Report: Cross Sector Working to Support Large Scale Change

The Health Foundation has come up trumps with a fabulous light touch literature scan of evidence around how cross sector working influences large scale change.

I commend you to read it.

Paper: Evidence based surgery - don't show this to the patients!

I stopped to read a summary of this paper, mainly because I was struck by the thought that surgery may not be evidence-based... The best bit about this paper, for me, is that the authors have described the elephant in the room (or should that be in the operating theatre). Well done to them.

World J Surg. 2012 Aug;36(8):1723-31.
Evidence-based surgery: barriers, solutions, and the role of evidence synthesis.
Garas G, Ibrahim A, Ashrafian H, Ahmed K, Patel V, Okabayashi K, Skapinakis P, Darzi A, Athanasiou T.

Evidence: Quality Improvement Training

The Health Foundation has released a useful, and I think important, scan of the literature surrounding the strategy, content and process of training others in quality improvement. The document is a comprehensive and well organised summary of their scan of an enormous number of papers.  You can download the 52 page PDF from their website.

What  I liked about this literature scan is their focus on the impact of training. If you are responsible for organising or delivering quality improvement training then I recommend this literature review.

Coaching, feedback and behavioural tools - MBTI

So what tool or method do you use for your coaching practice or other organisational and improvement work?

Over my career I've been on the receiving end of a number and also tried a variety with different clients.  I've ended up using MBTI (Myers Briggs Type Indicator) as my main method for helping others - to help themselves. My main reason is this tool is well evidenced, has been in place for decades and is used successfully in many countries. The evidence base is important for me as I believe it is necessary for healthcare to demonstrate the use of evidence-based techniques and tools.  The techniques can't be administered or debriefed unless you've been accreditated which means there is a consistent standard world-wide.

Other reasons I prefer MBTI:

• it is more than a one-off
• it can be scaled from individual through the team and organisation
• it works well to support change processes
• the evidence base, being huge, allows greater depth of understanding
• it is common enough that it provides a "language" for staff to use in times of difficulty

Do you know of or use other behavioural techniques which have an evidence base similar to MBTI and can also be scaled up in their use?

Leadership, Spread, Adoption & Sustainability

Here is a summary of some blog posts I've written with healthcare leadership in mind:

• Do middle managers matter in healthcare? (refers to a peer-reviewed paper)
• Why don't we search for evidence? (Importance of role modelling)
• Is the role of the organisational champion effective? (Refers to peer-reviewed paper)
• Leaders need to be productive (Video)
• Scheming virtuously: A handbook for public servants (links to the handbook)

How is evidence being used?

Having moaned in this blog a few days ago about people not searching for evidence, I see a small group have set out a protocol to examine just how managers and professionals access the evidence.

I hope they will also do the negative study - those who are not accessing the evidence...


Implement Sci. 2012 Mar 21;7(1):22. [Epub ahead of print]
Making sense of evidence in management decisions: the role of research-based knowledge on innovation adoption and implementation in healthcare. Study protocol.
Kyratsis Y, Ahmad R, Holmes AH.


"Abstract
BACKGROUND:
We know that patient care can be improved by implementing evidence-based innovations and applying research findings linked to good practice. Successfully implementing innovations in complex organisations, such as the UK’s National Health Service (NHS), is often challenging as multiple contextual dynamics mediate the process. Research studies have explored the challenges of introducing innovations into healthcare settings and have contributed to a better understanding of why potentially useful innovations are not always implemented in practice, even if backed by strong evidence. Mediating factors include health policy and health system influences, organisational factors, and individual and professional attitudes, including decision makers’ perceptions of innovation evidence. There has been limited research on how different forms of evidence are accessed and utilised by organisational decision makers during innovation adoption. We also know little about how diverse healthcare professionals (clinicians, administrators) make sense of evidence and how this collective sensemaking mediates the uptake of innovations.
METHODS:
The study will involve nine comparative-case study sites of acute care organisations grouped into three regional clusters across England. Each of the purposefully selected sites represents a variety of trust types and organisational contexts. We will use qualitative methods, in-depth interviews, observation of key meetings, and systematic analysis of relevant secondary data to understand the rationale and challenges involved in sourcing and utilising innovation evidence in the empirical setting of infection prevention and control. We will use theories of innovation adoption and sensemaking in organisations to interpret the data. The research will provide lessons for the uptake and continuous use of innovations in the English and international health systems.
DISCUSSION:
Unlike most innovation studies, which involve single-level analysis, our study will explore the innovation-adoption process at multiple embedded levels: micro (individual), meso (organisational), and macro (interorganisational). By comparing and contrasting across the nine sites, each with different organisational contexts, local networks, leadership styles, and different innovations considered for adoption, the findings of the study will have wide relevance. The research will produce actionable findings responding to the political and economic need for healthcare organisations to be innovation-ready."

Seven Key Factors in how minds change - 1: Changing Minds

Notes from the book "Changing Minds" by Howard Gardner (2004)

What I learnt was that if we want to help someone change their mind about what constitutes good practice (and thereby figure their practice is not the best so they need to decide to adopt a better practice), then it helps if we can:

1. Demonstrate what has to be changed in a way that someone can figure out for themselves what the reason is for them to change. Some people do this analytically and others deduce or infer from what they learn that a change is necessary. I think it's important to understand it's the adopter who needs to reason, not the person pushing the change.
2. Research, evidence, statistical analysis etc is crucial when working with healthcare professionals for whom this is the base of their practice. The onus of evidence is on the person pushing the change.
3. The proposed change needs to connect at the emotional and intuitive level with the potential adopter. The really good proponents of change can combine the emotive, rational and evidence content in their rhetoric.
4. The concept of redesciption intrigued me. I can see now that the person who can describe the proposed change in many different ways, whilst remaining true to the core concepts and values, is more likely to be able to convince others to change.  Not least, being able to redescribe means you know your stuff and this enhances the credibility of the proposal.
5. Rewards are obvious - pay someone and they are more likely to do it. But this doesn't always lead to the mind changing. The most basic reward is praise and confirmation of the new behaviour.
6. Real World Events - means tagging your proposals to outside influences. As a friend pointed out to me recently, a great time to raise the profile of pancreatic cancer would have been in the days after Steve Jobs died. To make the most fo these (not always sad) events, is to be prepared.
7. Resistance... it takes two to create resistance. The best way I know to deal with it is to stop pushing and to see things form the other's perspective - then, find a way to break through the debate.

Canadian Best Practices Portal - Healthcare

The Public Health Agency of Canada has a very interesting website: Canadian Best Practices Portal.  I think it is an excellent example of helping to spread good practice.

1. It describes interventions (best practices) without overly classifying them. The reader can make their own judgements of value and worth. I also like the way these are summarised as they are written for the reader and not as corporate sales pitches which is a temptation other organisations fall foul of. 
2. The resources have a great at-glance feature which show how they relate to define, search, appraise, synthesise, adapt, implement, evaluate.
3. Their list of systematic review sites is extensive and pitches these best practices as being based on evidence which is both appropriate and welcome for healthcare interventions.

Is there evidence for your quality improvement intervention?

Is there evidence for the interventions we're using to improve quality of services and to reduce costs? I suspect in many cases there isn't. Sometimes just doing something is better than nothing, though I do find it surprising that some organisations are strong at pushing a particular intervention, even though there are few (unpaid for) independent evaluations. And on the other hand, there are some well evidenced interventions that organisations don't want to use because they are appear old fashioned. Hmmm - we demand of healthcare professionals that they use the best evidenced methods - should we be demanding that of ourselves?

There's an excellent visualisation for the scientific evidence of dietary supplements. When I looked at this I wondered whether we could do something similar for the quality improvement interventions that are being used around the world?

In the meantime, using the SQUIRE Guidelines to write up your projects will go a long way to building up an evidence base of what works - and what doesn't.

New Paper: How to use an article about quality improvement (JAMA Nov 2010)

One of the difficulties in spread and adoption is, on the one hand avoiding the temptation to take the results from one project and then do a back of the envelope calculation and announce if the results were spread then there would be x billion savings etc; and on the other hand, if you're a project lead, how do you read a piece of evidence and work out its relevance for your own work?  There is a new paper out which touches on this subject.

 JAMA. 2010 Nov 24;304(20):2279-87.

How to use an article about quality improvement.

Fan E, Laupacis A, Pronovost PJ, Guyatt GH, Needham DM.

Abstract

Quality improvement (QI) attempts to change clinician behavior and, through those changes, lead to improved patient outcomes. The methodological quality of studies evaluating the effectiveness of QI interventions is frequently low. Clinicians and others evaluating QI studies should be aware of the risk of bias, should consider whether the investigators measured appropriate outcomes, should be concerned if there has been no replication of the findings, and should consider the likelihood of success of the QI intervention in their practice setting and the costs and possibility of unintended effects of its implementation. This article complements and enhances existing Users' Guides that address the effects of interventions--Therapy, Harm, Clinical Decision Support Systems, and Summarizing the Evidence guides--with an emphasis on issues specific to QI studies. Given the potential for widespread implementation of QI interventions, there is a need for robust study methods in QI research.