement projects, many of which sprung out of pledges from previous years. #SepsisToolkit was begun by the UK Sepsis Trust and encouraged doctors to download a toolkit that helps identify sepsis; #StopthePressure focuses on preventing pressure ulcers, and #StudentLedChange looks at how students can improve the system.
Change Day comes to Canada
Inspired by the NHS, Saskatchewan began having a Change Day in 2014, and BC followed in 2015. Andrew Neuner, CEO of the Health Quality Council of Alberta, was in the audience when BC launched its Change Day, and he was inspired. “I was caught up in the energy of the movement, and just how elegantly simple it was,” he says. “My pledge that day was to bring Change Day to Alberta.”
He brought the idea forward to the Health Quality Network. The group – which represents most of the health care players in Alberta, including all the colleges and regulators – agreed to sponsor and co-create the day, at a total cost of around $25,000.
Alberta’s goal is to hit 4,000 pledges before April 4. “The first year, you hold your breath for every pledge,” says van Dijk. “But I feel the momentum growing right now. People are excited about positive change.”
Pledges have included making RNs more knowledgeable about stroke processes, spending the day in a wheelchair, and promoting lifelong learning.
Keith King, an accreditation advisor for AHS, promised to Make sure patients and families are the reason for everything I do. “I wrote it on the back of my name badge,” he says. “Sometimes we get into these quality improvement meetings, and we’re very focused on the process. I’ll find myself fidgeting with my name badge, and it prompts me to say, What do you think the patient would think about this?”
Part of the reason Alberta has decided to embrace Change Day is that, similar to the NHS, the AHS is facing long-standing morale problems. Although employee engagement scores have risen since 2010, physicians and employees still report that they need more stability and vision from leadership to feel good about their jobs.
But not everyone is impressed with a system where doctors might pledge to smile more. The NHS received criticism that its pledges were too superficial. “My response to that criticism is that it’s not for me to tell people what to do, and to tell people whether their pledge is important or not,” says Roland. “Among all the pledges, there are loads of outcome based pledges, and the moment we try and limit stuff, you lose the whole purpose.”
In the NHS, there has also been “pressure on us to deliver some evidence of return on investments,” says Roland. “That is challenging for the type of work we’re doing.”
However, tracking the impact of changes is crucial, says Khalid Aziz, a professor of pediatrics at the University of Alberta. “We improve the quality of health care by doing three things: we collaborate with one another, we design strategies to implement, and we measure and evaluate what we’ve done. Change Day is nice, but it’s like you’re picking one wedge of the pie. It’s not a full quality improvement cycle.”
In the end, the stories, Roland says, are the best argument. “There can be a lot of cynicism,” he says. “But it’s quite difficult to backlash against people saying look, I’m feeling a bit browbeaten, but we tried this and actually, it was quite fun.”
BC considers its Change Day a success – they garnered nearly 8,000 pledges – but there was some some feedback that “there are many things pulling for time,” says Colleen Kennedy, director of innovation and engagement who led BC’s Change Day campaign. They’re taking a “pause” from Change Day this year to learn from their experience last year and to prevent this from becoming a regular program that feels obligatory.
This fits into a larger trend of testing new ways to try and get front line providers and patients involved in pushing change, says Danielle Martin, vice president of Medical Affairs and Health System Solutions at Women’s College Hospital. “This is a good instinct. We cannot continue to tell people how they need to change, we need to ask them,” she says. “And it’s tapping into employee engagement, tapping into that sense of fun.”
Yet she wonders whether Change Day will produce the “ripple effects” it’s promising. “It implies that individuals can make the change that we need to make in health care, and that puts too much pressure on individuals. Plus it ignores the evidence that individual change is really hard to make and really hard to sustain. It seems to me like what’s missing is the institutional commitment to taking what those front-line teams are doing and putting some muscle behind them.”
“But I don’t rule out the possibility that it will open the door to a culture change around making the workplace better for patients.”