Keys to improving healthcare services

Posted on March 17, 2014 by Sharon Mickan — Leave a comment

Can innovation be led by clinicians and professionals in local healthcare services?

Can these innovations drive improved services for patients?

It seems possible – at least in a recent learning report produced by the Health Foundation, who sponsored 32 Shine projects designed to do just this. They summarised internal lessons learned across 4 project categories; using IT to improve services, changing the way services are organised, improving access to information and by training staff. Despite emphasising the need for these projects to demonstrate cost benefits, many could not. In part this may be due to difficulties with data collection, project design and outcome measurement.

However, some interesting lessons have been reported about the way to design improvement projects, that could be a useful adjunct to what is known about implementing change in healthcare organisations. 4 success factors have been highlighted.

  1. Local clinical leadership is crucial to identify where the local improvement is needed, generate local ownership of the project, manage upwards through their organisations  and facilitate the promotion of new ideas
  2. Project managers are key to ensure successful logistics for the implementation and measurement of the proposed change
  3. Detailed early planning with all key players is necessary to generate comprehensive implementation plans
  4. Effective communication, using regular meetings and wide dissemination of important information, is necessary to engage staff and key stakeholders

While many of these projects were focussed on improving work flow efficiencies, it is important to build up the research evidence for key processes behind these success factors, that can show improvement, and for ways in which they can be measured.

We should separate out 2 types of change, to understand how to measure both;

  • the ‘actual’ change in how patients are treated; usually described as a clinical intervention and measured by an objective clinical outcome
  • the change in HOW the practice is implemented ; these conditions for improvement usually refer to key processes in the surrounding environment, or context, which can be monitored and measured

On the one hand, if we only report final outcomes, we know that variation in outcome measurements can be caused by differences in the type of patient, measurement tools, chance and actual differences in the quality of care. However, process measures are more sensitive that outcomes measures to quality differences, and they are easier to interpret. Process measures usually describe some aspect of the context, or conditions for improvement. Therefore, if we can show associations between key processes and meaningful clinical outcomes, it will be much easier to generate future improvements in the quality of health care.

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Posted in health care services, healthcare professional, implementation, improvement, information, innovation, learning, organisation

What is evidence?

Posted on March 11, 2014 by Sharon Mickan — 2 Comments

Over the last 20 years, in the world of evidence-based health care, there are running debates about what constitutes evidence and hidden assumptions in the way the word evidence is used.  In defining this word, it is important to recognise that there are different types of definition. The simplest descriptive definition of  the word evidence is defined by the Oxford dictionary as the available body of facts or information indicating whether a belief or proposition is true or valid.

Facts or information are the starting point of evidence. Yet,  information can mean different things to different people, and in different circumstances. It may be that information constitutes evidence in one setting, but not in another.

When used in the phrase, evidence-based, a different definition is offered as denoting disciplines of health care that proceed empirically with regard to the patient and reject more traditional protocols. It seems that by using the whole phrase evidence–based changes the emphasis of evidence to preferentially value scientific information. 

Further, our understanding of evidence may depend on what we want to know, why we want to know it and how we will use it. The potential use of evidence is well explained in an early definition … Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. Implicit in this definition is the recognition that doctors require additional information from and about patients and they also need to understand how to make judgements about what is the best scientific evidence.  Could this be a key to the debate? Can  information about patients’ needs and clinicians’ expertise be defined as evidence? While this information may constitute evidence according to our first definition, it may not concur as well with the definition of evidence-based.

However, information about patient conditions and preferences, and the clinicians’ expertise is required to interpret and use research evidence. The term practical evidence was used to describe judgements made about the meaning and applicability of research data in the context of information from personal experience, advice from colleagues and local norms of practice.

This argument has been well developed, such that there is now widespread opinion that research evidence is not sufficient to inform clinical practice or healthcare policy. Ten years ago a key nursing paper argued that there are 4 types of evidence;  namely research, clinical experience, patient experience and information from the local context, and that information from all 4 sources are necessary for making health care decisions. Although widely cited, this paper has had limited influence. It seems that the EBM movement continues to prioritise information about research, calling it evidence while implicitly downgrading information about patients and clinicians. Furthermore, information about the actual context of clinical practice has been assigned to a black hole, otherwise known as the knowledge-practice gap.

Can we describe evidence sufficiently by definition alone without understanding how it is being used? Perhaps it is useful to recognise that the word evidence has adopted an implicit acknowledgement of scientific rigour, when it is used in the phrase evidence-based. However the way in which evidence is being used is important, and the elite dominance of research evidence in clinical decision making needs to be contested.

It is important to realise the limitations of research evidence, such that average study results do not always apply to target populations. Additional knowledge is required to apply research results in particular cases. This knowledge requires key information about patients, clinicians and the context in which they work. There is a need to collate and organise practical, experiential and theoretical knowledge to judiciously use the research evidence to make the best decisions for patients.

There is a final challenge to this argument – when empirical research underpins information about patients,  clinicians’ experience and their local contexts, can we call this information evidence, especially if we can demonstrate how it influences the use of research results? Should we recognise a pragmatic working definition of evidence for improving health care?

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Posted in clinical practice, definition, evidence, evidence-based health care, information, using research

Why research may not help individuals

Posted on March 10, 2014 by Sharon Mickan — Leave a comment

Many of us have learned that large experiments with representative samples and random allocation of participants are vital to be able to generalise results back to the target population. Yet we must be careful in applying these results for individuals, for two reasons. Sometimes the individual may not represent the target population, and at other times, the individual may represent a sub-group within the target population for which the intervention was not beneficial or in fact, harmful.

A recent article explained this dilemma in relation to the benefits of taking certain drugs, and offered a short checklist to help make these recommendations. First of all, it is important to understand the pathophysiological explanation for how a particular drug works, in its target population. For many drugs, we have a good understanding of the way in which key chemicals and compounds are absorbed, distributed, metabolised and excreted. This is described as the normal mechanism of action.

Therefore, if the individual in question has the same normal mechanism of action, it is most likely that the chosen drug will have the same effect as it did on everyone else in the trial. However, if some aspect of the individual is different; they are much older, they have existing disease or they are overweight; then it is not so likely that the outcomes will be the same for that person. Some trials publish results for some of these key points of difference, but in many cases descriptions are limited.

Three key steps are offered as a way to better understand whether an individual may benefit from a specific research recommendation.

  1. is there a clear explanation of the mechanisms of how the intervention works? (is this supported by research evidence?)
  2. is the underlying mechanism of action for the target population, similar for the individual?
  3. are the contextual factors influencing whether relevant mechanisms are activated similar between the target population and individual?

The authors argue that judgement is always required in deciding to use research results for an individual. This article illustrates both how we do understand the mechanisms of actions for certain drugs and uses a black box to show where the mechanism of action is not well understood.

I wonder if this checklist of 3 important questions can also be applied to non-drug interventions, such as rehabilitation programmes, counselling or cognitive behaviour therapies? Instead of explaining the pathophysiological explanation for how a particular drug works, there will need to be a description of key components, and their associated materials, procedures, people, environments, and theoretical rationale. A new TIDieR checklist has been developed which emphasises the importance of describing the mechanisms of action for the active components of an intervention.

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Posted in behaviour, intervention, using research

Does research knowledge change clinical practice?

Posted on February 4, 2014 by Sharon Mickan — Leave a comment

When we teach clinicians the skills of  evidence-based practice (EBP), we encourage them to search for and critically appraise research  evidence to answer their clinical questions. Then, we expect them to apply this research evidence to improve their clinical practice, despite knowing that this is a complex intervention that is poorly understood.

How best should we conceptualise this process so that we can measure and document success, in order to  build the evidence base for implementing research? A key insight was shared in 2007; ” we need to move beyond the static view of knowledge translation and embrace the changing nature of context and individual decision making”. In short we need to find the best ways to understand and work within different healthcare organisational contexts and to recognise individual behaviours that can drive this change forward.

There are many organisational theories that offer explanations of change. From these, many models have been developed to highlight key aspects of organisational cultures. However, few have been validated in practice, and for those that have, there is a delicate balance between identifying key organisational factors for success and tailoring the intervention to the local context.

Social psychology theories offer insights into understanding individual behaviour change. A recent systematic review summarised that individuals’ beliefs about their capabilities and their intentions to act were predictive of their action. This is reminiscent of Bandura’s description of self-efficacy as a belief in one’s own ability to complete tasks and reach goals. It is also what we commonly call confidence, and there are reports from nurses, of the correlation between high levels of self -efficacy and the ability to perform a specific task, and the future propensity to act. 

Are we in a position to suggest that teaching EBP skills improves healthcare professionals’ self-efficacy, and their beliefs and behaviour about implementing research evidence? The developers of the Evidence-based Practice Confidence (EPIC) scale argue for this. They suggest that this scale can measure individual change. It sounds very promising – does anyone have any further evidence to contribute to this debate? Perhaps, we should also consider individuals’ views and beliefs in relation to their organisational context.

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Posted in change, complex interventions, evidence-based practice, implementation, knowledge translation, organisation, sustainability, using research

knowledge to change practice

Posted on February 4, 2014 by Sharon Mickan — Leave a comment

Recognising different types of knowledge helps to explain some of the difficulties of changing practice. I will summarise an impressive conceptual article that sadly, is not available via open access.  If we think about knowledge in its broader sense, it involves technical, theoretical and practical reasoning. Every day, healthcare professionals use theoretical and scientific knowledge of their discipline, together with their individually developed technical and professional skills and practical reasoning to respond to patients’ healthcare queries.

Another way of looking at this, is that the knowledge that professionals use is influenced by their cognitive learning, social experiences and cultural interactions. Healthcare professionals shape and reshape their knowledge through lived experiences and through interactions with other practitioners, in response to their profession and its history, and in relation to the organisation in which they are working.

Therefore, the knowledge that is required to change practice has at least 3 different components;

  1. relevant scientific and theoretical knowledge – formal education can be very helpful here, to identify where there is research evidence
  2. practical know-how – this is often dependent on personal skills and experience, and is usually located in a clinical setting and time
  3. critical reasoning, to integrate the first 2 types of knowledge in order to recognise the need to amend or change plans

Many of us can recognise that experts have the ability to identify abnormal patterns in either the patient or the environment that others may not even notice. This ability to understand all components of familiar situations and recognise small and significant changes is something that requires extensive experience and a form of reflexive thinking.

Further, to bring these three types of knowledge together requires more than just education. Ideally, relationships between researchers within universities who value scientific knowledge and clinicians and managers within healthcare organisations are required. From this, there needs to be a focus for change that

  • brings together key participants with scientific and practical knowledge
  • to solve an identified problem
  • and reach agreement for action

But first,  different alternatives need to be discussed from a variety of perspectives using a common language, that builds mutual understanding and respect of different benefits and barriers. Then, it is possible to negotiate about the priorities for change and agree on an appropriate action that can be implemented and monitored. It is important to monitor the process and measure the specific outcomes achieved.

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Posted in change, clinical practice, evidence, healthcare professional, knowledge, organisation, using research

5 components to exchange knowledge

Posted on December 10, 2013 by Sharon Mickan — Leave a comment

Instead of being translated from research to practice, knowledge could be better conceptualised as being continually and dynamically exchanged. Circular models may not be sufficient to detail the complex exchange of different forms of knowledge that occur when identifying the most appropriate research finding to answer a clinical question, and then implementing and sustaining change within complex healthcare environments. An alternative dynamic model has been promoted to describe the way knowledge is actually exchanged in practice.

Five important components have been identified from a synthesis of theoretical models of knowledge exchange and they have been tested in three team based projects in healthcare organisations. While each component is separate, they occur together and have different relative importance throughout the whole project of using research to change practice.

1. Problem identification requires agreement about an important issue that needs improvement or change. While activity is greatest at the beginning of the project, there is a need to continue to clarify, focus and review the clinical problem over time. It is often difficult to fully understand the problem at the beginning of a project, and there is a need to be flexible to new information and perspectives.

2. Analysis of the context requires the identification and exploration of unique personal, interpersonal, organisational and professional influences and characteristics, which could both facilitate or constrain activities.

3. Locating and tailoring knowledge requires an assessment of the relevance, credibility and usefulness of various types of knowledge. This is likely to be influenced by professional, geographic and organisational contexts. It is most useful when relevant knowledge can be classified and coded for everyday language and use.

4. Knowledge exchange interventions need to be clarified, before they can be implemented. There is usually an iterative process of negotiation and monitoring that enables knowledge to be integrated into normal tasks. Knowledge exchange interventions include information management, linking people together, learning from the process and supporting decision making.

5. Knowledge use occurs directly, conceptually and politically, with different types of knowledge being used at different times. It is important to identify practical ways to spread and sustain knowledge use.

What is unique about this model is that these five components do not occur in a set sequence; instead they all occur together, but with different patterns of emphasis.  At the beginning of each project, high levels of problem identification, context analysis and choice of knowledge exchange interventions are evident. As the projects develop, there is a greater emphasis on locating and tailoring knowledge. Towards the end of the projects there is an emphasis on implementing knowledge exchange interventions, and using knowledge.

Further the process of knowledge exchange is acknowledged to be a social and political phenomenon, where professional identities and cultural norms influence changes in individual beliefs and behaviours.The knowledge which was needed to solve the original problems came from many people and places across the organisation and was not limited to high quality research evidence. Many knowledge exchange activities were required and the use of knowledge was an integral part of each project, rather than a just an outcome.

Therefore future initiatives could benefit from looking beyond changing individual behaviour or organisational contexts, towards understanding how different types of knowledge and people are involved in processes of knowledge exchange.

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Posted in knowledge, knowledge translation

Using research in clinical practice

Posted on December 10, 2013 by Sharon Mickan — 1 Comment

Research findings need to be translated into information that is meaningful for clinicians, managers, policy makers, patients and their families. There is a need to exchange and transform knowledge between those producing and using it. Not only do clinicians need to be able to understand and apply the research evidence, but organisations need suitable leadership structures and a culture to value research. Successful knowledge translation is therefore an interactive and reciprocal process that requires consideration of the nature of the research evidence, the clinical context and methods to change practice.

There is an inherent challenge in building the evidence for how to do this. Most research evidence is focussed on specific implementation plans for particular clinical scenarios or problems. There are only a few theoretical models for incorporating research evidence into healthcare practice. Two will be introduced here.

The Canadian Health Research Foundation has emphasised a dynamic model of pushing researchers to communicate clearly, pulling research evidence for policy making and exchanging research priorities for clinical practice needs. At its core are relationships between researchers, clinicians and managers. Commonly, doctoral students who were experienced managers and clinicians, learn about research. They utilise their familiarity with their own healthcare systems to integrate research into everyday practice. Just-in-time teaching experiences are designed to be responsive to the clinical setting. Projects that have organisational support are the focus for change and improved evidence-informed practice.

In the UK, the National Institute for Health Research (NIHR) has established Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) to use research in clinical practice. Eight core principles have been identified to drive implementation:

  1. healthcare professionals draw on different sources of evidence beyond research
  2. research evidence needs to be interpreted in context, and in relation to other competing priorities
  3. implementation is an iterative, cyclical and interactive process
  4. the environment of proposed change needs careful evaluation, in consultation with key stakeholders
  5. effective multi-faceted interventions need to be adapted to respond to the unique context
  6. relationships and networks need to be created for learning and sharing information
  7. unique implementation structures and leadership processes are required to manage change
  8. co-production of knowledge enhances its relevance and transferability to practice

At the end of the day, there is a need for researchers and clinicians to have shared ownership about how research findings inform clinical care at the individual and organisational level.

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Posted in change, clinical practice, healthcare professional, implementation, knowledge translation, organisation, using research

Knowledge translation insights from management

Posted on December 6, 2013 by Sharon Mickan — 2 Comments

Knowledge translation (KT) in healthcare is often criticised for being too linear. However, a lot of clinical research and healthcare literature is conceived and expressed in a linear fashion. Therefore, it is often challenging to recognise that the translation of research knowledge into clinical practice requires a different way of thinking; that is more familiar to many other social science scholars, including management academics. I recently read a seminal article that shares some very useful insights…

We recognise that knowledge does not transfer passively from research to practice. Underlying this, is a recognition that knowledge is a complex concept, and that the research and clinical practice communities are extremely different. In  evidence-based health care, we emphasise the importance of prioritising high quality research knowledge, but are also criticised for neglecting other forms, such as theoretical, empirical and experiential knowledge. We argue that individual clinicians are motivated by best practice to initiate the search for scientific research to answer clinical questions. However we know that this is difficult and the barriers are well described in terms of time, ability and environmental resources. In arguing for active engagement across research and clinical environments, we have not fully recognised the different social and organisational systems involved, particularly when there are many different strategies used to reshape knowledge and information for use.

The management literature offers fresh insights into how both individuals and groups of people learn. Knowledge does not flow evenly within and between systems. In part, this has been recognised by leakage from the evidence pipeline. However, boundaries between organisations and professional groups impair the flow of knowledge, which itself can be more or less useful across different contexts. When clinicians consider an individual research study, the process of critical appraisal emphasises the need to evaluate results for applicability to their own patient and clinical context.  It is also important to recognise the social nature of learning – in that healthcare professionals learn within discrete communities, where meaning is ascribed, often in relation to practice. While we assume the objectivity of scientific knowledge, we cannot assume that all forms of knowledge are  objective and have the same meaning in different contexts. I have written previously in this blog about ways that knowledge can be used for power and political purposes.

Organisational learning is another important concept that was familiarised by Peter Senge in his 1990 book The Fifth Discipline. The emphasis is on effective transfer of knowledge, in all its forms within organisations, and between different departmental and professional groups. While this has been broadly applied to healthcare, it is made more difficult by increasing professional specialisation and the separation of clinical and management roles. Further, there has been an emphasis on sharing explicit and scientific knowledge, at the expense of tacit and experiential knowledge. There has been recent recognition of the importance of experiential knowledge, in areas such as implementation science, and there is now an increasing evidence base for effective methods of implementation.

I suggest that a challenge for healthcare research is to better understand the dynamic nature of learning for individuals and within organisations, so that knowledge can be transformed for shared meaning and maximal use. It makes practical sense to engage with management and social sciences literature, to build the evidence base for effective methods of enacting, negotiating and legitimising different types of knowledge between research and clinical environments, so that patients and families can experience the benefits of healthcare research…

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Posted in evidence-based health care, implementation, information, knowledge, knowledge translation, learning, management

Where do health professionals learn?

Posted on December 4, 2013 by Sharon Mickan — 2 Comments

Phrases like lifelong learning and continuing professional education are in common usage by healthcare professionals. There seems to be an acceptance that learning continues throughout professional careers. But the question for this post is, where do these professionals find their new knowledge to keep learning? Do they learn from printed or electronic resources or from each other? Are there other ways they look for and receive knowledge?

There is a strong argument that daily learning is most often related to needing immediate solutions to patient care – sometimes called just-in-time learning. It seems that peers provide this information most reliably. Nurses reported that they informally asked each other questions because their peers were helpful and supportive and they provided information that was relevant and practical. They often did not have time to find experts and many perceived that higher status professionals are less accessible and more unapproachable. I suspect this sort of collegial checking is extremely popular across the healthcare professions. In many instances, this social interaction and shared experiential knowledge is likely to be complementary. However, when there are inconsistencies between people, then maybe the research evidence could be a good arbitrator.

The alternative of looking up clinical questions using paper or electronic texts is something that is advocated in evidence-based health care courses, but is less often implemented. It has been suggested that only 30% of clinical questions are ever answered in this way. Major barriers of time, access and ability to interpret research evidence seem to limit these behaviours. However, there is some evidence that handheld computers make looking for information easier.

Perhaps it is important to investigate what knowledge healthcare professionals need in their normal clinical routines, and collate popular sources of information to learn about where they look for and receive information, and how they use it?  If we can understand these patterns, we might be able to disseminate and integrate research evidence, where it is most likely to be used..

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Posted in evidence-based health care, information, knowledge, learning, Uncategorized, using research

Knowledge brokers – a solution for knowledge translation?

Posted on November 27, 2013 by Sharon Mickan — 13 Comments

Can knowledge brokers help translate research evidence into practice – or do they add another cumbersome link to the chain of knowledge translation?

This sounds very positive when you review the definition of knowledge brokers in health policy – they facilitate interactions between decision makers and researchers so they can both understand each other’s goals and professional cultures and influence each others’ work to promote the use of research evidence in decision making. Further, three main activities have been identified:

  • managing knowledge to make existing evidence accessible to those who need it
  • facilitating interactions between decision makers and researchers towards solving practical problems
  • enhancing the communication, analytical and interpretation skills of those involved in doing and using research

This is so idealistic that perhaps, it is unattainable. It is useful to read a longitudinal analysis of 7 formalised full time knowledge broker roles within a series of health research-practice collaborative projects in the UK. The authors highlighted structural issues around professional boundaries, organisational norms and career pathways that made these roles difficult to sustain. Most knowledge brokers described ambiguity within their roles and expectations from both healthcare and research environments. While they suggested ways to manage these challenges, they often diluted the distinctive characteristics of these roles.

So I am left wondering whether knowledge brokering should really be an aspect of an  individual’s work roles, rather than a whole role? Further, could we recognise the knowledge brokering role within teams of decision makers and researchers who are working together over time to improve practice in a specific area? What if several researchers and decision makers met regularly to monitor and discuss ways of managing access to knowledge, to solve practical problems?

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Posted in knowledge broker, knowledge translation, sustainability, using research