improving clinical services: no magic bullet... some things work better than others - jeremy...
TRANSCRIPT
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 - [email protected] – [email protected] available from:
www.rxforchange.ca
http://ktclearinghouse.ca/ktcanada