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Suhr M, Bean A, Rolniak J, Paden Cargill L, Lyle S. The influence of classroom context on AAC device use for nonspeaking school-aged autistic children. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024; 26:434-444. [PMID: 37395393 DOI: 10.1080/17549507.2023.2220992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Purpose: Language learning, including on a speech-generating device (SGD), relies on having communication opportunities to use language. Yet, children who use SGDs do not consistently use their devices throughout the day. As a first step towards increasing device use, it is important to determine how the numerous contexts (e.g. recess, lunch, academic) that exist throughout the school day impact the frequency and type of communication opportunities that children have. Within this study, we used complex adaptive systems theory to investigate whether there were differences in how frequently nonspeaking autistic children classified as emerging communicators (i.e. children who do not consistently produce two-word utterances independently and do not communicate for a variety of communicative functions) used their SGDs to communicate and the type of communication they produced (i.e. spontaneous, prompted, or imitation) across different classroom contexts.Method: Fourteen autistic children who use an SGD as their primary mode of communication were videotaped up to nine times throughout different school days. The videos were coded for the type of device use (i.e. whether the child's use of the device was spontaneous, prompted, or imitation) and classroom context, which were categorised by the inherent level of support and directiveness.Result: There was a significant difference in SGD use across classroom contexts. Overall, the children communicated more and engaged in more spontaneous, prompted, and imitated communication in classroom contexts with high levels of structure (e.g. tabletop work) compared to contexts with low levels of structure and directiveness (e.g. free play).Conclusion: This study highlights the need to increase communication opportunities across all school contexts. Creating appropriate communication opportunities in all contexts, especially those with less structure, will help ensure that communication does not become context-bound.
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Affiliation(s)
- Meredith Suhr
- Department of Speech and Hearing Science, The Ohio State University, Columbus, OH, USA, and
| | - Allison Bean
- Department of Speech and Hearing Science, The Ohio State University, Columbus, OH, USA, and
| | - Jordyn Rolniak
- Department of Speech and Hearing Science, The Ohio State University, Columbus, OH, USA, and
| | | | - Samantha Lyle
- Bridgeway Academy and Therapy Center, Columbus, OH, USA
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Miao M, Morrow R, Salomon A, Mcculloch B, Evain JC, Wright MR, Murphy MT, Welsh M, Williams L, Power E, Rietdijk R, Debono D, Brunner M, Togher L. Digital Health Implementation Strategies Coproduced With Adults With Acquired Brain Injury, Their Close Others, and Clinicians: Mixed Methods Study With Collaborative Autoethnography and Network Analysis. J Med Internet Res 2023; 25:e46396. [PMID: 37725413 PMCID: PMC10548320 DOI: 10.2196/46396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/10/2023] [Accepted: 08/03/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Acquired brain injuries (ABIs), such as stroke and traumatic brain injury, commonly cause cognitive-communication disorders, in which underlying cognitive difficulties also impair communication. As communication is an exchange with others, close others such as family and friends also experience the impact of cognitive-communication impairment. It is therefore an internationally recommended best practice for speech-language pathologists to provide communication support to both people with ABI and the people who communicate with them. Current research also identifies a need for neurorehabilitation professionals to support digital communication, such as social media use, after ABI. However, with >135 million people worldwide affected by ABI, alternate and supplementary service delivery models are needed to meet these communication needs. The "Social Brain Toolkit" is a novel suite of 3 interventions to deliver communication rehabilitation via the internet. However, digital health implementation is complex, and minimal guidance exists for ABI. OBJECTIVE This study aimed to support the implementation of the Social Brain Toolkit by coproducing implementation knowledge with people with ABI, people who communicate with people with ABI, clinicians, and leaders in digital health implementation. METHODS A maximum variation sample (N=35) of individuals with living experience of ABI, close others, clinicians, and digital health implementation leaders participated in an explanatory sequential mixed methods design. Stakeholders quantitatively prioritized 4 of the 7 theoretical domains of the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework as being the most important for Social Brain Toolkit implementation. Qualitative interview and focus group data collection focused on these 4 domains. Data were deductively analyzed against the NASSS framework with stakeholder coauthors to determine implementation considerations and strategies. A collaborative autoethnography of the research was conducted. Interrelationships between considerations and strategies were identified through a post hoc network analysis. RESULTS Across the 4 prioritized domains of "condition," "technology," "value proposition," and "adopters," 48 digital health implementation considerations and 52 tailored developer and clinician implementation strategies were generated. Benefits and challenges of coproduction were identified. The post hoc network analysis revealed 172 unique relationships between the identified implementation considerations and strategies, with user and persona testing and responsive design identified as the potentially most impactful strategies. CONCLUSIONS People with ABI, close others, clinicians, and digital health leaders coproduced new knowledge of digital health implementation considerations for adults with ABI and the people who communicate with them, as well as tailored implementation strategies. Complexity-informed network analyses offered a data-driven method to identify the 2 most potentially impactful strategies. Although the study was limited by a focus on 4 NASSS domains and the underrepresentation of certain demographics, the wealth of actionable implementation knowledge produced supports future coproduction of implementation research with mutually beneficial outcomes for stakeholders and researchers. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/35080.
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Affiliation(s)
- Melissa Miao
- Graduate School of Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Rosemary Morrow
- Stakeholder with living experience of acquired brain injury, Sydney, Australia
| | - Alexander Salomon
- Stakeholder with living experience of acquired brain injury, Sydney, Australia
| | - Ben Mcculloch
- Stakeholder with living experience of acquired brain injury, Sydney, Australia
| | - Jean-Christophe Evain
- Acquired Brain Injury Rehabilitation Ward, Caulfield Hospital, Alfred Health Network, Melbourne, Australia
- Stakeholder with living experience of acquired brain injury, Melbourne, Australia
| | - Meg Rebecca Wright
- Stakeholder with living experience of acquired brain injury, Blenheim, Australia
| | - Marie Therese Murphy
- Stakeholder with living experience as a communication partner of a person with acquired brain injury, Sydney, Australia
- Faculty of Education, Western Sydney University, Sydney, Australia
- Faculty of Education and Social Work, The University of Sydney, Sydney, Australia
| | - Monica Welsh
- Brain Injury Rehabilitation Unit, South Australian Brain Injury Rehabilitation Service, Adelaide, Australia
| | - Liz Williams
- Brain Injury Rehabilitation Community and Home (BIRCH), South Australian Brain Injury Rehabilitation Service, Adelaide, Australia
| | - Emma Power
- Graduate School of Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Rachael Rietdijk
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Deborah Debono
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Melissa Brunner
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Leanne Togher
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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3
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Carroll Á, Collins C, McKenzie J, Stokes D, Darley A. Application of complexity theory in health and social care research: a scoping review. BMJ Open 2023; 13:e069180. [PMID: 36921939 PMCID: PMC10030763 DOI: 10.1136/bmjopen-2022-069180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
BACKGROUND Complexity theory has been chosen by many authors as a suitable lens through which to examine health and social care. Despite its potential value, many empirical investigations apply the theory in a tokenistic manner without engaging with its underlying concepts and underpinnings. OBJECTIVES The aim of this scoping review is to synthesise the literature on empirical studies that have centred on the application of complexity theory to understand health and social care provision. METHODS This scoping review considered primary research using complexity theory-informed approaches, published in English between 2012 and 2021. Cochrane Database of Systematic Reviews, MEDLINE, CINAHL, EMBASE, Web of Science, PSYCHINFO, the NHS Economic Evaluation Database, and the Health Economic Evaluations Database were searched. In addition, a manual search of the reference lists of relevant articles was conducted. Data extraction was conducted using Covidence software and a data extraction form was created to produce a descriptive summary of the results, addressing the objectives and research question. The review used the revised Arksey and O'Malley framework and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR). RESULTS 2021 studies were initially identified with a total of 61 articles included for extraction. Complexity theory in health and social care research is poorly defined and described and was most commonly applied as a theoretical and analytical framework. The full breadth of the health and social care continuum was not represented in the identified articles, with the majority being healthcare focused. DISCUSSION Complexity theory is being increasingly embraced in health and care research. The heterogeneity of the literature regarding the application of complexity theory made synthesis challenging. However, this scoping review has synthesised the most recent evidence and contributes to translational systems research by providing guidance for future studies. CONCLUSION The study of complex health and care systems necessitates methods of interpreting dynamic prcesses which requires qualitative and longitudinal studies with abductive reasoning. The authors provide guidance on conducting complexity-informed primary research that seeks to promote rigor and transparency in the area. REGISTRATION The scoping review protocol was registered at Open Science Framework, and the review protocol was published at BMJ Open (https://bit.ly/3Ex1Inu).
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Affiliation(s)
- Áine Carroll
- School of Medicine, University College Dublin, Dublin, Ireland
- Academic Department, National Rehabilitation University Hospital, Dublin, Ireland
| | - Claire Collins
- Henley Business School, University of Reading, Reading, UK
| | - Jane McKenzie
- Henley Business School, University of Reading, Reading, UK
| | - Diarmuid Stokes
- College of Health Sciences, University College Dublin, Dublin, Ireland
| | - Andrew Darley
- School of Medicine, University College Dublin, Dublin, Ireland
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Kirkegaard A, Mitchell L, Ball L, Williams LT. Developing the Quality in Nutrition Care Model for Dietitians (QUINCE-MOD) in primary care: A mixed-method survey of healthcare consumers and professionals. J Hum Nutr Diet 2023; 36:311-322. [PMID: 35822586 PMCID: PMC10087511 DOI: 10.1111/jhn.13065] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/16/2022] [Accepted: 06/24/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Evidence-based models are effective tools for informing quality improvement activities in health care. The Quality in Nutrition Care (QUINCE) model is an evidence-based model that describes quality nutrition care in the primary care setting but has not been applied to primary care dietetics. The present study comprised two phases. In the first phase, the study aimed to evaluate and compare healthcare consumers and professional perspectives on the importance of the 10 statements to understand their relevance for dietetics care. In the second phase, the study aimed to test and enhance the QUINCE model using healthcare consumer and professional responses to statements that were identified as relevant to primary care dietetics in the first phase. METHODS Quantitative and qualitative data were collected using an online survey comprising statements describing quality dietetic care adapted from the complexity literature. Quantitative data were analysed using descriptive statistical analysis to investigate statement importance as rated by participants using a six-point Likert scale. Qualitative content analysis was performed on the qualitative data using a deductive-inductive approach to identify patterns in the data. The QUINCE model was compared with identified patterns and modified as appropriate. RESULTS One hundred and fourteen consumers and 107 primary care professionals agreed on the importance of seven statements but expressed divergent views on the remaining three statements that addressed: (1) access to medical records; (2) access to performance and safety information; and (3) variation in care between dietitians. The QUINCE model was modified to produce the Quality in Nutrition Care Model for Dietitians (QUINCE-MOD) describing quality dietetic care in the primary care setting. CONCLUSIONS Consumers and professionals share views on some aspects of quality dietetic care but diverge on other aspects. The QUINCE-MOD is an evidence-based, complexity-informed model that describes components of quality relevant to primary care dietetics. The model should be applied at the practice level to reflect the unique perspective of quality at that level.
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Affiliation(s)
- Amy Kirkegaard
- Menzies Health Institute of Queensland, Griffith University, Southport, QLD, Australia.,School of Health Sciences and Social Work, Griffith University, Gold Coast, QLD, Australia
| | - Lana Mitchell
- Menzies Health Institute of Queensland, Griffith University, Southport, QLD, Australia.,School of Health Sciences and Social Work, Griffith University, Gold Coast, QLD, Australia
| | - Lauren Ball
- Menzies Health Institute of Queensland, Griffith University, Southport, QLD, Australia.,School of Health Sciences and Social Work, Griffith University, Gold Coast, QLD, Australia
| | - Lauren T Williams
- Menzies Health Institute of Queensland, Griffith University, Southport, QLD, Australia.,School of Health Sciences and Social Work, Griffith University, Gold Coast, QLD, Australia
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5
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Mumford EL, Martinez DJ, Tyance-Hassell K, Cook A, Hansen GR, Labonté R, Mazet JAK, Mumford EC, Rizzo DM, Togami E, Vreedzaam A, Parrish-Sprowl J. Evolution and expansion of the One Health approach to promote sustainable and resilient health and well-being: A call to action. Front Public Health 2023; 10:1056459. [PMID: 36711411 PMCID: PMC9880335 DOI: 10.3389/fpubh.2022.1056459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/21/2022] [Indexed: 01/15/2023] Open
Abstract
One Health is a transdisciplinary approach used to address complex concerns related to human, animal, plant, and ecosystem health. One Health frameworks and operational tools are available to support countries and communities, particularly for the prevention and control of zoonotic diseases and antimicrobial resistance and the protection of food safety. However, One Health has yet to be implemented in a manner that fully considers the complexities and interconnectedness of the diverse influences that have impacts at a larger system level. This lack of consideration can undermine the sustainability of any positive outcomes. To ensure the One Health approach can function effectively within the new global context of converging and escalating health, social, economic, and ecological crises, it must evolve and expand in three overlapping dimensions: (1) Scope: the partners, knowledge, and knowledge systems included, (2) Approach: the techniques, methodologies, and scholarship considered, and (3) Worldview inclusivity: the interweaving of other worldviews together with the mainstream scientific worldview that currently predominates. Diverse partners and knowledge from outside the mainstream health and scientific sectors, including Indigenous peoples and representatives of local communities, and traditionally generated knowledge, must be included. These systems of knowledge can then be braided together with mainstream science to comprise a holistic framework for decision-making. Scholarship and methodologies being applied in other fields and contexts to solve complex challenges and manage uncertainty, such as collaborative governance, social-ecologic systems theory, and complexity science, must be recognized and incorporated. The spectrum of considered worldviews must also expand to authentically integrate the expanded scope and approach into action and sustainable impact. By increasing community and social engagement and by recognizing and entwining different worldviews, the plurality of disciplines, and traditional and scientific ways of knowing to address community concerns in the contexts in which they exist, we can ensure that One Health remains effective and true to its paradigm in our rapidly changing and complex world.
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Affiliation(s)
- Elizabeth L. Mumford
- School of Veterinary Medicine, University of Surrey, Guildford, United Kingdom,*Correspondence: Elizabeth L. Mumford ✉
| | - Deniss J. Martinez
- Graduate Group in Ecology, University of California, Davis, Davis, CA, United States
| | - Karli Tyance-Hassell
- (Anishinaabe) Office of Research and Community Engagement, Alaska Pacific University, Anchorage, AK, United States
| | - Alasdair Cook
- Department of Veterinary Epidemiology and Public Health, University of Surrey, Guildford, United Kingdom
| | | | - Ronald Labonté
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Jonna A. K. Mazet
- Grand Challenges, University of California, Davis, Davis, CA, United States
| | | | - David M. Rizzo
- Department of Plant Pathology, University of California, Davis, Davis, CA, United States
| | - Eri Togami
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | | | - John Parrish-Sprowl
- Department of Communication Studies, Indiana University, Indianapolis, IN, United States
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6
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Hong QN, Bangpan M, Stansfield C, Kneale D, O'Mara-Eves A, van Grootel L, Thomas J. Using systems perspectives in evidence synthesis: A methodological mapping review. Res Synth Methods 2022; 13:667-680. [PMID: 35932206 DOI: 10.1002/jrsm.1595] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/15/2022] [Accepted: 08/01/2022] [Indexed: 01/07/2023]
Abstract
Reviewing complex interventions is challenging because they include many elements that can interact dynamically in a nonlinear manner. A systems perspective offers a way of thinking to help understand complex issues, but its application in evidence synthesis is not established. The aim of this project was to understand how and why systems perspectives have been applied in evidence synthesis. A methodological mapping review was conducted to identify papers using a systems perspective in evidence synthesis. A search was conducted in seven bibliographic databases and three search engines. A total of 101 papers (representing 98 reviews) met the eligibility criteria. Two categories of reviews were identified: (1) reviews using a "systems lens" to frame the topic, generate hypotheses, select studies, and guide the analysis and interpretation of findings (n = 76) and (2) reviews using systems methods to develop a systems model (n = 22). Several methods (e.g., systems dynamic modeling, soft systems approach) were identified, and they were used to identify, rank and select elements, analyze interactions, develop models, and forecast needs. The main reasons for using a systems perspective were to address complexity, view the problem as a whole, and understand the interrelationships between the elements. Several challenges for capturing the true nature and complexity of a problem were raised when performing these methods. This review is a useful starting point when designing evidence synthesis of complex interventions. It identifies different opportunities for applying a systems perspective in evidence synthesis, and highlights both commonplace and less familiar methods.
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Affiliation(s)
- Quan Nha Hong
- EPPI-Centre, UCL Social Research Institute, University College London, London, UK
| | - Mukdarut Bangpan
- EPPI-Centre, UCL Social Research Institute, University College London, London, UK
| | - Claire Stansfield
- EPPI-Centre, UCL Social Research Institute, University College London, London, UK
| | - Dylan Kneale
- EPPI-Centre, UCL Social Research Institute, University College London, London, UK
| | - Alison O'Mara-Eves
- EPPI-Centre, UCL Social Research Institute, University College London, London, UK
| | | | - James Thomas
- EPPI-Centre, UCL Social Research Institute, University College London, London, UK
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7
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Describing the Value of Physical Therapy in a Complex System Using the Socio-Ecological Model. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2022. [DOI: 10.1097/jat.0000000000000209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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8
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Kirkegaard A, Ball L, Mitchell L, Williams LT. A novel perspective of Australian primary care dietetics: Insights from an exploratory study using complex adaptive systems theory. Nutr Diet 2022; 79:469-480. [PMID: 35692187 PMCID: PMC9545103 DOI: 10.1111/1747-0080.12742] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/29/2022] [Accepted: 04/12/2022] [Indexed: 11/28/2022]
Abstract
Aims Effective quality improvement strategies are essential to enhancing outcomes of dietetic care. Interventions informed by complex adaptive systems theory have demonstrated effectiveness in other healthcare settings. This study aimed to explore primary care dietetics practice using complex adaptive systems theory and to identify factors that individuals across the healthcare system can examine and address to improve the quality of dietetic care. Methods Qualitative analysis of semi‐structured interviews of healthcare consumers and professionals involved in the provision of dietetic care. Data collection and analysis was guided by a complexity‐informed conceptual framework. The Framework Method was used to code transcripts and identify themes describing primary care dietetics. Results Twenty‐three consumers and 26 primary care professionals participated. Participants described dietetic care as being delivered by individuals organised into formal and informal systems that were influenced by the wider environment, including legal, economic, and socio‐cultural systems. Dietitians described interactions with consumers as a learning opportunity and sought education, mentoring, or supervision to address knowledge and skill gaps. Relationships underpinned transfer of information between individuals. Conclusion Complex adaptive systems theory proved to be a useful conceptual framework for primary care dietetics. Factors identified at the macro (e.g., funding), meso (e.g., professional networks), and micro (e.g., consumer education) levels should be examined and addressed to improve the quality of dietetic care.
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Affiliation(s)
- Amy Kirkegaard
- Menzies Health Institute of Queensland, Griffith University, Southport, QLD, Australia.,School of Health Sciences and Social Work, Griffith University, Gold Coast Campus, Southport, QLD, Australia
| | - Lauren Ball
- Menzies Health Institute of Queensland, Griffith University, Southport, QLD, Australia.,School of Health Sciences and Social Work, Griffith University, Gold Coast Campus, Southport, QLD, Australia
| | - Lana Mitchell
- Menzies Health Institute of Queensland, Griffith University, Southport, QLD, Australia.,School of Health Sciences and Social Work, Griffith University, Gold Coast Campus, Southport, QLD, Australia
| | - Lauren T Williams
- Menzies Health Institute of Queensland, Griffith University, Southport, QLD, Australia.,School of Health Sciences and Social Work, Griffith University, Gold Coast Campus, Southport, QLD, Australia
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Ransolin N, Saurin TA, Zani CM, Rapport F, Formoso CT, Clay-Williams R. The Built Environment Influence on Resilient Healthcare: A Systematic Literature Review of Design Knowledge. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2022; 15:329-350. [PMID: 35168374 DOI: 10.1177/19375867221077469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The aim of this study was to develop built environment (BE) design knowledge to support resilient healthcare by systematically reviewing the evidence-based design (EBD) literature. BACKGROUND Although the EBD literature is vast, it has not made explicit its contribution to resilient healthcare, which is a key component of the highly complex health service. METHOD This review followed the steps recommended by the Preferred Reporting Items for Systematic reviews and Meta-Analyses method. After applying the inclusion and exclusion criteria, 43 journal papers were selected. The papers were analyzed in light of five guidelines for coping with complexity, allowing for the development of BE design knowledge that supports resilient healthcare. RESULTS The design knowledge compiled by the review was structured according to four levels of abstraction: five design-meta principles, corresponding to the five complexity guidelines, seven design principles, 21 design prescriptions, and 58 practical examples. The design knowledge emphasizes the interactions between the BE as physical infrastructure and the functions that it supports. CONCLUSIONS The design knowledge is expected to be useful not only to architects but also to those involved in the functional design of health services as they interact with the BE. Furthermore, our proposal provides a knowledge template that can be continuously updated based on the experience of practitioners and academic research.
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Affiliation(s)
- Natália Ransolin
- Construction Management and Infrastructure Post-Graduation Program (PPGCI), Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Tarcisio Abreu Saurin
- Industrial Engineering and Transportation Department (DEPROT), Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Carolina Melecardi Zani
- Bartlett School of Sustainable Construction (BSSC), University College London (UCL), United Kingdom
| | - Frances Rapport
- Australian Institute of Health Innovation (AIHI), Macquarie University, Sydney, New South Wales, Australia
| | - Carlos Torres Formoso
- Construction Management and Infrastructure Post-Graduation Program (PPGCI), Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Robyn Clay-Williams
- Australian Institute of Health Innovation (AIHI), Macquarie University, Sydney, New South Wales, Australia
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10
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Pullmann MD, Dorsey S, Duong MT, Lyon AR, Muse I, Corbin CM, Davis CJ, Thorp K, Sweeney M, Lewis CC, Powell BJ. Expect the Unexpected: A Qualitative Study of the Ripple Effects of Children's Mental Health Services Implementation Efforts. IMPLEMENTATION RESEARCH AND PRACTICE 2022; 3:10.1177/26334895221120797. [PMID: 36504561 PMCID: PMC9731268 DOI: 10.1177/26334895221120797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Strategies to implement evidence-based interventions (EBIs) in children's mental health services have complex direct and indirect causal impacts on multiple outcomes. Ripple effects are outcomes caused by EBI implementation efforts that are unplanned, unanticipated, and/or more salient to stakeholders other than researchers and implementers. The purpose of the current paper is to provide a compilation of possible ripple effects associated with EBI implementation strategies in children's mental health services, to be used for implementation planning, research, and quality improvement. Methods Participants were identified via expert nomination and snowball sampling. Online surveys were completed by 81 participants, each representing one of five roles: providers of mental health services to children or youth, researchers, policy makers, caregivers, and youth. A partially directed conventional content analysis with consensus decision making was used to code ripple effects. Results Four hundred and four unique responses were coded into 66 ripple effects and 14 categories. Categories include general knowledge, skills, attitudes, and confidence about using EBIs; general job-related ripple effects; EBI treatment adherence, fidelity, and alignment; gaming the system; equity and stigma; shifting roles, role clarity, and task shifting; economic costs and benefits; EBI treatment availability, access, participation, attendance, barriers, and facilitators; clinical process and treatment quality; client engagement, therapeutic alliance, and client satisfaction; clinical organization structure, relationships in the organization, process, and functioning; youth client and caregiver outcomes; and use of EBI strategies and insights in one's own life. Conclusions This research advances the field by providing children's mental health implementers, researchers, funders, policy makers, and consumers with a menu of potential ripple effects. It can be a practical tool to ensure compliance with guidance from Quality Improvement/Quality Assurance, Complexity Science, and Diffusion of Innovation Theory. Future phases will match potential ripple effects with salient children's mental health implementation strategies for each participant role.
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Affiliation(s)
- Michael D. Pullmann
- Department of Psychiatry and Behavioral Sciences, University of Washington School of
Medicine, School Mental Health Assessment, Research, and Training Center,
Seattle, WA, USA
- Michael Pullmann, University of Washington
School of Medicine, Department of Psychiatry and Behavioral Sciences, School
Mental Health Assessment, Research, and Training Center, 6200 NE 74th Street,
Suite 110, Seattle, WA 98115-6560, USA.
| | - Shannon Dorsey
- Department of Psychology, University of Washington, Seattle, WA, USA
| | - Mylien T. Duong
- Education, Research, and Impact Committee for Children, Seattle, WA,
USA
| | - Aaron R. Lyon
- Department of Psychiatry and Behavioral Sciences, University of Washington School of
Medicine, School Mental Health Assessment, Research, and Training Center,
Seattle, WA, USA
| | - Ian Muse
- Department of Psychiatry and Behavioral Sciences, University of Washington School of
Medicine, School Mental Health Assessment, Research, and Training Center,
Seattle, WA, USA
| | - Cathy M. Corbin
- Department of Psychiatry and Behavioral Sciences, University of Washington School of
Medicine, School Mental Health Assessment, Research, and Training Center,
Seattle, WA, USA
| | - Chayna J. Davis
- Department of Psychiatry and Behavioral Sciences, University of Washington School of
Medicine, School Mental Health Assessment, Research, and Training Center,
Seattle, WA, USA
| | | | - Millie Sweeney
- Family-Run Executive Director Leadership Association (FREDLA),
Columbia, MD, USA
| | - Cara C. Lewis
- Kaiser Permanente Washington Health
Research Institute, Seattle, WA, USA
| | - Byron J. Powell
- Center for Mental Health Services Research, Brown School, Washington
University, St. Louis, MO, USA
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11
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Albsoul RA, FitzGerald G, Hughes JA, Ahmed Alshyyab M. Missed nursing care and complexity theory: a conceptual paper. J Res Nurs 2021; 26:809-823. [DOI: 10.1177/17449871211013073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Missed nursing care is a complex healthcare problem. Extant literature in this area identifies several interventions that can be used in acute hospital settings to minimise the impact of missed nursing care. However, controversy still exists as to the effectiveness of these interventions on reducing the occurrence of missed nursing care. Aim This theoretical paper aimed to provide a conceptual understanding of missed nursing care using complexity theory. Methods The method utilised for this paper is based on a literature review on missed care and complexity theory in healthcare. Results We found that the key virtues of complexity theory relevant to the missed nursing care phenomenon were adaptation and self-organisation, non-linear interactions and history. It is suggested that the complex adaptive systems approach may be more useful for nurse managers to inform and prepare nurses to meet uncertain encounters in their everyday clinical practice and therefore reduce instances of missed care. Conclusions This paper envisions that it is time that methods used to explore missed care changed. Strategies proposed in this paper may have an important impact on the ability of nursing staff to provide quality and innovative healthcare in the modern healthcare system.
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Affiliation(s)
- Rania Ali Albsoul
- Assistant Professor in Healthcare Management, Department of Family and Community Medicine, Jordan University, Jordan
| | - Gerard FitzGerald
- Professor in Public Health, School of Public Health and Social Work, Queensland University of Technology, Australia
| | - James A Hughes
- Nurse Researcher, Emergency and Trauma Centre, Royal Brisbane and Women's Hospital and Conjoint Senior Research Fellow, School of Nursing, Queensland University of Technology, Australia
| | - Muhammad Ahmed Alshyyab
- Assistant Professor in Health Services Management, Department of Public Health and Community Medicine, Jordan University of Science and Technology, Jordan
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12
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Morgan-Trimmer S, Kudlicka A, Warmoth K, Leroi I, Oyebode JR, Pool J, Woods R, Clare L. Implementation processes in a cognitive rehabilitation intervention for people with dementia: a complexity-informed qualitative analysis. BMJ Open 2021; 11:e051255. [PMID: 34702730 PMCID: PMC8549661 DOI: 10.1136/bmjopen-2021-051255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Healthcare is often delivered through complex interventions. Understanding how to implement these successfully is important for optimising services. This article demonstrates how the complexity theory concept of 'self-organisation' can inform implementation, drawing on a process evaluation within a randomised controlled trial of the GREAT (Goal-oriented cognitive Rehabilitation in Early-stage Alzheimer's and related dementias: a multi-centre single-blind randomised controlled Trial) intervention which compared a cognitive rehabilitation intervention for people with dementia with usual treatment. DESIGN A process evaluation examined experiences of GREAT therapists and participants receiving the intervention, through thematic analysis of a focus group with therapists and interviews with participants and their carers. Therapy records of participants receiving the intervention were also analysed using adapted framework analysis. Analysis adopted a critical realist perspective and a deductive-inductive approach to identify patterns in how the intervention operated. SETTING The GREAT intervention was delivered through home visits by therapists, in eight regions in the UK. PARTICIPANTS Six therapists took part in a focus group, interviews were conducted with 25 participants and 26 carers, and therapy logs for 50 participants were analysed. INTERVENTION A 16-week cognitive rehabilitation programme for people with mild-to-moderate dementia. RESULTS 'Self-organisation' of the intervention occurred through adaptations made by therapists. Adaptations included simplifying the intervention for people with greater cognitive impairment, and extending it to meet additional needs. Relational work by therapists produced an emergent outcome of 'social support'. Self-organised aspects of the intervention were less visible than formal components, but were important aspects of how it operated during the trial. This understanding can help to inform future implementation. CONCLUSIONS Researchers are increasingly adopting complexity theory to understand interventions. This study extends the application of complexity theory by demonstrating how 'self-organisation' was a useful concept for understanding aspects of the intervention that would have been missed by focusing on formal intervention components. Analysis of self-organisation could enhance future process evaluations and implementation studies. TRIAL REGISTRATION NUMBER ISRCTN21027481.
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Affiliation(s)
| | | | - Krystal Warmoth
- School of Health and Social Work & NIHR Applied Research Collaboration East of England, University of Hertfordshire, Hatfield, UK
| | - Iracema Leroi
- School of Medicine and Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
| | - Jan R Oyebode
- Centre for Applied Dementia Studies, University of Bradford, Bradford, UK
| | - Jackie Pool
- Dementia Pal Ltd, QCS Quality Compliance Systems, Guildford, UK
| | - Robert Woods
- Dementia Services Development Centre Wales, School of Health Sciences, Bangor University, Bangor, UK
| | - Linda Clare
- College of Medicine and Health & NIHR Applied Research Collaboration South-West Peninsula, University of Exeter, Exeter, UK
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13
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Zucca C, Long E, Hilton J, McCann M. Appraising the Implementation of Complexity Approaches Within the Public Health Sector in Scotland. An Assessment Framework for Pre-Implementation Policy Evaluation. Front Public Health 2021; 9:653588. [PMID: 34631638 PMCID: PMC8492954 DOI: 10.3389/fpubh.2021.653588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 08/25/2021] [Indexed: 12/04/2022] Open
Abstract
Complexity approaches have gained international attention as potentially effective strategies to address population health challenges. In light of this, the Scottish government (Scot. Gov.) set the implementation of these approaches as the recommended practice for its public health sector organizations. This study evaluates the opportunity and feasibility of implementing complexity approaches in public health Scotland employees' everyday routine by employing a qualitative study that involves 20 stakeholders, representative of different organizations and roles. We made use of an assessment framework based on Soft Systems Methodology (SSm) and Normalization Process Theory (NPT) comprised of five phases: Phase One defines the boundaries, aims, and goals of the issue under study; Phase Two consists of data collection, drawing on the e-Health Implementation Toolkit (e-HIT); Phase Three involves short presentations and breakout group activities to provide information on the new policy; Phase Four employs system thinking tasks to structure debate and builds shared understanding among participants; Phase Five applies NPT to appraise the organizational position around complexity based on information from the preceding steps. We found two main obstacles to implementing complexity approaches: (1) a lack of a shared understanding of the key concepts in complexity and their practical implications; (2) stakeholders' fear of significant disruption to work routines and power relationships. We recommend addressing these issues with appropriate training and customization of goals and tools that may enable complexity approaches to succeed within the Scottish public health context. Our assessment framework allows the recognition of key mechanisms to support how Scotland's Public Health body can enhance the implementation of complexity approaches. The appraisal framework could be used to study early-stage policy implementation in other contexts.
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Affiliation(s)
- Claudia Zucca
- Jheronimus Academy of Data Science, Tilburg University, Tilburg, Netherlands,*Correspondence: Claudia Zucca
| | - Emily Long
- MRC/CSO Social and Public Health Sciences Unit (MRC), University of Glasgow, Glasgow, United Kingdom
| | - Jeremy Hilton
- School of Defence and Security, Cranfield University at the Defence Academy of the UK, Cranfield, United Kingdom
| | - Mark McCann
- MRC/CSO Social and Public Health Sciences Unit (MRC), University of Glasgow, Glasgow, United Kingdom
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14
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Aminoff H, Meijer S. Context and Complexity in Telemedicine Evaluation: Work Domain Analysis in a Surgical Setting. JMIR Perioper Med 2021; 4:e26580. [PMID: 34528894 PMCID: PMC8485199 DOI: 10.2196/26580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 04/19/2021] [Accepted: 08/01/2021] [Indexed: 11/13/2022] Open
Abstract
Many promising telemedicine innovations fail to be accepted and used over time, and there are longstanding questions about how to best evaluate telemedicine services and other health information technologies. In response to these challenges, there is a growing interest in how to take the sociotechnical complexity of health care into account during design, implementation, and evaluation. This paper discusses the methodological implications of this complexity and how the sociotechnical context holds the key to understanding the effects and outcomes of telemedicine. Examples from a work domain analysis of a surgical setting, where a telemedicine service for remote surgical consultation was to be introduced, are used to show how abstracted functional modeling can provide a structured and rigorous means to analyze and represent the implementation context in complex health care settings.
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Affiliation(s)
- Hedvig Aminoff
- Division of Health Informatics and Logistics, Department of Biomedical Engineering and Health Systems, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Sebastiaan Meijer
- Division of Health Informatics and Logistics, Department of Biomedical Engineering and Health Systems, KTH Royal Institute of Technology, Stockholm, Sweden
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15
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Carroll A, Stokes D, Darley A. Use of complexity theory in health and social care: a scoping review protocol. BMJ Open 2021; 11:e047633. [PMID: 34321301 PMCID: PMC8319978 DOI: 10.1136/bmjopen-2020-047633] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 06/29/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Despite the use of a wide variety of improvement tools and approaches, healthcare organisations continue to struggle in several key areas. Complexity-informed approaches have the potential to offer health and social care a new paradigm for understanding, designing, implementing and evaluating solutions, yet so far has failed to gain the traction anticipated some years ago. There is a growing need for high quality syntheses of the existing knowledge base in this area and given the diversity of theory and approaches, a scoping review is the best approach to curate this knowledge. METHODS A scoping review of relevant literature from January 2000 to present, using the refined Arksey and O'Malley six-stage framework will be conducted. This protocol will follow the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols Extension for Scoping Reviews. A three-step search strategy will be used. An initial search of databases will be undertaken to identify key search terms followed by an analysis of retrieved papers title and abstract text words, and of index terms used to describe the articles. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference lists of identified reports and articles will be searched. Authors of primary articles will be contacted and a search for grey material performed. Finally, a complete search strategy of one major database will be included. ETHICS AND DISSEMINATION As this is a scoping review, ethical approval is not required. The results of the scoping review will be published in a peer-reviewed journal and presented at national and international conferences and will guide a large research project investigating teamwork. All data will be stored in accordance with best General Data Protection Regulation practice. REGISTRATION This scoping review protocol has been registered with Open Science Framework.
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Affiliation(s)
- Aine Carroll
- School of Medicine, University College Dublin, Dublin, Ireland
- Medical Department, National Rehabilitation Hospital, Dublin, Ireland
| | | | - Andrew Darley
- School of Medicine, University College Dublin, Dublin, Ireland
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16
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Conroy T, Pinero de Plaza MA, Mudd A, Mitchell M, Kitson A. Measuring fundamental care using complexity science: A descriptive case study of a methodological innovation. J Clin Nurs 2021; 32:2903-2912. [PMID: 34137100 DOI: 10.1111/jocn.15905] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES This paper presents an exploratory account of an innovative methodology to record and evaluate fundamental care. Fundamental care is defined as the care required by everyone for survival, health and welfare. BACKGROUND Fundamental care has been informed by the development and testing of the Fundamentals of Care Framework, which describes how fundamental care is complex and multidimensional, and consists of three interrelated dimensions and 38 elements. This accords with a broader re-examination of care provision as part of a complex adaptive system in which existing linear models of cause and effect are inadequate to describe the totality of activity. DESIGN Informed by graph theory and complexity science, this paper presents a novel methodological innovation. It uses the Fundamentals of Care Framework to create a Matrix to quantify the relationships between different elements within the Framework. METHODS We use a Matrix methodology to process care recipient narratives to generate three outputs: a heat map, a summary table and a network analysis. CONCLUSIONS The three outputs serve to quantify and evaluate fundamental care in a multidimensional manner. They capture different perspectives (care recipients and their families, direct care providers and care managers) to improve care outcomes. The future aim is to advance this exploration into digitalising and operationalising the Matrix in a user-friendly manner for it to become a real-time mechanism to evaluate and potentially predict patterns of fundamental care.
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Affiliation(s)
- Tiffany Conroy
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.,Caring Futures institute, Adelaide, SA, Australia
| | | | - Alexandra Mudd
- Flinders University College of Nursing and Health Sciences, Adelaide, SA, Australia
| | - Merle Mitchell
- Aged Care Consumer Advocate and Community Activist, Victoria, Australia
| | - Alison Kitson
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.,Caring Futures institute, Adelaide, SA, Australia
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17
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Sharif Z, Peiravian F, Salamzadeh J, Mohammadi NK, Jalalimanesh A. Irrational use of antibiotics in Iran from the perspective of complex adaptive systems: redefining the challenge. BMC Public Health 2021; 21:778. [PMID: 33892681 PMCID: PMC8063475 DOI: 10.1186/s12889-021-10619-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 03/14/2021] [Indexed: 11/12/2022] Open
Abstract
Background Irrational use of antibiotics is proving to be a major concern to the health systems globally. This results in antibiotics resistance and increases health care costs. In Iran, despite many years of research, appreciable efforts, and policymaking to avoid irrational use of antibiotics, yet indicators show suboptimal use of antibiotics, pointing to an urgent need for adopting alternative approaches to further understand the problem and to offer new solutions. Applying the Complex Adaptive Systems (CAS) theory, to explore and research health systems and their challenges has become popular. Therefore, this study aimed to better understand the complexity of the irrational use of antibiotics in Iran and to propose potential solutions. Method This research utilized a CAS observatory tool to qualitatively collect and analyse data. Twenty interviews and two Focus Group discussions were conducted. The data was enriched with policy document reviews to fully understand the system. MAXQDA software was used to organize and analyze the data. Result We could identify several diverse and heterogeneous, yet highly interdependent agents operating at different levels in the antibiotics use system in Iran. The network structure and its adaptive emergent behavior, information flow, governing rules, feedback and values of the system, and the way they interact were identified. The findings described antibiotics use as emergent behavior that is formed by an interplay of many factors and agents over time. According to this study, insufficient and ineffective interaction and information flow regarding antibiotics between agents are among key causes of irrational antibiotics use in Iran. Results showed that effective rules to minimize irrational use of antibiotics are missing or can be easily disobeyed. The gaps and weaknesses of the system which need redesigning or modification were recognized as well. Conclusion The study suggests re-engineering the system by implementing several system-level changes including establishing strong, timely, and effective interactions between identified stakeholders, which facilitate information flow and provision of on-time feedback, and create win-win rules in a participatory manner with stakeholders and the distributed control system.
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Affiliation(s)
- Zahra Sharif
- School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farzad Peiravian
- School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Jamshid Salamzadeh
- School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nastaran Keshavarz Mohammadi
- Health Promotion School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran. .,Scientific Committee of UNESCO global Chair on Health and Education Associate Editor, Health Promotion International, UZH, Zurich, Switzerland.
| | - Ammar Jalalimanesh
- Iranian Research Institute for Information Science and Technology (IRANDOC), Tehran, Iran
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18
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Roussy V, Riley T, Livingstone C. Together stronger: boundary work within an Australian systems-based prevention initiative. Health Promot Int 2021; 35:671-681. [PMID: 31257421 DOI: 10.1093/heapro/daz065] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Complexity and systems science are increasingly used to devise interventions to address health and social problems. Boundaries are important in systems thinking, as they bring attention to the power dynamics that guide decision-making around the framing of a situation, and how it is subsequently tackled. Using complexity theory as an analytical frame, this qualitative exploratory study examined boundary interactions between local government and community health organizations during the operationalization of a systems-based initiative to prevent obesity and chronic diseases (Healthy Together Communities-HTCs) in Victoria, Australia. Across two HTC sites, data was generated through semi-structured interviews with 20 key informants, in mid-2015. Template analysis based on properties of complex systems was applied to the data. The dynamics of boundary work are explored using three case illustrations: alignment, boundary spanning and boundary permeability. Alignment was both a process and an outcome of boundary work, and occurred at strategic, operational and individual levels. Boundary spanning was an important mechanism to develop a unified collaborative approach, and ensure that mainstream initiatives reached disadvantaged groups. Finally, some boundaries exhibited different levels of permeability for local government and community health organizations. This influenced how each organization could contribute to HTC interventions in unique, yet complementary ways. The study of boundary work offers potential for understanding the mechanisms that contribute to the nonlinear behaviour of complex systems. The complementarity of partnering organizations, and boundary dynamics should be considered when designing and operationalizing multilevel, complex systems-informed prevention initiatives.
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Affiliation(s)
- Véronique Roussy
- Gambling and Social Determinants Unit, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Therese Riley
- Therese Riley Consulting, PO Box 292, Sandringham, VIC 3191, Australia
| | - Charles Livingstone
- Gambling and Social Determinants Unit, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
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19
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Wolfenden L, Foy R, Presseau J, Grimshaw JM, Ivers NM, Powell BJ, Taljaard M, Wiggers J, Sutherland R, Nathan N, Williams CM, Kingsland M, Milat A, Hodder RK, Yoong SL. Designing and undertaking randomised implementation trials: guide for researchers. BMJ 2021; 372:m3721. [PMID: 33461967 PMCID: PMC7812444 DOI: 10.1136/bmj.m3721] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Implementation science is the study of methods to promote the systematic uptake of evidence based interventions into practice and policy to improve health. Despite the need for high quality evidence from implementation research, randomised trials of implementation strategies often have serious limitations. These limitations include high risks of bias, limited use of theory, a lack of standard terminology to describe implementation strategies, narrowly focused implementation outcomes, and poor reporting. This paper aims to improve the evidence base in implementation science by providing guidance on the development, conduct, and reporting of randomised trials of implementation strategies. Established randomised trial methods from seminal texts and recent developments in implementation science were consolidated by an international group of researchers, health policy makers, and practitioners. This article provides guidance on the key components of randomised trials of implementation strategies, including articulation of trial aims, trial recruitment and retention strategies, randomised design selection, use of implementation science theory and frameworks, measures, sample size calculations, ethical review, and trial reporting. It also focuses on topics requiring special consideration or adaptation for implementation trials. We propose this guide as a resource for researchers, healthcare and public health policy makers or practitioners, research funders, and journal editors with the goal of advancing rigorous conduct and reporting of randomised trials of implementation strategies.
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Affiliation(s)
- Luke Wolfenden
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Noah M Ivers
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Department of Family Medicine and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Byron J Powell
- Brown School and School of Medicine, Washington University in St Louis, St Louis, MI, USA
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - John Wiggers
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Rachel Sutherland
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Nicole Nathan
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Christopher M Williams
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Melanie Kingsland
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Andrew Milat
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Rebecca K Hodder
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Sze Lin Yoong
- Swinburne University of Technology, School of Health Sciences, Faculty Health, Arts and Design, Hawthorn, VIC, Australia
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20
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Hitch D, Leech K, Neale S, Malcolm A. Evaluating the implementation of an early supported discharge (ESD) program for stroke survivors: A mixed methods longitudinal case study. PLoS One 2020; 15:e0235055. [PMID: 32579574 PMCID: PMC7313954 DOI: 10.1371/journal.pone.0235055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 06/08/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Early supported discharge (ESD) models of care for stroke survivors coordinate inpatient and community services, with the aim of reducing length of stay. While there is an established evidence base around the clinical outcomes of ESD), less is known about the implementation of this approach into existing stroke care service. The aim of this case study was to describe staff perceptions of the implementation of an ESD model of care for stroke survivors at a large metropolitan public hospital in Australia. METHODS This case study utilised a mixed methods design, which was designed in explicit alignment with the Consolidated Framework for Implementation Research (CFIR). Participants included staff that referred patients for ESD, and staff involved in the planning, implementation or delivery of ESD. Survey data was collected at three time points (ESD commencement, 3 months and 6 months), and focus groups were undertaken at the conclusion of the study. All quantitative data was analysed descriptive, while qualitative data was evaluated using thematic analysis. RESULTS Results from both sources of data identified changes in staff perceptions of ESD implementation over time. While very few changes were statistically significant, they were diverse patterns of change across the CFIR constructs over time. The characteristics of individuals and ESD characteristics attracted consistently positive perceptions, while patient needs and resources was the most prevalent theme within the data. While perceptions of factors related to the inner setting were mixed, there was a steady improvement in perceptions about the process across the later stages of implementation. CONCLUSIONS The sophistication of knowledge translation and implementation in modern complex healthcare environments is highlighted by the multiple interactions between the CFIR domains and constructs. While the implementation process described was generally positive and effective, using the CFIR as a framework confirmed that it also entailed some challenges and unanticipated outcomes.
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Affiliation(s)
- Danielle Hitch
- Allied Health, Western Health, Sunshine, Victoria, Australia
- Occupational Therapy, Deakin University, Geelong, Victoria, Australia
- * E-mail:
| | - Kathleen Leech
- Allied Health, Western Health, Sunshine, Victoria, Australia
| | - Sharon Neale
- Allied Health, Western Health, Sunshine, Victoria, Australia
| | - Avetta Malcolm
- Allied Health, Western Health, Sunshine, Victoria, Australia
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Abstract
Purpose of Review Clinical trials have found that PrEP is highly effective in reducing risk of HIV acquisition across types of exposure, gender, PrEP regimens, and dosing schemes. Evidence is urgently needed to inform scale-up of PrEP to meet the ambitious WHO/UNAIDS prevention target of 3,000,000 individuals on PrEP by 2020. Recent Findings Successful models of delivering HIV services at scale evolved from years of formal research and programmatic evidence. These efforts produced lessons-learned relevant for scaling-up PrEP delivery, including the importance of streamlining laboratory tests, expanding prescription and management authority, differentiating medication access points, and reducing stigma and barriers of parental consent for PrEP uptake. Further research is especially needed in areas differentiating PrEP from ART delivery, including repeat HIV testing to ensure HIV negative status and defining and measuring prevention-effective adherence. Summary Evidence from 15 years of ART scale-up could immediately inform a public health approach to PrEP delivery.
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Öhlén J, Sawatzky R, Pettersson M, Sarenmalm EK, Larsdotter C, Smith F, Wallengren C, Friberg F, Kodeda K, Carlsson E. Preparedness for colorectal cancer surgery and recovery through a person-centred information and communication intervention - A quasi-experimental longitudinal design. PLoS One 2019; 14:e0225816. [PMID: 31830066 PMCID: PMC6907786 DOI: 10.1371/journal.pone.0225816] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 10/23/2019] [Indexed: 12/11/2022] Open
Abstract
To meet patients’ information and communication needs over time in order to improve their recovery is particularly challenging for patients undergoing cancer surgery. The aim of the study was to evaluate whether an intervention with a person-centred approach to information and communication for patients diagnosed with colorectal cancer undergoing surgery can improve the patients’ preparedness for surgery, discharge and recovery during six months following diagnosis and initial treatment. The intervention components involving a novel written interactive patient education material and person-centred communication was based on critical analysis of conventional information and communication for these patients. During 2014–2016, 488 consecutive patients undergoing elective surgery for colorectal cancer were enrolled in a quasi-experimental longitudinal study. In three hospitals, first a conventional care group (n = 250) was recruited, then the intervention was introduced, and finally the intervention group was recruited (n = 238). Patients’ trajectories of preparedness for surgery and recovery (Preparedness for Colorectal Cancer Surgery Questionnaire—PCSQ) health related quality of life (EORTC QLQ-C30) and distress (NCCS Distress Thermometer) were evaluated based on self-reported data at five time points, from pre-surgery to 6 months. Length of hospital stay and patients’ behavior in seeking health care pre- and post-surgery were extracted from patient records. Longitudinal structural equation models were used to test the hypothesized effects over time. Statistically significant positive effects were detected for two of the four PCSQ domains (patients searching for and making use of information, and making sense of the recovery) and for the role functioning domain of the EORTC QLQ-C30. Patients in the intervention group were also more likely to contact their assigned cancer “contact nurse” (a.k.a. nurse navigator) instead of contacting a nurse on duty at the ward or visiting the emergency department. In conclusion, the overall hypothesis was not confirmed. Further research is recommended on written and oral support tools to facilitate person-centred communication.
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Affiliation(s)
- Joakim Öhlén
- Institute of Health and Care Sciences and University of Gothenburg Centre for Person-Centred Care, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Palliative Centre, Sahlgrenska University Hospital Västra Götaland Region, Gothenburg, Sweden
- * E-mail:
| | - Richard Sawatzky
- Institute of Health and Care Sciences and University of Gothenburg Centre for Person-Centred Care, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- School of Nursing, Trinity Western University, Langley, BC, Canada
- Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, Canada
| | - Monica Pettersson
- Institute of Health and Care Sciences and University of Gothenburg Centre for Person-Centred Care, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Vascular Department, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Elisabeth Kenne Sarenmalm
- Institute of Health and Care Sciences and University of Gothenburg Centre for Person-Centred Care, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Research & Development Unit, Skaraborg Hospital, Skövde, Sweden
| | - Cecilia Larsdotter
- Department of Nursing science, Sophiahemmet University, Stockholm, Sweden
| | - Frida Smith
- Center for Health Care Improvement, Department of Technology Management and Economics, Division of Service Management and Logistics, Chalmers University of Technology, Gothenburg, Sweden
- Regional Cancer Center West, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Catarina Wallengren
- Institute of Health and Care Sciences and University of Gothenburg Centre for Person-Centred Care, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Febe Friberg
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Karl Kodeda
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Eva Carlsson
- Institute of Health and Care Sciences and University of Gothenburg Centre for Person-Centred Care, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
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Storkholm MH, Mazzocato P, Savage C. Make it complicated: a qualitative study utilizing a complexity framework to explain improvement in health care. BMC Health Serv Res 2019; 19:842. [PMID: 31727069 PMCID: PMC6857274 DOI: 10.1186/s12913-019-4705-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 10/31/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Successful application of Quality Improvement (QI) methods is challenging, and awareness of the role context plays has increased. Complexity science has been advocated as a way to inform change efforts. However, empirical support is scarce, and it is still difficult to grasp the practical implications for QI interventions. The aim of this study was to use a complexity-based leadership framework to explain how managers in a clinical department addressed external requirements to cut costs without compromising patient outcomes and experience. METHODS Explanatory case study design of a Danish OB/GYN department tasked to improve efficiency. Data came from documents, 30 interviews, and 250 h of observations over 3 years. A Complexity Analysis Framework that combined two complexity-based leadership frameworks was developed to analyze all changes implemented to reduce cost, while maintaining clinical quality. RESULTS Managers reframed the efficiency requirement as an opportunity for quality improvement. Multiple simple, complicated, and complex situations were addressed with an adaptive approach to quality improvement. Changes were made to clinical pathways for individual conditions (n = 37), multiple conditions (n = 7), and at the organizational level (n = 9). At the organizational level, changes addressed referral practice, physical space in the department, flow and capacity, discharge speed, and managerial support. Managers shared responsibility with staff; together they took a "professional path" and systematically analyzed each clinical pathway through process mapping, attentive to patterns that emerged, before deciding on the next steps, such as a engaging in a complex process of probing - the iterative development and testing of new responses. CONCLUSIONS Quality improvement efforts could benefit from an understanding of the importance of learning and sharing responsibility to deal with the co-existing degrees of contextual complexity in modern health care. By "making things complicated" through a systematic analysis that engages staff in an open and reflective dialog, clinical praxis and established organizational structures can be questioned and improved. The Complexity Analysis Framework could then help managers to identify improvement opportunities, know when to implement technical solutions, and when to keep abreast of emerging patterns and allow appropriate responses to complex challenges to evolve.
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Affiliation(s)
- Marie Höjriis Storkholm
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Pamela Mazzocato
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden
| | - Carl Savage
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden
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Byskov J, Maluka S, Marchal B, Shayo EH, Blystad A, Bukachi S, Zulu JM, Michelo C, Hurtig AK, Bloch P. A systems perspective on the importance of global health strategy developments for accomplishing today's Sustainable Development Goals. Health Policy Plan 2019; 34:635-645. [PMID: 31363736 PMCID: PMC6880334 DOI: 10.1093/heapol/czz042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2019] [Indexed: 12/01/2022] Open
Abstract
Priority setting within health systems has not led to accountable, fair and sustainable solutions to improving population health. Providers, users and other stakeholders each have their own health and service priorities based on selected evidence, own values, expertise and preferences. Based on a historical account, this article analyses if contemporary health systems are appropriate to optimize population health within the framework of cross cutting targets of the Sustainable Development Goals (SDGs). We applied a scoping review approach to identify and review literature of scientific databases and other programmatic web and library-based documents on historical and contemporary health systems policies and strategies at the global level. Early literature supported the 1977 launching of the global target of Health for All by the year 2000. Reviewed literature was used to provide a historical overview of systems components of global health strategies through describing the conceptualizations of health determinants, user involvement and mechanisms of priority setting over time, and analysing the importance of historical developments on barriers and opportunities to accomplish the SDGs. Definitions, scope and application of health systems-associated priority setting fluctuated and main health determinants and user influence on global health systems and priority setting remained limited. In exploring reasons for the identified lack of SDG-associated health systems and priority setting processes, we discuss issues of accountability, vested interests, ethics and democratic legitimacy as conditional for future sustainability of population health. To accomplish the SDGs health systems must engage beyond their own sector boundary. New approaches to Health in All Policies and One Health may be conducive for scaling up more democratic and inclusive priority setting processes based on proper process guidelines from successful pilots. Sustainable development depends on population preferences supported by technical and managerial expertise.
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Affiliation(s)
- Jens Byskov
- Research and Health Systems Advisor, School of Public Health, Ridgeway Campus, University of Zambia, Lusaka, Zambia
| | - Stephen Maluka
- Institute of Development Studies, University of Dar Es Salaam, Tanzania
| | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Nationalestraat 155, B Antwerpen, Belgium
| | - Elizabeth H Shayo
- National Institute for Medical Research (NIMR), Dar Es Salaam, Tanzania
| | - Astrid Blystad
- Department of Global Health and Primary Care, University of Bergen, Norway
| | - Salome Bukachi
- Institute of Anthropology, Gender and African Studies University of Nairobi, Nairobi, Kenya
| | - Joseph M Zulu
- School of Public Health, Ridgeway Campus, University of Zambia, Lusaka, Zambia
| | - Charles Michelo
- School of Public Health, Ridgeway Campus, University of Zambia, Lusaka, Zambia
| | - Anna-Karin Hurtig
- Department of Epidemiology and Global Health, Umeå University, SE, Umea, Sweden
| | - Paul Bloch
- Steno Diabetes Center Copenhagen, Niels Steensens Vej 6, DK Gentofte, Denmark
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Krieger T, Boumans N, Feron F, Dorant E. The development of implementation management instruments for a new complex stroke caregiver intervention based on systematic stakeholder and risk analyses. Scand J Caring Sci 2019; 34:215-229. [PMID: 31250940 DOI: 10.1111/scs.12723] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 05/14/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Stakeholders are important contributors in the implementation of a complex public health intervention. During the development phase of an implementation, alongside careful design of its components and investing in the exploration of the dynamic multi-stakeholder stroke rehabilitation setting, it is essential to assess possible implementation risks. Systematic stakeholder and risk analyses can guide the exploration process and enable teams involved in complex interventions to develop context-tailored implementation management instruments. PURPOSE To develop instruments that facilitate the implementation of the complex stroke caregiver intervention project in the real-life support system. METHODS Systematic stakeholder and risk analyses were conducted composing five activities. Project stakeholders were identified, classified and assessed using a top-down approach, while implementation risks were identified and assessed by applying a bottom-up approach. Data were collected through interviews and focus groups. RESULTS Based on the knowledge provided by the stakeholders, two context-tailored implementation management instruments were designed with a top-down approach: (1) a comprehensive 'stakeholder-risk atlas' providing individual stakeholder information, such as role, access, contribution, power and interest, expectations, perceived risks and specific engagement activities and (2) an overall 'project implementation strategy' concentrating on communication, transparency, network building and professionalism. CONCLUSION Complex interventions will benefit from early and comprehensive stakeholder and risk analyses. The early involvement of stakeholders, with their insightful knowledge, enables the research team to develop context-tailored implementation management instruments. Instruments will support the team during implementation and may impact positively on the outcome of the intervention. Knowledge can be obtained by combining top-down and bottom-up working approaches.
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Affiliation(s)
- Theresia Krieger
- Institute for Health Research and Social Psychiatry, Catholic University of Applied Sciences North-Rhine Westphalia, Aachen, Germany
| | - Nicolle Boumans
- Faculty of Health Medicine and Life Sciences, Department of Social Medicine, Maastricht University, Maastricht, The Netherlands
| | - Frans Feron
- Faculty of Health Medicine and Life Sciences, Department of Social Medicine, Maastricht University, Maastricht, The Netherlands
| | - Elisabeth Dorant
- Department of Social Medicine, Maastricht University, Maastricht, The Netherlands
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Orton L, Ponsford R, Egan M, Halliday E, Whitehead M, Popay J. Capturing complexity in the evaluation of a major area-based initiative in community empowerment: what can a multi-site, multi team, ethnographic approach offer? Anthropol Med 2019; 26:48-64. [DOI: 10.1080/13648470.2018.1508639] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Lois Orton
- University of Liverpool, Public Health and Policy, Whelan Building, The Qudrangle, Liverpool L69 3GB, UK
| | - Ruth Ponsford
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Matt Egan
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Emma Halliday
- Department of Health Research; Furness Building, Lancaster University, Bailrigg, Lancaster LA1 4YG, UK
| | - Margaret Whitehead
- University of Liverpool, Public Health and Policy, Whelan Building, The Qudrangle, Liverpool L69 3GB, UK
| | - Jennie Popay
- Department of Health Research; Furness Building, Lancaster University, Bailrigg, Lancaster LA1 4YG, UK
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Churruca K, Ludlow K, Taylor N, Long JC, Best S, Braithwaite J. The time has come: Embedded implementation research for health care improvement. J Eval Clin Pract 2019; 25:373-380. [PMID: 30632246 DOI: 10.1111/jep.13100] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 12/19/2018] [Accepted: 12/22/2018] [Indexed: 12/23/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES The field of implementation science has developed in response to slow and inconsistent translation of evidence into practice. Despite utilizing increasingly sophisticated approaches to implementation, including applying a complexity science lens and conducting realist evaluations, challenges remain to getting the kinds of outcomes hoped for by implementation efforts. These include gaining access and buy-in from those implementing the change and accounting for the influence of local context. One emerging approach to address these challenges is embedded implementation research-a collaborative, adaptive approach to improvement. It involves researchers and implementers working together in situ from the outset of, and throughout, an implementation project. Both groups can benefit from the collaboration: it increases the rigor of evaluation, provides opportunities to improve the intervention through direct feedback, and promotes better on-the-ground understanding of the change process. We aimed to examine the potential benefits, and some of the challenges, of increased embeddedness. METHOD We performed a multi-case analysis of implementation research projects that varied by degree of embeddedness. RESULTS Embedded implementation research may offer a range of advantages over dichotomized research-practice designs, including better understanding of local context and direct feedback to improve the implementation along the way. We present a model that spans four approaches: dichotomized research-practice, collaborative linking-up, partially-embedded, and deep immersion. CONCLUSION Embedded implementation research approaches hold promise in comparison to traditional dichotomized-research practice designs, where the research is external to the implementation and conducts a summative evaluation. We are only beginning to understand how such partnerships operate in practice and what makes them successful. Our analysis suggests the time has come to consider such approaches.
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Affiliation(s)
- Kate Churruca
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Kristiana Ludlow
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | | | - Janet C Long
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Stephanie Best
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia.,Murdoch Children's Research Institute, Melbourne, Australia
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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Reed JE, Howe C, Doyle C, Bell D. Successful Healthcare Improvements From Translating Evidence in complex systems (SHIFT-Evidence): simple rules to guide practice and research. Int J Qual Health Care 2019; 31:238-244. [PMID: 30085160 PMCID: PMC6464098 DOI: 10.1093/intqhc/mzy160] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 04/23/2018] [Accepted: 06/30/2018] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Evidence translation and improvement research indicate that healthcare contexts are complex systems, characterized by uncertainty and surprise, which often defy orchestrated intervention attempts. This article reflects on the implications of complexity on attempts to translate evidence, and on a newly published framework for Successful Healthcare Improvements From Translating Evidence in complex systems (SHIFT-Evidence). DISCUSSION SHIFT-Evidence positions the challenge of evidence translation within the complex and evolving context of healthcare, and recognizes the wider issues practitioners routinely face. It is empirically grounded, and designed to be comprehensive, practically relevant and actionable. SHIFT-evidence is summarized by three principles designed to be intuitive and memorable: 'act scientifically and pragmatically'; 'embrace complexity'; and 'engage and empower'. Common challenges and strategies to overcome them are summarized in 12 'simple rules' that provide actionable guidance. CONCLUSION SHIFT-Evidence provides a practical tool to guide practice and research of evidence translation and improvement within complex dynamic healthcare settings. Implications are that improvement initiatives and research study designs need to take into account the unique initial conditions in each local setting; conduct needs to respond to unpredictable effects and address dependent problems; and evaluation needs to be sensitive to evolving priorities and the emergent range of activities required to achieve improvement.
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Affiliation(s)
- Julie E Reed
- National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London, Chelsea and Westminster Hospital, Imperial College, UK
| | - Cathy Howe
- National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London, Chelsea and Westminster Hospital, Imperial College, UK
| | - Cathal Doyle
- National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London, Chelsea and Westminster Hospital, Imperial College, UK
| | - Derek Bell
- National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London, Chelsea and Westminster Hospital, Imperial College, UK
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29
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Toma M, Dreischulte T, Gray NM, Guthrie B. A balanced approach to identifying, prioritising and evaluating all potential consequences of quality improvement: modified Delphi study. BMJ Open 2019; 9:e023890. [PMID: 30904844 PMCID: PMC6475234 DOI: 10.1136/bmjopen-2018-023890] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 01/16/2019] [Accepted: 02/06/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Healthcare is a complex system, so quality improvement will commonly lead to unintended consequences which are rarely evaluated. In previous qualitative work, we proposed a framework for considering the range of these potential consequences, in terms of their desirability and the extent to which they were predictable or expected during planning. This paper elaborates on the previous findings, using consensus methods to examine what consequences should be identified, why and how to prioritise, evaluate and interpret all identified consequences, and what stakeholders should be involved throughout this process. DESIGN Two-round modified Delphi consensus study. SETTING AND PARTICIPANTS Both rounds were completed by 60 panellists from an academic, clinical or management background and experience in designing, implementing or evaluating quality improvement programmes. RESULTS Panellists agreed that trade-offs (expected undesirable consequences) and unpleasant surprises (unexpected undesirable consequences) should be actively considered. Measurement of harmful consequences for patients, and those with high workload or financial impact was prioritised, and their evaluation could also involve the use of qualitative methods. Clinical teams were agreed as important to involve at all stages, from identifying potential consequences, prioritising which of those to systematically evaluate, undertaking appropriate evaluation and interpreting the findings. Patients were necessary in identifying consequences, managers in identifying and prioritising, and improvement advisors in interpreting the data. CONCLUSION There was consensus that a balanced approach to considering all the consequences of improvement can be achieved by carefully considering predictable trade-offs from the outset and deliberately pausing after implementation to identify any unexpected surprises and make an informed decision as to whether quantitative or qualitative evaluation is needed and feasible. Stakeholders' roles in in the process of identifying, prioritising, evaluating and interpreting potential consequences should be explicitly addressed within planning and revisited during and after implementation.
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Affiliation(s)
- Madalina Toma
- Scottish Improvement Science Collaborating Centre (SISCC), School of Nursing and Health Sciences, University of Dundee, Dundee, UK
| | - Tobias Dreischulte
- Division of Population Health and Genomics, University of Dundee, Dundee, UK
- NHS Tayside, Prescribing Support Unit, Dundee, UK
- Institute of General Practice and Family Medicine, University Hospital of Ludwig-Maximilians-University, Munich, Germany
| | - Nicola M Gray
- Scottish Improvement Science Collaborating Centre (SISCC), School of Nursing and Health Sciences, University of Dundee, Dundee, UK
| | - Bruce Guthrie
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
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30
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Churruca K, Pomare C, Ellis LA, Long JC, Braithwaite J. The influence of complexity: a bibliometric analysis of complexity science in healthcare. BMJ Open 2019; 9:e027308. [PMID: 30904877 PMCID: PMC6475366 DOI: 10.1136/bmjopen-2018-027308] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES To analyse trends in the academic literature applying complexity science to healthcare, focusing specifically on bibliometric characteristics and indicators of influence. DESIGN This study reports a bibliometric analysis via a systematic search of the academic literature applying complexity science to healthcare. METHOD A search of four academic databases was performed on 19 April 2018. Article details were downloaded and screened against inclusion criteria (peer-reviewed journal articles applying complexity science to healthcare). Publication and content data were then collected from included articles, with analysis focusing on trends over time in the types and topics of articles, and where they are published. We also analysed the influence of this body of work through citation and network analyses. RESULTS Articles on complexity science in healthcare were published in 268 journals, though a much smaller subset was responsible for a substantial proportion of this literature. USA contributed the largest number of articles, followed by the UK, Canada and Australia. Over time, the number of empirical and review articles increased, relative to non-empirical contributions. However, in general, non-empirical literature was more influential, with a series of introductory conceptual papers being the most influential based on both overall citations and their use as index references within a citation network. The most common topics of focus were health systems and organisations generally, and education, with recent uptake in research, policy, and change and improvement. CONCLUSIONS This study identified changes in the types of articles on complexity science in healthcare published over time, and their content. There was evidence to suggest a shift from conceptual work to the application of concrete improvement strategies and increasingly in-depth examination of complex healthcare systems. We also identified variation in the influence of this literature at article level, and to a lesser extent by topic of focus.
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Affiliation(s)
- Kate Churruca
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
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31
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Long JC, Winata T, Debono D, Phan-Thien KC, Zhu C, Taylor N. Process evaluation of a behaviour change approach to improving clinical practice for detecting hereditary cancer. BMC Health Serv Res 2019; 19:180. [PMID: 30894169 PMCID: PMC6425681 DOI: 10.1186/s12913-019-3985-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/01/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND This retrospective process evaluation reports on the application of a 1-year implementation program to increase identification and management of patients at high risk of a hereditary cancer syndrome. The project used the Theoretical Domains Framework Implementation (TDFI) approach, a promising implementation methodology, used successfully in the United Kingdom to address patient safety issues. This Australian project run at two large public hospitals aimed to increase referrals of patients flagged as being at risk of Lynch syndrome on the basis of a screening test to genetic services. At the end of the project, the pathologists' processes had changed, but the referral rate remained inconsistent and low. METHODS Semi-structured interviews explored participants' perceptions of the TDFI approach and Health services researchers wrote structured reflections. Interview transcripts and reflections were coded initially against implementation outcomes for the various TDFI approach activities: acceptability, appropriateness, feasibility, value for time cost, and adoption. On a second pass, themes were coded around challenges to the approach. RESULTS Interviews were held with nine key project participants including pathologists, oncologists, surgeons, genetic counsellors and an administrative officer. Two health services researchers wrote structured reflections. The first of two major themes was 'Theory-related challenges', with subthemes of accessibility of theory underpinning the TDFI, commitment to that theory-based approach, and the problem of complexity. The second theme was 'Practical challenges' with subthemes of stakeholder management, navigating the system, and perceptions of the problem. Health services researchers reflected on the benefits of bridging professional divides and facilitating collective learning and problem solving, but noted frustrations around clinicians' time constraints that led to sparse interactions with the team, and lack of authority to effect change themselves. CONCLUSIONS Mixed success of adoption as an outcome was attributed to the complexity and highly nuanced nature of the setting. This made identifying the target behaviour, a key step in the TDFI approach, challenging. Introduced changes in the screening process led to new, unexpected issues yet to be addressed. Strategies to address challenges are presented, including using an internal facilitator with a focus on applying a theory-based implementation approach.
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Affiliation(s)
- Janet C Long
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, 2109, Australia
| | - Teresa Winata
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, 2109, Australia
| | - Deborah Debono
- Centre for Health Services Management, Faculty of Health, University of Technology, Sydney, NSW, 2007, Australia
| | - Kim-Chi Phan-Thien
- St George and Sutherland Clinical School, University of New South Wales, Kensington, Sydney, NSW, 2052, Australia
| | - Christine Zhu
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, 2109, Australia
| | - Natalie Taylor
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, 2109, Australia. .,Cancer Research Division, Cancer Council NSW, 153 Dowling St, Woolloomooloo, NSW, 2011, Australia. .,Faculty of Health Sciences, University of Sydney, Camperdown, Sydney, NSW, 2006, Australia.
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Moore GF, Evans RE, Hawkins J, Littlecott H, Melendez-Torres G, Bonell C, Murphy S. From complex social interventions to interventions in complex social systems: Future directions and unresolved questions for intervention development and evaluation. EVALUATION (LONDON, ENGLAND : 1995) 2019; 25:23-45. [PMID: 30705608 PMCID: PMC6330692 DOI: 10.1177/1356389018803219] [Citation(s) in RCA: 182] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Complex systems approaches to social intervention research are increasingly advocated. However, there have been few attempts to consider how models of intervention science, such as the UK's Medical Research Council complex interventions framework, might be reframed through a complex systems lens. This article identifies some key areas in which this framework might be reconceptualized, and a number of priority areas where further development is needed if alignment with a systems perspective is to be achieved. We argue that a complex systems perspective broadens the parameters of 'relevant' evidence and theory for intervention development, before discussing challenges in defining feasibility in dynamic terms. We argue that whole systems evaluations may be neither attainable, nor necessary; acknowledgment of complexity does not mean that evaluations must be complex, or investigate all facets of complexity. However, a systems lens may add value to evaluation design through guiding identification of key uncertainties, and informing decisions such as timings of follow-up assessments.
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Affiliation(s)
| | | | | | | | | | - Chris Bonell
- London School of Hygiene & Tropical Medicine, UK
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Reed JE, Howe C, Doyle C, Bell D. Simple rules for evidence translation in complex systems: A qualitative study. BMC Med 2018; 16:92. [PMID: 29921274 PMCID: PMC6009041 DOI: 10.1186/s12916-018-1076-9] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 05/14/2018] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Ensuring patients benefit from the latest medical and technical advances remains a major challenge, with rational-linear and reductionist approaches to translating evidence into practice proving inefficient and ineffective. Complexity thinking, which emphasises interconnectedness and unpredictability, offers insights to inform evidence translation theories and strategies. Drawing on detailed insights into complex micro-systems, this research aimed to advance empirical and theoretical understanding of the reality of making and sustaining improvements in complex healthcare systems. METHODS Using analytical auto-ethnography, including documentary analysis and literature review, we assimilated learning from 5 years of observation of 22 evidence translation projects (UK). We used a grounded theory approach to develop substantive theory and a conceptual framework. Results were interpreted using complexity theory and 'simple rules' were identified reflecting the practical strategies that enhanced project progress. RESULTS The framework for Successful Healthcare Improvement From Translating Evidence in complex systems (SHIFT-Evidence) positions the challenge of evidence translation within the dynamic context of the health system. SHIFT-Evidence is summarised by three strategic principles, namely (1) 'act scientifically and pragmatically' - knowledge of existing evidence needs to be combined with knowledge of the unique initial conditions of a system, and interventions need to adapt as the complex system responds and learning emerges about unpredictable effects; (2) 'embrace complexity' - evidence-based interventions only work if related practices and processes of care within the complex system are functional, and evidence-translation efforts need to identify and address any problems with usual care, recognising that this typically includes a range of interdependent parts of the system; and (3) 'engage and empower' - evidence translation and system navigation requires commitment and insights from staff and patients with experience of the local system, and changes need to align with their motivations and concerns. Twelve associated 'simple rules' are presented to provide actionable guidance to support evidence translation and improvement in complex systems. CONCLUSION By recognising how agency, interconnectedness and unpredictability influences evidence translation in complex systems, SHIFT-Evidence provides a tool to guide practice and research. The 'simple rules' have potential to provide a common platform for academics, practitioners, patients and policymakers to collaborate when intervening to achieve improvements in healthcare.
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Affiliation(s)
- Julie E Reed
- National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London, Chelsea, London, UK. .,Westminster Hospital, Imperial College, London, SW10 9NH, UK.
| | - Cathy Howe
- National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London, Chelsea, London, UK.,Westminster Hospital, Imperial College, London, SW10 9NH, UK
| | - Cathal Doyle
- National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London, Chelsea, London, UK.,Westminster Hospital, Imperial College, London, SW10 9NH, UK
| | - Derek Bell
- National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London, Chelsea, London, UK.,Westminster Hospital, Imperial College, London, SW10 9NH, UK
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Bucknall T, Hitch D. Connections, Communication and Collaboration in Healthcare's Complex Adaptive Systems Comment on "Using Complexity and Network Concepts to Inform Healthcare Knowledge Translation". Int J Health Policy Manag 2018; 7:556-559. [PMID: 29935133 PMCID: PMC6015507 DOI: 10.15171/ijhpm.2017.138] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 11/25/2017] [Indexed: 12/31/2022] Open
Abstract
A more sophisticated understanding of the unpredictable, disorderly and unstable aspects of healthcare organisations is developing in the knowledge translation (KT) literature. In an article published in this journal, Kitson et al introduced a new model for KT in healthcare based on complexity theory. The Knowledge Translation Complexity Network Model (KTCNM) provides a fresh perspective by making the complexity inherent in complex systems overt. The model encourages a whole system view and focuses on the interdependent relationships between actions, interactions and actors. Taking a systems approach assists our understanding of the connections, communication and collaboration necessary to promote knowledge mobilisation and facilitate the adoption of change. With further development, this could enable the targeting of more effective strategies across the various stakeholders and levels of service, fostering redesign and innovation.
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Affiliation(s)
- Tracey Bucknall
- School of Nursing and Midwifery, Faculty of Health, Deakin University, Geelong, VIC, Australia
- Alfred Health, Melbourne, VIC, Australia
| | - Danielle Hitch
- Occupational Therapy, School of Health and Social Development, Deakin University, Geelong, VIC, Australia
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Braithwaite J, Churruca K, Long JC, Ellis LA, Herkes J. When complexity science meets implementation science: a theoretical and empirical analysis of systems change. BMC Med 2018; 16:63. [PMID: 29706132 PMCID: PMC5925847 DOI: 10.1186/s12916-018-1057-z] [Citation(s) in RCA: 302] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 04/20/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Implementation science has a core aim - to get evidence into practice. Early in the evidence-based medicine movement, this task was construed in linear terms, wherein the knowledge pipeline moved from evidence created in the laboratory through to clinical trials and, finally, via new tests, drugs, equipment, or procedures, into clinical practice. We now know that this straight-line thinking was naïve at best, and little more than an idealization, with multiple fractures appearing in the pipeline. DISCUSSION The knowledge pipeline derives from a mechanistic and linear approach to science, which, while delivering huge advances in medicine over the last two centuries, is limited in its application to complex social systems such as healthcare. Instead, complexity science, a theoretical approach to understanding interconnections among agents and how they give rise to emergent, dynamic, systems-level behaviors, represents an increasingly useful conceptual framework for change. Herein, we discuss what implementation science can learn from complexity science, and tease out some of the properties of healthcare systems that enable or constrain the goals we have for better, more effective, more evidence-based care. Two Australian examples, one largely top-down, predicated on applying new standards across the country, and the other largely bottom-up, adopting medical emergency teams in over 200 hospitals, provide empirical support for a complexity-informed approach to implementation. The key lessons are that change can be stimulated in many ways, but a triggering mechanism is needed, such as legislation or widespread stakeholder agreement; that feedback loops are crucial to continue change momentum; that extended sweeps of time are involved, typically much longer than believed at the outset; and that taking a systems-informed, complexity approach, having regard for existing networks and socio-technical characteristics, is beneficial. CONCLUSION Construing healthcare as a complex adaptive system implies that getting evidence into routine practice through a step-by-step model is not feasible. Complexity science forces us to consider the dynamic properties of systems and the varying characteristics that are deeply enmeshed in social practices, whilst indicating that multiple forces, variables, and influences must be factored into any change process, and that unpredictability and uncertainty are normal properties of multi-part, intricate systems.
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Affiliation(s)
- Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, NSW, 2109, Australia.
| | - Kate Churruca
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, NSW, 2109, Australia
| | - Janet C Long
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, NSW, 2109, Australia
| | - Louise A Ellis
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, NSW, 2109, Australia
| | - Jessica Herkes
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, NSW, 2109, Australia
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Kitson A, Brook A, Harvey G, Jordan Z, Marshall R, O'Shea R, Wilson D. Using Complexity and Network Concepts to Inform Healthcare Knowledge Translation. Int J Health Policy Manag 2018. [PMID: 29524952 PMCID: PMC5890068 DOI: 10.15171/ijhpm.2017.79] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Many representations of the movement of healthcare knowledge through society exist, and multiple models for the
translation of evidence into policy and practice have been articulated. Most are linear or cyclical and very few come close
to reflecting the dense and intricate relationships, systems and politics of organizations and the processes required to
enact sustainable improvements. We illustrate how using complexity and network concepts can better inform knowledge
translation (KT) and argue that changing the way we think and talk about KT could enhance the creation and movement
of knowledge throughout those systems needing to develop and utilise it. From our theoretical refinement, we propose
that KT is a complex network composed of five interdependent sub-networks, or clusters, of key processes (problem
identification [PI], knowledge creation [KC], knowledge synthesis [KS], implementation [I], and evaluation [E]) that
interact dynamically in different ways at different times across one or more sectors (community; health; government;
education; research for example). We call this the KT Complexity Network, defined as a network that optimises the
effective, appropriate and timely creation and movement of knowledge to those who need it in order to improve what
they do. Activation within and throughout any one of these processes and systems depends upon the agents promoting
the change, successfully working across and between multiple systems and clusters. The case is presented for moving to
a way of thinking about KT using complexity and network concepts. This extends the thinking that is developing around
integrated KT approaches. There are a number of policy and practice implications that need to be considered in light of
this shift in thinking.
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Affiliation(s)
- Alison Kitson
- Adelaide Nursing School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia.,Green Templeton College, University of Oxford, Oxford, UK
| | - Alan Brook
- Adelaide Dental School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia.,Institute of Dentistry, Queen Mary University of London, London, UK
| | - Gill Harvey
- Adelaide Nursing School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia.,Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Zoe Jordan
- Faculty of Health and Medical Sciences, The Joanna Briggs Institute, University of Adelaide, Adelaide, SA, Australia
| | - Rhianon Marshall
- Adelaide Nursing School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Rebekah O'Shea
- Adelaide Nursing School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - David Wilson
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
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Fung-Kee-Fung M, Maziak DE, Pantarotto JR, Smylie J, Taylor L, Timlin T, Cacciotti T, Villeneuve PJ, Dennie C, Bornais C, Madore S, Aquino J, Wheatley-Price P, Ozer RS, Stewart DJ. Regional process redesign of lung cancer care: a learning health system pilot project. ACTA ACUST UNITED AC 2018; 25:59-66. [PMID: 29507485 DOI: 10.3747/co.25.3719] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background The Ottawa Hospital (toh) defined delay to timely lung cancer care as a system design problem. Recognizing the patient need for an integrated journey and the need for dynamic alignment of providers, toh used a learning health system (lhs) vision to redesign regional diagnostic processes. A lhs is driven by feedback utilizing operational and clinical information to drive system optimization and innovation. An essential component of a lhs is a collaborative platform that provides connectivity across silos, organizations, and professions. Methods To operationalize a lhs, we developed the Ottawa Health Transformation Model (ohtm) as a consensus approach that addresses process barriers, resistance to change, and conflicting priorities. A regional Community of Practice (cop) was established to engage stakeholders, and a dedicated transformation team supported process improvements and implementation. Results The project operationalized the lung cancer diagnostic pathway and optimized patient flow from referral to initiation of treatment. Twelve major processes in referral, review, diagnostics, assessment, triage, and consult were redesigned. The Ottawa Hospital now provides a diagnosis to 80% of referrals within the provincial target of 28 days. The median patient journey from referral to initial treatment decreased by 48% from 92 to 47 days. Conclusions The initiative optimized regional integration from referral to initial treatment. Use of a lhs lens enabled the creation of a system that is standardized to best practice and open to ongoing innovation. Continued transformation initiatives across the continuum of care are needed to incorporate best practice and optimize delivery systems for regional populations.
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Affiliation(s)
- M Fung-Kee-Fung
- The Ottawa Hospital, ON.,Division of Gynecologic Oncology, University of Ottawa, ON; and
| | - D E Maziak
- The Ottawa Hospital, ON.,Department of Surgery, Division of Thoracic Surgery, University of Ottawa, Ottawa Hospital Research Institute, ON
| | - J R Pantarotto
- The Ottawa Hospital, ON.,Division of Radiation Oncology, University of Ottawa, ON
| | | | | | | | | | - P J Villeneuve
- The Ottawa Hospital, ON.,Department of Surgery, Division of Thoracic Surgery, University of Ottawa, Ottawa Hospital Research Institute, ON
| | - C Dennie
- The Ottawa Hospital, ON.,Department of Medical Imaging, The Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa, ON
| | | | | | - J Aquino
- The Ottawa Hospital, ON.,Department of Medical Imaging, The Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa, ON
| | - P Wheatley-Price
- The Ottawa Hospital, ON.,Department of Medicine, University of Ottawa, ON
| | | | - D J Stewart
- The Ottawa Hospital, ON.,Department of Medicine, University of Ottawa, ON
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Moore GF, Evans RE. What theory, for whom and in which context? Reflections on the application of theory in the development and evaluation of complex population health interventions. SSM Popul Health 2017; 3:132-135. [PMID: 29302610 PMCID: PMC5742639 DOI: 10.1016/j.ssmph.2016.12.005] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 09/22/2016] [Accepted: 12/12/2016] [Indexed: 01/10/2023] Open
Abstract
Recent years have seen a growing emphasis on the value of building and testing middle range theory throughout the development and evaluation of complex population health interventions. We agree that a coherent theoretical basis for intervention development, and use of evaluation to test key causal assumptions and build theory, are crucial. However, in this editorial, we argue that such recommendations have often been operationalised in somewhat simplistic terms with potentially perverse consequences, and that an uncritical assumption that an intervention explicitly based on theory is inherently superior carries significant risks. We first argue that the drive for theory-based approaches may have exacerbated a propensity to select ‘off-the-shelf’ theories, leading to the selection of inappropriate theories which distract attention from the mechanisms through which a problem is actually sustained. Second, we discuss a tendency toward over-reliance on individual-level theorising. Finally, we discuss the relatively slow progress of population health intervention research in attending to issues of context, and the ecological fit of interventions with the systems whose functioning they attempt to change. We argue that while researchers should consider a broad range of potential theoretical perspectives on a given population health problem, citing a popular off-the-shelf theory as having informed an intervention and its evaluation does not inherently make for better science. Before identifying or developing a theory of change, researchers should develop a clear understanding of how the problem under consideration is created and sustained in context. A broader conceptualisation of theory that reaches across disciplines is vital if theory is to enhance, rather than constrain, the contribution of intervention research. Finally, intervention researchers need to move away from viewing interventions as discrete packages of components which can be described in isolation from their contexts, and better understand the systems into which change is being introduced.
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Affiliation(s)
- Graham F Moore
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), School of Social Sciences, Cardiff University, Wales, United Kingdom
| | - Rhiannon E Evans
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), School of Social Sciences, Cardiff University, Wales, United Kingdom
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Toma M, Dreischulte T, Gray NM, Campbell D, Guthrie B. Balancing measures or a balanced accounting of improvement impact: a qualitative analysis of individual and focus group interviews with improvement experts in Scotland. BMJ Qual Saf 2017; 27:547-556. [PMID: 29055901 DOI: 10.1136/bmjqs-2017-006554] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 09/01/2017] [Accepted: 09/23/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND As quality improvement (QI) programmes have become progressively larger scale, the risks of implementation having unintended consequences are increasingly recognised. More routine use of balancing measures to monitor unintended consequences has been proposed to evaluate overall effectiveness, but in practice published improvement interventions hardly ever report identification or measurement of consequences other than intended goals of improvement. METHODS We conducted 15 semistructured interviews and two focus groups with 24 improvement experts to explore the current understanding of balancing measures in QI and inform a more balanced accounting of the overall impact of improvement interventions. Data were analysed iteratively using the framework approach. RESULTS Participants described the consequences of improvement in terms of desirability/undesirability and the extent to which they were expected/unexpected when planning improvement. Four types of consequences were defined: expected desirable consequences (goals); expected undesirable consequences (trade-offs); unexpected undesirable consequences (unpleasant surprises); and unexpected desirable consequences (pleasant surprises). Unexpected consequences were considered important but rarely measured in existing programmes, and an improvement pause to take stock after implementation would allow these to be more actively identified and managed. A balanced accounting of all consequences of improvement interventions can facilitate staff engagement and reduce resistance to change, but has to be offset against the cost of additional data collection. CONCLUSION Improvement measurement is usually focused on measuring intended goals, with minimal use of balancing measures which when used, typically monitor trade-offs expected before implementation. This paper proposes that improvers and leaders should seek a balanced accounting of all consequences of improvement across the life of an improvement programme, including deliberately pausing after implementation to identify and quantitatively or qualitatively evaluate any pleasant or unpleasant surprises.
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Affiliation(s)
- Madalina Toma
- Scottish Improvement Science Collaborating Centre (SISCC), University of Dundee School of Nursing and Health Science, Dundee, UK
| | | | - Nicola M Gray
- Scottish Improvement Science Collaborating Centre (SISCC), University of Dundee School of Nursing and Health Science, Dundee, UK
| | | | - Bruce Guthrie
- Quality, Safety and Informatics Research Group, Population Health Sciences Division, University of Dundee School of Medicine, Dundee, UK
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Borghi J, Chalabi Z. Square peg in a round hole: re-thinking our approach to evaluating health system strengthening in low-income and middle-income countries. BMJ Glob Health 2017; 2:e000406. [PMID: 29082021 PMCID: PMC5656120 DOI: 10.1136/bmjgh-2017-000406] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 07/19/2017] [Accepted: 07/21/2017] [Indexed: 11/20/2022] Open
Affiliation(s)
- Josephine Borghi
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Zaid Chalabi
- Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London, UK
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