Improving healthcare value: Choosing Wisely Canada's hospital designation program

Choosing Wisely is a campaign led by clinicians to reduce unnecessary resource use in healthcare. It began with a focus on raising awareness about the harms of overuse of unnecessary tests and treatments. Choosing Wisely Canada (CWC) has since been actively leading and guiding organizations in system-level implementation through education, advocacy, the creation of a community of practice, and national collaborative implementation programs. Like all quality improvement work, implementation efforts are more likely to be successful when supported by system-level enablers. Some enablers that have been studied include mandatory accreditation programs, financial incentives, and intrinsic motivators. Choosing Wisely Canada chose to incorporate key elements of intrinsic motivators in a program tailored to recognize its resource stewardship goals. In many jurisdictions, quality improvement enablers take the form of mandatory accreditation programs such as Accreditation Canada and the Joint Commission in the United States, designed for hospitals to meet quality indicators. However, accreditation bodies tend to be designed in partnership with regulatory bodies with frameworks which are neither specific nor all relevant to Choosing Wisely recommendations.1 Financial incentives for the purposes of improved sustainability and stewardship are also found in healthcare systems worldwide2, 3 and have been shown to improve care in certain contexts.2-4 However, there are criticisms levied towards stewardship programs structured around financial incentives and rewards,5 including from physicians themselves.6, 7 Many physicians may not feel that monetary incentives would motivate them to change practice patterns and feel they would increase discomfort or cause backlash from patients.7 They may prefer intrinsic motivation driven by peer perception, professional pride, and reputation. Intrinsic motivation is a well-studied behavioral factor related to the core human drive to feel competent and effective in order to maintain some control on causality in their surroundings.8 Whereas financial motivations and one-time payments diminish in effect over longer periods of time,9-11 intrinsic motivators may sustain long-term and promote behavioral changes.7, 12 Unlike financial incentives, these motivators also address the issue of dual agency: the perception that physicians place financial factors above their patients' interests. This approach builds trust by having conversations and discussions with experts rather than decreeing absolute policy changes, and produces learning networks to disseminate information, engage partners, and implement new approaches to healthcare, all of which are indicators of a reliable, competent, and sustainable program.6 Further studies are necessary to properly evaluate the relationship between stewardship program efficacy and interventions developed with behavior change theory principles,13 but common practices shown to be promising include peer reputation, electronic medical record support, individualized overuse data, and expert discussions and forums.7 Accreditation programs designed in collaboration with the government or other regulatory bodies have also been studied extensively, with varying degrees of success in implementation and outcomes, dependent on multiple parameters of each program.14 They can improve patient safety and reduce medical error rates while enhancing staff proficiency and organizational transparency.15-17 However, large-scale mandatory programs have also been perceived as bureaucratic, with more paperwork and other time-consuming tasks that take away time from clinical work, negatively impacting employee performance and subsequently patient care.18, 19 Thus, while accreditation programs can benefit healthcare delivery, the degree to which this is achieved is highly dependent on the approach, implementation, and goals of the governing organization. The Choosing Wisely Canada Hospital Designation Program was created by combining strengths of established frameworks. It leverages the spirit of the Choosing Wisely Campaign, which started as a grass-roots initiative driven by professional societies to create lists relevant to their speciality to reduce low-value care. Healthcare professionals not only created lists of low-value targets but also began implementing the recommendations across hospitals. Because HDP is a voluntary program, it uses intrinsic motivators of clinicians who are committed to a bottom-up approach to high-value care. In the following section, we describe the Hospital Designation Program and early learnings which may be useful in creating similar programs in other jurisdictions. In 2019, in recognition of outstanding commitment to high-value care, Choosing Wisely Canada created a Hospital Designation Program (HDP) that seeks to elevate the status of hospitals successfully implementing CWC recommendations with a certificate of designation and broad-reaching public acknowledgment. The appeal of the Hospital Designation Program is that it is driven by clinicians based on intrinsic motivations. The program was conceived and designed with input from stakeholders from CWC, the hospital sector, and professional societies. In Phase 1 of the HDP, three levels of designation were offered, with Level 3 corresponding to the highest level of commitment and demonstrated improvement, including embedding a commitment to CWC into the hospital's strategic plans and mentorship of peer hospital(s) in their Choosing Wisely implementation. The HDP requirements for each level and designated hospital characteristics are described in Table 1. Level 1 designated hospitals must demonstrate successful implementation of 5 “easy wins,” system-level interventions that are simple to implement such as removing the ability to order folate testing. Level 3 designated hospitals must demonstrate successful implementation of at least 7 CWC recommendations in all or many clinical areas. The program has received national interest, with 64 hospitals designated in Phase 1, and is an effective strategy to engage clinicians in resource stewardship. Uncouple PT/INR and aPTT tests and revise ED order panels Eliminate creatinine kinase testing if troponin is available Remove “daily lab” options from order sets Remove folate testing from your hospital's ordering systems Stop ordering routine chest X-rays in the intensive care unit, except to answer specific clinical questions Academic medical center: 10 Community hospital: 19 Regional health authoritya: 17 British Columbia: 17 Alberta: 2 Ontario: 20 Quebec: 3 Nova Scotia: 4 Quality improvement methods must include collection of baseline data, the intervention(s), and collection of results data Projects could include implementation of Choosing Wisely Canada toolkits Academic medical center: 2 Community hospital: 8 Alberta: 1 Ontario: 8 New Brunswick: 1 Make Choosing Wisely part of the hospital's operating/strategic plan Implement at least 10 distinct Choosing Wisely Canada recommendations, across multiple hospital departments. The recommendations implemented in Levels 1 and 2 may count towards the 10. Mentor or collaborate with at least 1 other hospital on Choosing Wisely Academic medical center: 4 Community hospital: 4 As the program matured, it was re-launched as Phase 2 in 2022 with a simplified 2-level designation process of “Quality Improvement” and “Leadership” status. Hospitals designated as Phase 1 hospitals continued to maintain their prior designation but were also eligible to transfer their designation to a Phase 2 status hospital. Hospitals seeking designation for the first time can only apply to a Phase 2 status (QI or Leadership). One reason for the new program, while still requiring the implementation of Choosing Wisely recommendations, is to focus on sustainability of results, which was not a requirement of Phase 1 hospitals. Hospitals in both the Quality Improvement and Leadership levels must demonstrate their intention to sustain Choosing Wisely efforts in the years following designation through regular submission of outcomes data. Requirements for the new program are described in Table 2. Since the re-launch in Phase 2, 25 out of the 64 hospitals designated in Phase 1 have been approved for new designations under either QI or Leadership Status and one new hospital has achieved a Phase 2 designation, bringing the total number of hospital designations achieved to 90. Becoming a Using Blood Wisely Hospital (Counts as two credits) Participating in Using Labs Wisely (Counts as two credits) Take on a self-directed Choosing Wisely QI project (Counts as one credit each) Demonstrate sustained efforts and ongoing organizational commitment to Choosing Wisely at year 1 and year 2 post-designation, and every 2 years thereafter Five credits can be used from the QI Status designation Becoming a Using Blood Wisely Hospital (Counts as two credits) Participating in Using Labs Wisely (Counts as two credits) Take on a self-directed Choosing Wisely QI project (Counts as one credit each) Mentor another hospital Make Choosing Wisely a strategic priority/operating plan Demonstrate sustained efforts and ongoing organizational commitment to Choosing Wisely at year 1 and year 2 post-designation, and every 2 years thereafter Key success factors of the program demonstrating positive change include a clinician-driven, bottom-up approach, emphasis on measurable outcome data using improvement science methods, and high-profile recognition attained with designation in public and healthcare fora. Many designated hospitals describe strong clinician-led approaches to reducing unnecessary care, supported by organizational leadership. This bottom-up approach encouraged clinician engagement which aligned with hospitals' mandated goals of demonstrating system improvement. Hospitals were eager to provide quality improvement supports (e.g., data extraction and analysis, access to improvement specialists, etc.). Support offered by CWC included targeted educational webinars about the program and showcasing success stories from across the country. CWC provided opportunities to meet one-on-one with the hospital's implementation teams for any questions or issues that arose, connected hospitals with regional CWC offices to navigate local issues, and matched applicants to other similar hospitals (in size, location, population served, etc.) for informal mentorship. Through these supports, hospitals gained insight from experts on successful quality improvement implementation. The CWC recommendations are a facilitator for hospitals looking to undertake QI projects, and we find that hospitals take pride in attaining recognition for their achievements, especially when compared to peer hospitals. Designated hospital leaders indicate that the program is a win-win for their hospitals: demonstrating improved patient care with the creditability of implementing evidence-based CWC recommendations, while receiving national recognition via the Hospital Designation Program. The designation process requires peer-reviewed applications by quality experts in the field and the inclusion of quality improvement methods, such as the use of statistical control process charts to elevate the status of the designation. In addition, designated hospitals are frequently provided several opportunities for wide-reaching recognition through public announcements on the CWC website, newsletters and social media, and spotlight opportunities at numerous CWC webinars and conferences. Designated hospitals join the network of ‘Choosing Wisely Canada Hospitals’ with benefits of inter-hospital collaboration and mentorship opportunities, providing dissemination of success stories and furthering the reach of the program. Other quality improvement designation programs exist, however most tend to adopt a top-down rather than bottom-up approach. These include Magnet, Best Practice Spotlight Organizations, and the European Society for Medical Oncology (ESMO) Designated Centres Accreditation Program, all having been shown to benefit healthcare systems in a variety of ways.10, 20-23 The Choosing Wisely Canada Hospital Designation program is a novel quality improvement model for the recognition of sustainable resource stewardship. It focuses its reward mechanisms predominately on factors of intrinsic motivation, independent of financial and regulatory bodies, in order to generate organic growth and discussion surrounding the implementation of countless evidence-based guidelines. Its grass-roots approach to sustaining improvement has garnered interest with 65 hospitals in Canada voluntarily undergoing the designation process. We believe this approach of supporting clinician-driven improvement produces results that “stick” and valuable lessons learned in quality improvement and implementation science. The next phase of Choosing Wisely focuses on engaging teams to sustain change and demonstrate ongoing improvement with data measurement. Future work will evaluate the impact of the Designation Program on clinical outcomes. Doreen Day is an employee of Choosing Wisely Canada, and Dr. Christine Soong receives salary support from Choosing Wisely Canada, a non-profit organization. Choosing Wisely Canada did not contribute to the content or drafting of this paper. The authors do not have other relevant conflicts of interest to disclose.

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