improving clinical services: no magic bullet... some things work better than others - jeremy...

Improving clinical services No magic bullet...but some

things work better than others

Jeremy GrimshawSenior Scientist, Ottawa Hospital Research Institute

Professor, Department of Medicine, University of OttawaCanada Research Chair in Health Knowledge Transfer and Uptake

Greetings from Ottawa

Background

Why do we need to think about service improvement?

Consistent evidence of failure to translate research findings into clinical practice

30-40% patients do not get treatments of proven effectiveness

20–25% patients get care that is not needed or potentially harmful

Schuster, McGlynn, Brook (1998). Milbank Memorial Quarterly

Grol R (2001). Med Care

Suggests that service improvement is fundamental challenge for healthcare systems to optimise care, outcomes and costs

How do healthcare systems and organisations currently try to

improve clinical services?

Issue guidance

Internal solutions

ISLAGIATT

principle

Martin P Eccles

‘It Seemed Like A Good Idea At The Time’

Favourite solutions

If you have a hammer, everything looks like nail

External solutions

Current situation

All of these solutions work some of the time. None work all of the time.It is unclear when they do work whether they

maximally improve practice. It is unclear when they do work whether they

represent the most efficient use of scarce health care quality improvement resources.

‘Evidence based medicine should be complemented by evidence based implementation’

Grol (1997). British Medical Journal

Cochrane Effective Practice and Organisation of Care (EPOC) Group

Cochrane Effective Practice and Organisation of Care (EPOC) group undertakes systematic reviews of interventions to improve health care systems and health care delivery including:

Professional interventions (e.g. continuing medical education, audit and feedback)

Financial interventions (e.g. professional incentives)

Organisational interventions (e.g. the expanded role of pharmacists)

Regulatory interventions

Cochrane Effective Practice and Organisation of Care (EPOC) Group

Intervention # of trials Median absolute effect

Interquartile range

Audit and feedback(Ivers 2011)

140 +4.3% +0.5% - +16%

Educational meetings(Forsetlund 2009)

81 +6% +3 – +15%

Financial incentives(Scott 2011)

3 NA NA

Hand hygiene(Gould 2010)

1 NA NA

Key challenge is to determine which improvement ‘tool’ is likely to achieve optimal improvement within available resources

Key challenge for improvement

Selecting improvement interventions

Behavioural perspective Implementation depends on behaviour

Citizens, patients, health professionals, managers, policy makers

To improve care, we need to change behaviour

To change behaviour, it helps to understand determinants of current behaviour and how behaviour changes

Selecting improvement interventions

Selecting improvement interventions

Who needs to do what differently?

Using a theoretical framework, which barriers and enablers need to be addressed?

Which intervention components could overcome the modifiable barriers and enhance the enablers?

How will we measurebehaviour change?

Who needs to do what differently?

What is the behavior (or series of linked behaviors) that you are trying to change?

Who performs the behavior(s)? (potential adopter)

When and where does the potential adopter perform the behavior?

Are there obvious practical barriers to performing the behavior?

Is the behavior usually performed in stressful circumstances? (potential for acts of omission)

Which barriers and enablers need to be addressed?

KnowledgeSkillsSocial/professional

role and identity Beliefs about

capabilitiesOptimismBeliefs about

consequencesReinforcement

Which barriers and enablers need to be addressed?

Intentions GoalsMemory, attention

and decision processes

Environmental context and resources

Social influencesEmotionBehavioural

regulation

Cane 2012 – Theoretical Domains Framework v2

Which intervention components could overcome barriers?

Which intervention components could overcome barriers?

Technique for behaviour change

Social/ Professional role & identity

Knowledge Skills Beliefs about capabilities

Beliefs about consequences

Motivation and goals

Memory, attention, decision processes

Environmental context and resources

Social influences

Emotion Action planning

Goal/target specified:

1 2 1 3 2 3 1 3 1 3 3 3 3 1 1 1 1 1 1 3 2 3 3

Monitoring 1 2 3 3 3 1 2 2 1 2 2 1 2 2 1 2 2 2 1 2 2 1 1 2

Self-monitoring 2 3 3 3 3 2 3 3 2 2 2 1 3 2 1 2 2 3 2 1 3

Contract 2 1 1 1 1 1 2 3 1 2 2 3 2 2 2 2

Rewards; 1 2 1 1 3 3 3 2 1 2 1 2 2 3 3 3 1 1 2 1 1 2 1 2 1 2 1 1

Graded task, 1 1 3 3 2 2 2 3 2 2 3 2 2 1 2 1 1 1 1 2 1*

Increasing skills: 1 2 3 3 3 3 2 2 3 2 1 2 3 2 1 2 1 2 3 1

Stress management

1 1 2 1 1 1 1 1 2 1 1 2 1 1 3 3 2 1 1

Coping skills 1 2/3 3 1 2 2 2 1 1 1 1 1 1 3 2 2 1/2

Rehearsal of relevant skills

1 3 3 3 3 2 3 2 2 1 2 1 3 2 3 1 1

Matching behaviour change techniques to theoretical constructs

agree use; agree don’t use; disagreement; indefinite

Which intervention components could overcome barriers?We have found it useful to distinguish:

What we are trying to change Why are we trying to change it?

(constructs: barriers and enablers) How are we going to change it, including

Behaviour change technique Context: the mode of delivery (eg group

meeting, DVD) Content: how the technique will be

operationalised

Implementation laboratories to optimise audit and feedback Cochrane 2012 review – 140 trials of audit and

feedback, median absolute improvement +4%, interquartile range +1% to +16%

Larger effects were seen if: baseline compliance was low. the source was a supervisor or colleague it was provided more than once it was delivered in both verbal and written

formats it included both explicit targets and an action

plan

Ivers (2012) Cochrane Library

Implementation laboratories to optimise audit and feedbackFuture studies need to evaluate comparative

effectiveness of different methods of delivering audit and feedback Timing Design Content Delivery Sustainability Co-interventions

Need large sample sizes that are unlikely to be realised in one off research projects but opportunities to collaborate with health care systems already delivering audit and feedback programs

Implementation laboratories to optimise audit and feedback

Implementation laboratories to optimise audit and feedback

• UK NIHR funded 5 year research program• 2x2 factorial trial testing different ways of

designing and delivering blood utilisation audits

• Randomising 152 UK trusts

Meta-Implementation laboratories

Summary

Service improvement is about saving lives, improving health outcomes and the quality of health services.

Substantive evidence base on the effects of different improvement interventions; good news is that it is possible to change stakeholder decisions and behaviours!

However current evidence base provides little practical guidance for health care systems about which interventions to use and how to optimise them

Future evaluative efforts need to focus on better, more transparent intervention development, more creative designs to enhance the informativeness of studies

Substantial theoretical and methodological development needed.

Contact details

Jeremy Grimshaw - jgrimshaw@ohri.caEPOC – epoc@uottawa.caResults available from:

www.rxforchange.ca

http://ktclearinghouse.ca/ktcanada