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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.