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Improving clinical services: no magic bullet... some things work better than others - Jeremy Grimshaw
1. Improving clinical services
No magic bullet...but some things
work better than others
Jeremy Grimshaw
Senior Scientist, Ottawa Hospital Research Institute
Professor, Department of Medicine, University of Ottawa
Canada Research Chair in Health Knowledge Transfer and Uptake
3. 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
4. How do healthcare systems and
organisations currently try to
improve clinical services?
9. 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
10. 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
11. 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
12. Key challenge is to
determine which
improvement ‘tool’ is
likely to achieve
optimal improvement
within available
resources
Key challenge for improvement
13. 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
15. 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 measure
behaviour change?
16. 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)
18. Knowledge
Skills
Social/professional
role and identity
Beliefs about
capabilities
Optimism
Beliefs about
consequences
Reinforcement
Which barriers and enablers need
to be addressed?
Intentions
Goals
Memory, attention and
decision processes
Environmental context
and resources
Social influences
Emotion
Behavioural regulation
Cane 2012 – Theoretical Domains Framework v2
22. 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
23.
24. 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
25. Implementation laboratories to
optimise audit and feedback
Future 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
27. 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
29. 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.
30. Contact details
Jeremy Grimshaw - jgrimshaw@ohri.ca
EPOC – epoc@uottawa.ca
Results available from:
www.rxforchange.ca
http://ktclearinghouse.ca/ktcanada