We need to know how to embed the findings of high quality research into the day-to-day practice of heath professionals…..
“ Health professionals and policy makers have access to a large volume of research evidence and guidance relevant to clinical effectiveness” with which to inform their decisions on how to effect the necessary changes. Getting evidence into practice, 1999 … Yet the gap between research evidence and implementation at policy and local level remains.
A great deal of work has already been undertaken on what it takes to Get Research Into Practice. Late 90s saw publication/commissioning of several pieces of work reviewing the evidence into aspects of the dissemination, and implementation of research, yet this research itself seems to be poorly utilised! Together these reports inform our understanding: 1. Recognise barriers to making use of research findings which we need to overcome 2. Identify the factors that are critical to the success of implementation programmes 3. Think about the implications for Quality: Mk
To paint a broad brush - extrapolate on patient safety issues from national data – using slides shared by MoM
Courtesy of Bill Runciman, APSF – Extracted data from AHRQ 2006 report, USA Start with the Australian patient safety foundation
Mike Stein – Map of medicine. September 2007
“ Getting evidence into practice , a selective review of the literature by staff of CRD published as an Effective Health Care Bulletin - back in 1999 , Identified 5 major reasons for resistance to change
VERY Small scale survey, Of a total of 31 respondents 21 people (67.7%) listed the main difficulties they experience in their practice in adopting research findings into day-to-day care. Quotations: Issues around applying evidence-based medicine came to the fore eg. skills, confidence in validity of research, ease of interpreting findings, practicality, “Research is often restricted to narrow cases - not everyday reality”. “time to keep abreast of new findings” concerns around access to information eg. “easy ways of finding out what is best practice in a particular area”. There were other issues around access: “Accessibility of research material - cannot be copied / passwords & access arrangements keep changing”. A lack of resources was highlighted by seven people “eg CBT”. Five respondents picked up on the number of guidelines now available. One mentioned “conflict with national guidelines.”
Lest we risk losing our grip on day to day practice – Doctors set any discussion on using evidence, guidelines, etc in terms of their time, and the sheer QUANTITY of information they already get!
The Front-Line Evidence Based Medicine Project studied twenty teams in hospitals across North Thames for three years. This research identified a number of practical barriers to the use of databases and the application of research evidence by doctors in the context of their routine clinical practice: Donald, A. The frontline evidence based medicine project: the final report London: NHSE North Thames Regional office, 1998.
Problems deriving from medical and nursing hierarchies, perceived threats to medical autonomy and a lack of relevant evidence too
In Getting evidence into practice CRD recommended carrying out an “’information and diagnostic analysis’ to inform the development of an appropriate dissemination and implementation strategy” as the first stage of any proposed change. This analysis might include identification and assessment of:
There are tools we can use to measure the barriers that our colelagues face Closs and Bryar looked at the BARRIERS scale, developed in the States – and concluded that along with characteristics of the adopter, the organisation, the innovation itself and the communication process, other issues are also critical in the UK environment: reveals that issues relating to ”the benefits, quality and accessibility of research and resources for implementation” are also critical in a UK context. 22 They believe that there is also a need to look at the impact of organizational culture, staffing issues and personal feelings.
* Marshall J G. The impact of the hospital library on clinical decision making: the Rochester study. Bull Med Libr Assoc. 1992 April; 80(2): 169–178 ** Fischer MA, Avorn J. Economic implications of evidence-based prescribing for hypertension: can better care cost less? JAMA 2004;291:1850-6.
Suppporting journal clubs: finding information, facilitating, recording discussion, sharing CATS Supporting service review and development: evidence, best practice, models of service Supporting patient engagement workstream Information skills : finding information, reading for effectiveness, critical appraisal “ Alerts” Access to resources Promoting use of the Map of medicine
The Kings’ fund report on Getting better with evidence pooled the findings of seventeen projects across fifteen project teams, over eighteen months: They identified 4 critical success factors: Sufficient resources - In terms of time, money and skills Benefits - The proposed change needs to offer benefits of interest to frontline staff Collaboration - Enough of the right people need to ‘on board’ early enough Relevance - The approach needs to be interactive and relate research clearly to practice
The Kings’ Fund published a book on Experience, evidence and everyday practice . Creating systems for delivering effective health care Learning from the experiences of the NHS staff involved in three prestigious programmes (PACE, 18 the Front-Line project 20 and FACTS 23 ) And these are the common practical and organizational issues that need to be addressed to influence the behaviour of health professionals:
Palmer and Fenner’s getting the message across INFORMATION: Its nature & quality CONTEXT: Supporting Local priorities; Involving all the groups involved in the proposed change; Overcoming organizational barriers. PROCESS: Leadership: allocating responsibility to an authoritative figure Collaboration – with local services and initiatives COMMUNICATION A planned process, creating new mechanisms where necessary Come back to this separately; key issue. Checklist for comms.
Drawing on the evidence uncovered, the NHMRC handbook poses a series of questions to guide the steps involved in guideline dissemination and implementation. Those planning “deliberate actions” to implement research based knowledge are advised to consider:
7 stage model Identifying the blockages
Summarising the lessons derived from the Promoting Action on Clinical Effectiveness (PACE) project, Dunning et al confirmed the key message from previous studies, in their book on Experience, evidence and everyday practice. Creating systems for delivering effective health care – book Far from being a linear task, it is rather “ a group of complex inter-related tasks.” No magic bullets: Oxman, A.D. et al. No magic bullets: a systematic review of 102 trials of interventions to help health care professionals deliver services more effectively or efficiently . London: North East Thames Regional Health Authority, 1994
The authors of Getting better with evidence showed that the scope of the work of implementation amplifies over time, involving a widening circle of professionals and organizations They recommend:
Getting a GRIP October 2007
Get a GRIPGetting Research Into Practice Sue Lacey Bryant Whittlebury Hall October 2007
Getting research into practice“Health professionals and policy makers have access to a large volume of research evidence and guidance relevant to clinical effectiveness”
Getting a GRIP on the evidence1. The challenge2. Barriers3. Tools we can use4. Success factors5. Implications for Quality: MK
Courtesy of Bill Runciman, APSF;Data extracted from AHRQ 2006report
UK and Australia Wrong plan nearly 50% of the time Harm a patient with 10% of admissions The harm is permanent or severe with 2% of admissions Death is associated with the harm in 1/300 patientsThis amounts to 100,000 preventable deaths since 1995 (Australia alone) Costs as much as $1 million /hour (Australia alone) Data courtesy of Professor Jeff Richardson, CHE, Monash University and Professor Runciman, Professorial Research Fellow, Patient Safety, University of Adelaide
Put another way50% more deaths than annual combined total from:AIDS +Suicide +Motor vehicle accidents +Homicide +Drowning +Falls +Poisonings
OR – put another wayThe equivalent of a jumbo jet crashing every week with over 300 UK citizens on board
2.BARRIERS• Information and technology overload Growing information base• Specialty silos Communication issues• Clinical governance Plethora of guidelines Trainees, locum and agency staff• Increasing patient safety issues Less patient time, more referrals Medical errors Rising cost of claims
Reasons for resisting change• Information problems• Individual decision-making• Effects of stress• Getting the right people together• The status quo Getting evidence into practice
Main difficulties No.Adopting Evidence based practice 13 research Time 12evidence Access to information 8 Resources 7 Guidelines - overload 5Baseline Changing practice 4survey Costs 4 Patient expectations 2 Other 4
Information’s just landing on us!“Robin weighed the NSF for the elderly, measured its height and found it had a BMI of 86”
View from the frontline1. Access 2. Skills • Low levels of baseline• Inadequate access to information skills in using IT • Low levels of baseline• Lack of relevant evidence skills in critical appraisal • Insufficient time for clinicians to acquire new skills
View from the frontline3. Funding 4. HierarchyInsufficient money to Problems relating to help clinicians to medical and nursing acquire new skills hierarchies 5. Autonomy Perceived threats to medical autonomy
3. TOOLS WE CAN USE1. All groups involved2. Characteristics of the change that might influence its adoption3. Readiness of health professionals in the target group to change4. Potential external barriers to change5. Likely enabling factors (including resources and skills)
Tools we can use: Barriers scale • Benefits of change • Quality of research • Access to research • Resources• Adopter • Organisational• Organization culture• Innovation • Staffing issues• Communication process • Personal feelings
Tools we can use: Survey monkey • Online survey • Different types of question - single answer, multiple answers, or a matrix • Mandatory questions • Conditional logic to direct users • View results online • Download as a *.csv file • Make results available online
Tools we can use: the power ofEvidence• 80% of physicians changed their care as a result of evidence* - as follows: • Avoided hospitalisation in 12% • Reduced overall length of stay in hospital in 19% • Changed diagnostic tests in 51% and drug choices in 45% • Avoided additional tests or procedures in 49%• Adhering to evidence-based guidelines for treating hypertension alone could save at least $1.2 billion annually in US** •Marshall J G. …. The Rochester study. •** Fischer MA, Avorn J. Economic implications of E-B-based prescribing for hypertension:
Tools we can use:Knowledge management• Public Health professionals are the ‘pumping stations’ that drive the ‘water’ (knowledge) through the organisation• The librarians are the ‘treatment works’ that ensure that the knowledge is fit for purpose and available in the right quantities to be consumed’
Tools we can use:Information team• Suppporting journal clubs• Supporting service review and developmen• Supporting patient engagement workstream• Best evidence, best practice, models of service• Information skills training• “Alerts”• Access to resources• Promoting use of the Map of medicine• Sharing information: intranet / internet
•Evidence based care pathways•Framework for available tosharing clinical clinicians at theknowledge across point of carecare settings •Localizable benchmark for clinical processes
Influencing behaviour Identifying local priorities for change Exploring barriers to change Gaining commitment, building coalitions Incentives for change Effective communication Supporting/managing change Monitoring change Experience, evidence and everyday practice. King’s Fund
Getting the message across Information Context: Local priorities, Involvement, Overcoming barriers Process: Leadership, Collaboration Communication
Key questions for managers Who wants the change? Why? What is its importance for the service and for the organization? What are the measures of success? Which staff groups are to be involved with this change?
How to put evidence into practice• What is the purpose? • What are the barriers?• Who can help? • Are things on track?• What is the situation? • What are the options?• Who should be involved? • Which strategies should• What are the key be used? messages? • Is support available?• What is the aim? • What would it cost, and• Is the available is it worth doing? information suitable? • Has it worked?
Research-to-practice pipelineBy clinicians: 1. Awareness 2. Acceptance 3. Applicable 4. Available and able 5. Acted onBy patients: 1. Agreed to 2. Adhered to Taking the paths from research to improved health outcomes
5. LESSONS FOR QUALITY:MK Analyse the local situation There will always be unplanned consequences Getting evidence into practice is a lengthy and complicated business Change must offer benefits to frontline staff
No magic bullets• “A multi-faceted approach using a range of techniques can be successful”.• “A costly and messy process”• “ A group of complex inter-related tasks.” Experience, evidence and everyday practice
Changing clinical behaviour Be flexible Tailor the approach Start small Build incrementally Use existing channels Build on previous work Target enthusiasts first AND it takes several years
Reality checkImplementation is the real workWhile some teams focus on developing guidelines the “much harder task of implementation was sometimes under-prioritised”Use the evidence we have Getting better with evidence
The challenge for Quality: MK• “the field of quality improvement is broadly accepted and institutionalised now and is highly politically correct.”• “What is left is the question whether it really contributes to a better, a more effective, efficient and patient centred care.