1
|
Borders A, Keenan-Devlin L, Oh EH, Young D, Grobman W, Lee King P. Reducing Severe Maternal Morbidity for Birthing Persons with Severe Hypertension through a Statewide Quality Improvement Initiative. Am J Obstet Gynecol 2024:S0002-9378(24)00549-0. [PMID: 38697335 DOI: 10.1016/j.ajog.2024.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 04/23/2024] [Accepted: 04/23/2024] [Indexed: 05/04/2024]
Abstract
BACKGROUND Hypertensive disorders of pregnancy are a leading preventable cause of severe maternal morbidity and maternal mortality worldwide. OBJECTIVE To assess the improvement in hospital care processes and patient outcomes associated with hypertensive disorders of pregnancy after introduction of a statewide Severe Maternal Hypertension quality improvement initiative. STUDY DESIGN A prospective cohort design comparing outcomes before and after introduction of the Illinois Perinatal Quality Collaborative statewide hypertension quality improvement initiative among 108 hospitals across Illinois. Participating hospitals recorded data for all cases of new-onset severe hypertension (>160 systolic or >110 diastolic) during pregnancy through 6 weeks postpartum from May 2016 to December 2017. Introduction of the statewide quality improvement initiative included implementation of severe maternal hypertension protocols, standardized patient education and discharge planning, rapid access to medications and standardized treatment order sets, and provider and nurse education. The main outcome measure was the reduction of severe maternal morbidity for pregnant/postpartum patients with severe hypertension. Key process measures include time-to-treatment of severe hypertension, frequency of provider/nurse debriefs, appropriate patient education, and early postpartum follow up. RESULTS Data were reported for 8,073 cases of severe maternal hypertension. The frequency of patients with new-onset severe hypertension treated within 60 minutes increased from 41% baseline to 87% (p<0.001) at the end of the initiative. The initiative was associated with increased proportion of patients receiving preeclampsia education at discharge (41% to 89%, p<0.001), scheduling follow-up appointments within 10 days of discharge (68% to 83%, p<0.001), and having a care team debrief after severe hypertension was diagnosed (17% to 59%, p<0.001). Conversely, severe maternal morbidity was reduced from 11.5% baseline to 8.4% (p<0.002) at the end of the study period. Illinois hospitals were able to achieve time-to-treatment goal regardless of hospital characteristics including geography, birth volume, and patient mix. CONCLUSIONS Introduction of a statewide quality improvement effort was associated with improved time-to-treatment of severe hypertension, as well as increased frequency of provider/nurse debriefs, appropriate patient education, and early postpartum follow up scheduled at discharge, and reduced severe maternal morbidity.
Collapse
Affiliation(s)
- Ann Borders
- NorthShore University HealthSystem, Evanston, IL;; University of Chicago Pritzker School of Medicine, Chicago, IL;; Northwestern University Feinberg School of Medicine, Chicago, IL;.
| | - Lauren Keenan-Devlin
- NorthShore University HealthSystem, Evanston, IL;; University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Elissa H Oh
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Danielle Young
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - William Grobman
- Northwestern University Feinberg School of Medicine, Chicago, IL;; The Ohio State University Wexner Medical Center, Columbus, OH
| | - Patricia Lee King
- NorthShore University HealthSystem, Evanston, IL;; University of Chicago Pritzker School of Medicine, Chicago, IL;; Northwestern University Feinberg School of Medicine, Chicago, IL
| |
Collapse
|
2
|
Greenhalgh T, Darbyshire JL, Lee C, Ladds E, Ceolta-Smith J. What is quality in long covid care? Lessons from a national quality improvement collaborative and multi-site ethnography. BMC Med 2024; 22:159. [PMID: 38616276 PMCID: PMC11017565 DOI: 10.1186/s12916-024-03371-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/26/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Long covid (post covid-19 condition) is a complex condition with diverse manifestations, uncertain prognosis and wide variation in current approaches to management. There have been calls for formal quality standards to reduce a so-called "postcode lottery" of care. The original aim of this study-to examine the nature of quality in long covid care and reduce unwarranted variation in services-evolved to focus on examining the reasons why standardizing care was so challenging in this condition. METHODS In 2021-2023, we ran a quality improvement collaborative across 10 UK sites. The dataset reported here was mostly but not entirely qualitative. It included data on the origins and current context of each clinic, interviews with staff and patients, and ethnographic observations at 13 clinics (50 consultations) and 45 multidisciplinary team (MDT) meetings (244 patient cases). Data collection and analysis were informed by relevant lenses from clinical care (e.g. evidence-based guidelines), improvement science (e.g. quality improvement cycles) and philosophy of knowledge. RESULTS Participating clinics made progress towards standardizing assessment and management in some topics; some variation remained but this could usually be explained. Clinics had different histories and path dependencies, occupied a different place in their healthcare ecosystem and served a varied caseload including a high proportion of patients with comorbidities. A key mechanism for achieving high-quality long covid care was when local MDTs deliberated on unusual, complex or challenging cases for which evidence-based guidelines provided no easy answers. In such cases, collective learning occurred through idiographic (case-based) reasoning, in which practitioners build lessons from the particular to the general. This contrasts with the nomothetic reasoning implicit in evidence-based guidelines, in which reasoning is assumed to go from the general (e.g. findings of clinical trials) to the particular (management of individual patients). CONCLUSION Not all variation in long covid services is unwarranted. Largely because long covid's manifestations are so varied and comorbidities common, generic "evidence-based" standards require much individual adaptation. In this complex condition, quality improvement resources may be productively spent supporting MDTs to optimise their case-based learning through interdisciplinary discussion. Quality assessment of a long covid service should include review of a sample of individual cases to assess how guidelines have been interpreted and personalized to meet patients' unique needs. STUDY REGISTRATION NCT05057260, ISRCTN15022307.
Collapse
Affiliation(s)
- Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Rd, Oxford, OX2 6GG, UK.
| | - Julie L Darbyshire
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Rd, Oxford, OX2 6GG, UK
| | - Cassie Lee
- Imperial College Healthcare NHS Trust, London, UK
| | - Emma Ladds
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Rd, Oxford, OX2 6GG, UK
| | - Jenny Ceolta-Smith
- LOCOMOTION Patient Advisory Group and Lived Experience Representative, London, UK
| |
Collapse
|
3
|
Laher F, Malahleha M, Ramirez S, Brumskine W, Otwombe K, Moodie Z, Allen M. Data quality in an HIV vaccine efficacy clinical trial in South Africa: through natural disasters and with discipline. BMC Med Res Methodol 2023; 23:147. [PMID: 37355583 PMCID: PMC10290289 DOI: 10.1186/s12874-023-01967-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 06/07/2023] [Indexed: 06/26/2023] Open
Abstract
BACKGROUND To produce quality data that informs valid clinical trial results and withstands regulatory inspection, trial sites should adhere to many complex and dynamic requirements. Understanding non-conformance to requirements informs the emerging field of improvement science. We describe protocol deviations in South Africa's largest HIV vaccine efficacy trial. METHODS We analysed data from the HVTN 702 trial using mixed methods. We obtained descriptive statistics, from protocol deviation case report forms collected from 2016-2022, of deviation by participant, trial site, and time to site awareness. We thematically analysed text narratives of deviation descriptions, corrective and preventive actions, generating categories, codes and themes which emerged from the data. RESULTS For 5407 enrollments, 4074 protocol deviations were reported (75 [95% CI: 73.0-77.6] deviations per 100 enrolments). There was a median of 1 protocol deviation per participant (IQR 1-2). Median time from deviation to site awareness was 31 days (IQR 0-146). The most common category of deviation type was omitted data and/or procedures (69%), and 54% of these omissions were stated to have arisen because of the national lockdown at the beginning of the COVID-19 pandemic. The ratio of protocol deviations to cumulative enrolments was highest in the year 2020 (0.34). Major themes of deviations were: COVID-19 and climate disasters giving rise to deviation trends, subroutines introducing an opportunity for deviation, and document fragmentation (such as requirements dispersed across multiple guidance documents) as an obstacle. Preventive action categories were: no preventive measures; discipline, training and/or awareness; quality review, checking and verifying and changing the process and/or implementation tools. Major themes of preventive actions were that systems-based actions are unusual, with people-based actions dominating, and that root cause analysis was rarely mentioned. CONCLUSIONS In the age of infectious and climate disaster risks, trials may benefit from simple study designs and trial-related documents. To optimise protocol adherence, sponsors and sites should consider ongoing training, and routinely review deviation reports with a view to adjusting processes. These data quality lessons may inform future trial design, training and implementation. TRIAL REGISTRATION HVTN 702 was registered with the South African National Clinical Trials Register (DOH-27-0916-5327) and ClinicalTrials.gov ( NCT02968849 ).
Collapse
Affiliation(s)
- Fatima Laher
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Diepkloof, P.O. Box 114, Johannesburg, 1864, Soweto, South Africa.
| | - Mookho Malahleha
- Synergy Biomed Research Institute, East London, Eastern Cape, South Africa
| | - Shelly Ramirez
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - William Brumskine
- The Aurum Institute NPC, Johannesburg, Gauteng, South Africa
- Department of Medicine, School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Kennedy Otwombe
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Diepkloof, P.O. Box 114, Johannesburg, 1864, Soweto, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Zoe Moodie
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Mary Allen
- Vaccine Research Program, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| |
Collapse
|
4
|
Wagstaff D, Moonesinghe SR. Publishing quality improvement studies: learning to share and sharing to learn. BJA Open 2023; 5:100123. [PMID: 37587994 PMCID: PMC10430837 DOI: 10.1016/j.bjao.2023.100123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 01/03/2023] [Indexed: 08/18/2023]
Abstract
This editorial welcomes the decision of BJA Open to publish quality improvement (QI) studies. It summarises the current problems with conducting, evaluating, and publishing QI studies. It highlights existing guidance for prospective authors to follow regarding the reporting of QI interventions, their context(s), underlying theories, and evaluation. In so doing, we hope to encourage the publication of more QI studies of sufficient quality to facilitate learning or replication elsewhere.
Collapse
Affiliation(s)
- Duncan Wagstaff
- Centre for Perioperative Medicine and Division of Surgery and Interventional Science, University College London, London, UK
| | - Suneetha Ramani Moonesinghe
- Department for Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
| |
Collapse
|
5
|
Rohanna KL, Christie CA. A problem-bound evaluation approach. Eval Program Plann 2023; 96:102187. [PMID: 36413889 DOI: 10.1016/j.evalprogplan.2022.102187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 06/16/2023]
Abstract
Traditional modes of evaluation can be constraining when seeking to improve persistent societal problems within complex systems. Frameworks that assume stability and predictability may not match the system dynamics within which a program resides. This paper seeks to further evaluators' understanding of how to improve problems in complex systems by offering a "problem-bound" evaluation approach. This model is grounded in theoretical concepts from complexity science, complex adaptive systems, systems thinking, and improvement science. As such, it provides an agile and flexible framework for continually learning from emergent findings related to the problem. By offering this model, we seek to contribute to the limited knowledge base on how to apply systems change theoretical ideas in evaluation practice, along with practical implications regarding the evaluator's role.
Collapse
Affiliation(s)
- Kristen L Rohanna
- School of Education & Information Studies, University of California Los Angeles, USA.
| | - Christina A Christie
- School of Education & Information Studies, University of California Los Angeles, USA
| |
Collapse
|
6
|
Mathura P, Lee DH, Thompson A, McMurtry N, Kassam N. Providing quality improvement training in an advanced pharmacy practice experience elective. Curr Pharm Teach Learn 2021; 13:397-402. [PMID: 33715802 DOI: 10.1016/j.cptl.2020.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 10/15/2020] [Accepted: 11/24/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND AND PURPOSE Quality Improvement (QI) science is a burgeoning component of healthcare systems and the practice of pharmacy. There is limited published literature on the implementation of QI training in undergraduate pharmacy education. We describe the development and implementation of QI training in an experiential course. EDUCATIONAL ACTIVITY AND SETTING A QI curriculum was developed for an existing eight-week pharmacy practice elective experience for year four pharmacy students. The curriculum was divided into two, four-week blocks, combining didactic instruction and applied learning activities. A partnership between university departments and a local health organization provided a QI preceptor along with an interdisciplinary clinical team in an acute care setting to improve clinical services. FINDINGS Six students have completed the elective along with completing three QI projects. The Kirkpatrick 4 level model guided course evaluation. A curriculum strength was no additional cost or educational burden on the faculty of pharmacy and pharmaceutical sciences. Students recognized benefit from (1) course flexibility and independence to learn, (2) clear expectations and weekly guidance from the preceptor, (3) alignment of weekly readings and real-time application of QI concepts, and (4) the Institute for Healthcare Improvement education modules. Reducing the number of assigned tasks per week and improving availability of the clinical QI team to support student learning were identified as areas for improvement. SUMMARY This elective course demonstrated a starting point from which QI education can be formally included in pharmacy undergraduate education.
Collapse
Affiliation(s)
- Pamela Mathura
- Alberta Health Services, and University of Alberta Department of Medicine, 8440 112 Street, Edmonton, AB T6G 2B7, Canada.
| | - Dillon H Lee
- Univeristy of Alberta, 2-35, Medical Sciences Building University of Alberta, 8613 114 St., Edmonton, AB T6G 2H7, Canada.
| | - Ann Thompson
- University of Alberta, Experiential Education Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, 3-281 Edmonton Clinic Health Academy, 11405 87 Ave NW, Edmonton, AB T6G 1C9, Canada.
| | - Natalie McMurtry
- Alberta health Services, 14(th) Floor Seventh Street Plaza, 10030-107 Street, Edmonton, AB T5J 3E4, Canada.
| | - Narmin Kassam
- University of Alberta, Department of Medicine, Clinical Department of Medicine, Alberta Health Services, 13-103 Clinical Science Building, 11350 - 83 Ave. NW, Edmonton, AB T6G 2V2, Canada.
| |
Collapse
|
7
|
Fischbacher CM, Lewsey J, Muirie J, McCartney G. A critical reflection on the use of improvement science approaches in public health. Scand J Public Health 2021; 50:389-394. [PMID: 33596733 DOI: 10.1177/1403494821990245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE 'Improvement science' is used to describe specific quality improvement methods (including tests of change and statistical process control). The approach is spreading from clinical settings to population-wide interventions and is being extended from supporting the adoption of proven interventions to making generalisable claims about new interventions. The objective of this narrative review is to evaluate the strengths and risks of current improvement science practice, particularly in relation to how they might be used in population health. METHODS A purposive sampling of published studies to identify how improvement science methods are being used and for what purpose. The setting was Scotland and studies that focused on health and wellbeing outcomes. RESULTS We have identified a range of improvement science approaches which provide practitioners with accessible tools to assess small-scale changes in policy and practice. The strengths of such approaches are that they facilitate consistent implementation of interventions already known to be effective and motivate and empower staff to make local improvements. However, we also identified a number of potential risks. In particular, their use to assess the effectiveness of new interventions often seems to pay insufficient attention to random variation, measurement bias, confounding and ethical issues. CONCLUSIONS The use of current improvement science methods to generate evidence of effectiveness for population-wide interventions is problematic and risks unjustified claims of effectiveness, inefficient resource use and harm to those not offered alternative effective interventions. Newer methodological approaches offer alternatives and should be more widely considered.
Collapse
Affiliation(s)
| | - Jim Lewsey
- Institute of Health and Wellbeing, University of Glasgow, UK
| | - Jill Muirie
- Glasgow Centre for Population Health, Glasgow, UK
| | | |
Collapse
|
8
|
Dongelmans DA, Pilcher D, Beane A, Soares M, Del Pilar Arias Lopez M, Fernandez A, Guidet B, Haniffa R, Salluh JIF. Linking of global intensive care (LOGIC): An international benchmarking in critical care initiative. J Crit Care 2020; 60:305-310. [PMID: 32979689 DOI: 10.1016/j.jcrc.2020.08.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/06/2020] [Accepted: 08/30/2020] [Indexed: 12/14/2022]
Abstract
Benchmarking is a common and effective method for measuring and analyzing ICU performance. With the existence of national registries, objective information can now be obtained to allow benchmarking of ICU care within and between countries. The present manuscript briefly describes the current status of benchmarking in healthcare and critical care and presents the LOGIC project, an initiative to promote international benchmarking for intensive care units. Currently 13 registries have joined LOGIC. We showed large differences in the utilization of ICU as well as resources and in outcomes. Despite the need for careful interpretation of differences due to variation in definitions and limited risk adjustment, LOGIC is a growing worldwide initiative that allows access to insightful epidemiologic data from ICUs in multiple databases and registries.
Collapse
Affiliation(s)
- D A Dongelmans
- Amsterdam UMC, University of Amsterdam, Department of Intensive Care Medicine, Meibergdreef 9, Amsterdam, the Netherlands; National Intensive Care Evaluation (NICE) foundation, Amsterdam, the Netherlands; Department of Intensive Care, The Alfred Hospital, Commercial Road, Prahran VIC 3004, Australia.
| | - David Pilcher
- Department of Intensive Care, The Alfred Hospital, Commercial Road, Prahran VIC 3004, Australia; The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Camberwell VIC 3124, Australia; Crit Care Asia, Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
| | - Abigail Beane
- Department of Intensive Care, The Alfred Hospital, Commercial Road, Prahran VIC 3004, Australia; Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, University of Oxford, UK; D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Marcio Soares
- Department of Intensive Care, The Alfred Hospital, Commercial Road, Prahran VIC 3004, Australia; Post Graduation Program, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Argentine Society of Intensive Care (SATI). SATI-Q Program, Buenos Aires, Argentina
| | - Maria Del Pilar Arias Lopez
- Department of Intensive Care, The Alfred Hospital, Commercial Road, Prahran VIC 3004, Australia; Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina; Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, Service de réanimation, F75012 Paris, France
| | - Ariel Fernandez
- Department of Intensive Care, The Alfred Hospital, Commercial Road, Prahran VIC 3004, Australia; Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina
| | - Bertrand Guidet
- Department of Intensive Care, The Alfred Hospital, Commercial Road, Prahran VIC 3004, Australia; Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, Service de réanimation, F75012 Paris, France
| | - Rashan Haniffa
- Department of Intensive Care, The Alfred Hospital, Commercial Road, Prahran VIC 3004, Australia; Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, University of Oxford, UK; D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Jorge I F Salluh
- Department of Intensive Care, The Alfred Hospital, Commercial Road, Prahran VIC 3004, Australia; Post Graduation Program, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Argentine Society of Intensive Care (SATI). SATI-Q Program, Buenos Aires, Argentina
| |
Collapse
|
9
|
Gilhooly D, Green SA, McCann C, Black N, Moonesinghe SR. Barriers and facilitators to the successful development, implementation and evaluation of care bundles in acute care in hospital: a scoping review. Implement Sci 2019; 14:47. [PMID: 31060625 PMCID: PMC6501296 DOI: 10.1186/s13012-019-0894-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 04/12/2019] [Indexed: 12/21/2022] Open
Abstract
Background Care bundles are small sets of evidence-based recommendations, designed to support the implementation of evidence-based best clinical practice. However, there is variation in the design and implementation of care bundles, which may impact on the fidelity of delivery and subsequently their clinical effectiveness. Methods A scoping review was carried out using the Arksey and O’Malley framework to identify the literature reporting on the design, implementation and evaluation of care bundles. The Embase, CINAHL, Cochrane and Ovid MEDLINE databases were searched for manuscripts published between 2001 and November 2017; hand-searching of references and citations was also undertaken. Data were initially assessed using a quality assessment tool, the Downs and Black checklist, prior to further analysis and narrative synthesis. Implementation strategies were classified using the Expert Recommendations for Implementing Change (ERIC) criteria. Results Twenty-eight thousand six hundred ninety-two publications were screened and 348 articles retrieved in full text. Ninety-nine peer-reviewed quantitative publications were included for data extraction. These consisted of one randomised crossover trial, one randomised cluster trial, one case-control study, 20 prospective cohort studies and 76 non-parallel cohort studies. Twenty-three percent of studies were classified as poor based on Downs and Black checklist, and reporting of implementation strategies lacked structure. Negative associations were found between the number of elements in a bundle and compliance (Spearman’s rho = − 0.47, non-parallel cohort and − 0.65, prospective cohort studies), and between the complexity of elements and compliance (p < 0.001, chi-squared = 23.05). Implementation strategies associated with improved compliance included evaluative and iterative approaches, development of stakeholder relationships and education and training strategies. Conclusion Care bundles with a small number of simple elements have better compliance rates. Standardised reporting of implementation strategies may help to implement care bundles into clinical practice with high fidelity. Trial Registration This review was registered on the PROSPERO database: CRD 42015029963 in December 2015. Electronic supplementary material The online version of this article (10.1186/s13012-019-0894-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- D Gilhooly
- UCLH NIHR Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College Hospital, London, NW1 2BU, UK.
| | - S A Green
- NIHR CLAHRC Northwest London, Imperial College London Chelsea and Westminster Hospital, London, SW10 9NH, UK.,Department of Health Services Research Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - C McCann
- UCLH NIHR Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College Hospital, London, NW1 2BU, UK
| | - N Black
- Department of Health Services Research Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - S R Moonesinghe
- Division of Surgery and Interventional Science Charles Bell House, University College London, London, W1W 7TS, UK.,Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, Churchill House, 35 Red Lion Square, London, WC1R 4SG, UK
| |
Collapse
|
10
|
Kampstra NA, Zipfel N, van der Nat PB, Westert GP, van der Wees PJ, Groenewoud AS. Health outcomes measurement and organizational readiness support quality improvement: a systematic review. BMC Health Serv Res 2018; 18:1005. [PMID: 30594193 PMCID: PMC6311059 DOI: 10.1186/s12913-018-3828-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 12/17/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Using outcome measures to advance healthcare continues to be of widespread interest. The goal is to summarize the results of studies which use outcome measures from clinical registries to implement and monitor QI initiatives. The second objective is to identify a) facilitators and/or barriers that contribute to the realization of QI efforts, and b) how outcomes are being used as a catalyst to change outcomes over time. METHODS We searched the PubMed, EMBASE and Cochrane databases for relevant articles published between January 1995 and March 2017. We used a standardized data abstraction form. Studies were included when the following three criteria were fulfilled: 1) they relied on structural data collection, 2) when a structural and comprehensive QI intervention had been implemented and evaluated, and 3) impact on improving clinical and/or patient-reported outcomes was described. Data on QI strategies, QI initiatives and the impact on outcomes was extracted using standardized assessment tools. RESULTS We included 21 articles, of which eight showed statistically significant improvements on outcomes using data from clinical registries. Out of these eight studies, the Chronic Care Model, IT application as feedback, benchmarking and the Collaborative Care Model were used as QI methods. Encouraging trends in realizing improved outcomes through QI initiatives were observed, ranging from improving teamwork, implementation of clinical guidelines, implementation of physician alerts and development of a decision support system. Facilitators for implementing QI initiatives included a high quality database, audits, frequent reporting and feedback, patient involvement, communication, standardization, engagement, and leadership. CONCLUSION This review suggests that outcomes collected in clinical registries are supportive to realize QI initiatives. Organizational readiness and an active approach are key in achieving improved outcomes.
Collapse
Affiliation(s)
- Nynke A Kampstra
- Department of Value-Based Healthcare, St. Antonius Hospital, Nieuwegein, the Netherlands. .,Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud university medical center, Nijmegen, the Netherlands.
| | - Nina Zipfel
- Department of Value-Based Healthcare, St. Antonius Hospital, Nieuwegein, the Netherlands.,Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud university medical center, Nijmegen, the Netherlands
| | - Paul B van der Nat
- Department of Value-Based Healthcare, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Gert P Westert
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud university medical center, Nijmegen, the Netherlands
| | - Philip J van der Wees
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud university medical center, Nijmegen, the Netherlands
| | - A Stef Groenewoud
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud university medical center, Nijmegen, the Netherlands
| |
Collapse
|
11
|
Pap R, Shabella L, Morrison AJ, Simpson PM, Williams DM. Teaching improvement science to paramedicine students: protocol for a systematic scoping review. Syst Rev 2018; 7:236. [PMID: 30572946 PMCID: PMC6300882 DOI: 10.1186/s13643-018-0910-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 12/06/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is now more important than ever to equip paramedic students, the likely future managers and leaders of ambulance services, with the knowledge and skills of improvement science. Effective teaching requires a range of teaching methods that will engage students actively in learning. Although the array and effectiveness of methods used for teaching improvement science to clinicians and healthcare students has been systematically reviewed, the evidence regarding the specific sub-group of paramedicine students has yet to be fully explored and synthesized in the literature. The aim of this scoping review is to systematically explore and critically appraise the current state of evidence regarding strategies to teach improvement science to paramedicine students. METHODS A number of electronic databases (i.e., PubMed, CINAHL, Embase, Scopus, and ERIC) and gray literature (i.e., ProQuest Dissertations and Theses, Open Thesis, and Networked Digital Library of Theses and Dissertations) will be searched for published and unpublished evidence regarding teaching improvement science to paramedicine students. Included studies will undergo narrative synthesis to examine similarities and differences and to identify patterns, themes, and relationships (e.g., how and why certain teaching strategies or methods have worked in achieving desired learning outcomes (or not) and factors that might have influenced this). DISCUSSION To the knowledge of the authors, this is the first review that will systematically explore and critically appraise the current state of research evidence regarding strategies to teach improvement science specifically to paramedicine students. It is anticipated that the findings of this review will help to inform academics, developers of paramedicine teaching curricula, and researchers who are planning projects in this area. SYSTEMATIC REVIEW REGISTRATION Scoping reviews are currently not eligible for registration on the international prospective register of systematic reviews (i.e., PROSPERO).
Collapse
Affiliation(s)
- Robin Pap
- School of Science and Health, Western Sydney University, Locked Bag 1797, Penrith, NSW 2751 Australia
| | - Louis Shabella
- Ambulance Service of New South Wales, Locked Bag 105, Rozelle, NSW 2039 Australia
| | - Alan J. Morrison
- School of Science and Health, Western Sydney University, Locked Bag 1797, Penrith, NSW 2751 Australia
| | - Paul M. Simpson
- School of Science and Health, Western Sydney University, Locked Bag 1797, Penrith, NSW 2751 Australia
| | - David M. Williams
- Institute for Healthcare Improvement, 53 State Street, 19th Floor, Boston, MA 02109 USA
| |
Collapse
|
12
|
Portela MC, Lima SML, da Costa Reis LG, Martins M, Aveling EL. Challenges to the improvement of obstetric care in maternity hospitals of a large Brazilian city: an exploratory qualitative approach on contextual issues. BMC Pregnancy Childbirth 2018; 18:459. [PMID: 30477475 PMCID: PMC6258487 DOI: 10.1186/s12884-018-2088-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 11/14/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Maternal morbidity and mortality are still serious public health concerns in Brazil, and access to quality obstetric care is one critical point of this problem. Despite efforts, obstetric care quality problems and sub-optimal/poor outcomes persist. The study aimed to identify contextual elements that would potentially affect the implementation of an obstetric care quality improvement intervention. METHODS A qualitative study was conducted in three public maternity hospitals of a large Brazilian city, with high annual volume of births and buy-in from high-level managers. Individual interviews with doctors and nurses were conducted from July to October 2015. Semi-structured interviews sought to explore teamwork, coordination and communication, and leadership, being open to capture other contextual elements that could emerge. Interviews were recorded and transcribed, and the categories of analysis were identified and updated based on the constant comparative method. RESULTS Twenty-seven interviews were carried out. Extra-organizational context concerning the dependence of the maternity hospitals on primary care units, responsible for antenatal care, and on other healthcare organizations' services emerged from interviews, but the main findings of the study centered on intra-organizational context with potential to affect healthcare quality and actions for its improvement, including material resources, work organization design, teamwork, coordination and communication, professional responsibility vis-à-vis the patient, and leadership. A major issue was the divergence of physicians' and nurses' perspectives on care quality, which in turn negatively affected their capacity to work together. CONCLUSION Overall, the findings suggest that care on the maternity hospitals was fragmented and lacked continuity, putting at risk the quality. Redesigning work organization, promoting conditions for multi-professional teamwork, better communication and coordination, improving more systemic accountability/lines of authority, and investing in team members' technical competence, and fitness of organizational structures and processes are all imbricated actions that may contribute to obstetric care quality improvement.
Collapse
Affiliation(s)
- Margareth Crisóstomo Portela
- Department of Health Administration and Planning, National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, RJ Brazil
| | - Sheyla Maria Lemos Lima
- Department of Health Administration and Planning, National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, RJ Brazil
| | - Lenice Gnocchi da Costa Reis
- Department of Health Administration and Planning, National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, RJ Brazil
| | - Mônica Martins
- Department of Health Administration and Planning, National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, RJ Brazil
| | - Emma-Louise Aveling
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA USA
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
| |
Collapse
|
13
|
Abstract
I argue that greater attention to human agency and normativity in both researching and practicing service improvement may be one strategy for enhancing improvement science, illustrating with examples from cancer screening. Improvement science tends to deliberately avoid explicit normativity, for paradigmatically coherent reasons. But there are good reasons to consider including explicit normativity in thinking about improvement. Values and moral judgements are central to social life, so an adequate account of social life must include these elements. And improvement itself is unavoidably normative: it assumes that things could and should be better than they are. I seek to show that normativity will always be implicated in the creation of evidence, the design of programs, the practice of healthcare, and in citizens' judgements about that care, and to make a case that engaging with this normativity is worthwhile.
Collapse
|
14
|
Shiell A, Hawe P, Kavanagh S. Evidence suggests a need to rethink social capital and social capital interventions. Soc Sci Med 2018; 257:111930. [PMID: 30219489 DOI: 10.1016/j.socscimed.2018.09.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 09/03/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
Abstract
In the 21 years since social capital first appeared in the public health literature, the evidence base has grown enormously, now reaching 28 systematic reviews encompassing more than 850 individual studies. We summarise this evidence and explain why conclusions relating to both the relationship between social capital and health, and the effectiveness of interventions to promote population health remain elusive and contradictory. A critical factor is the inadequate way that context is treated in the research, and especially how context interacts with efforts to promote health in a dynamic fashion. Of all the different types of interventions one could employ to improve the health of the public, 'social capital' interventions are likely to be the most context specific and especially affected by the boundaries placed around the context. A way forward is offered that requires a combination of insights from systems thinking, community-based participatory research, and intervention and improvement sciences. This requires renewed focus on the specific components of social capital, an understanding of how context interacts dynamically with efforts to improve health, a greater role for practice in the design, implementation, adaptation and evaluation of interventions, and the support of researchers to develop better methods for recognising and classifying the knowledge generated by complex interventions.
Collapse
Affiliation(s)
- Alan Shiell
- Department of Public Health, La Trobe University and the Australian Prevention Partnership Centre, Australia.
| | - Penelope Hawe
- Menzies Centre for Health Policy, University of Sydney, and the Australian Prevention Partnership Centre, Australia
| | - Shane Kavanagh
- Department of Public Health, La Trobe University and the Australian Prevention Partnership Centre, Australia
| |
Collapse
|
15
|
Abstract
In this editorial essay I explore the possibilities of 'improvement scholarship' in order to set the scene for the theme of, and the other papers in, this issue. I contrast a narrow conception of quality improvement (QI) research with a much broader and more inclusive conception, arguing that we should greatly extend the existing dialogue between 'problem-solving' and 'critical' currents in improvement research. I have in mind the potential for building a much larger conversation between those people in 'improvement science' who are expressly concerned with tackling the problems facing healthcare and the wider group of colleagues who are engaged in health-related scholarship but who do not see themselves as particularly interested in quality improvement, indeed who may be critical of the language or concerns of QI. As one contribution to that conversation I suggest that that the increasing emphasis on theory and rigour in improvement research should include more focus on normative theory and rigour. The remaining papers in the issue are introduced including the various ways in which they handle the 'implicit normativity' of QI research and practice, and the linked theme of combining relatively 'tidy' and potentially 'unruly' forms of knowledge.
Collapse
Affiliation(s)
- Alan Cribb
- Centre for Public Policy Research, King's College London, Waterloo Bridge Wing FWB, London, SE1 9NH, UK.
| |
Collapse
|
16
|
Abstract
Responding to this issue's invitation to bring new disciplinary insights to the field of improvement science, this article takes as its starting point one of the field's guiding metaphors: the imperative to "mind the gap". Drawing on insights from anthropology, history, and philosophy, the article reflects on the origins and implications of this metaphoric imperative, and suggests some ways in which it might be in tension with the means and ends of improvement. If the industrial origins of improvement science in the twentieth century inform a metaphor of gaps, chasms, and spaces of misalignment as invariably imperfect and potentially dangerous, and therefore requiring bridging or closure, other currents that feed the discipline of improvement science suggest the potential value and uses of spaces of openness and ambiguity. These currents include the science of complex adaptive systems, and certain precepts of philosophical pragmatism acknowledged to inform improvement science. Going a step further, I reflect on whether or not these two contrasting approaches within improvement science should be treated as incommensurable paradigms, and what each approach tells us about the very possibility of accommodating seemingly irreconcilable or incommensurable approaches within improvement science.
Collapse
|
17
|
Goldhaber-Fiebert SN, Macrae C. Emergency Manuals: How Quality Improvement and Implementation Science Can Enable Better Perioperative Management During Crises. Anesthesiol Clin 2018; 36:45-62. [PMID: 29425598 DOI: 10.1016/j.anclin.2017.10.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
How can teams manage critical events more effectively? There are commonly gaps in performance during perioperative crises, and emergency manuals are recently available tools that can improve team performance under stress, via multiple mechanisms. This article examines how the principles of implementation science and quality improvement were applied by multiple teams in the development, testing, and systematic implementations of emergency manuals in perioperative care. The core principles of implementation have relevance for future patient safety innovations perioperatively and beyond, and the concepts of emergency manuals and interprofessional teamwork are applicable for diverse fields throughout health care.
Collapse
Affiliation(s)
- Sara N Goldhaber-Fiebert
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Room H3580, Stanford, CA 94305-5640, USA.
| | - Carl Macrae
- Department of Experimental Psychology, University of Oxford, Tinbergen Building, 9 South Parks Road, Oxford OX1 3UD, UK
| |
Collapse
|
18
|
Pronovost PJ, Weaver SJ, Berenholtz SM, Lubomski LH, Maragakis LL, Marsteller JA, Pham JC, Sawyer MD, Thompson DA, Weeks K, Rosen MA. Reducing preventable harm: observations on minimizing bloodstream infections. J Health Organ Manag 2017; 31:2-9. [PMID: 28260406 DOI: 10.1108/jhom-10-2016-0197] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose The purpose of this paper is to provide a practical framework that health care organizations could use to decrease preventable healthcare-acquired harms. Design/methodology/approach An existing theory of how hospitals succeeded in reducing rates of central line-associated bloodstream infections was refined, drawing from the literature and experiences in facilitating improvement efforts in thousands of hospitals in and outside the USA. Findings The following common interventions were implemented by hospitals able to reduce and sustain low infection rates. Hospital and intensive care unit (ICU) leaders demonstrated and vocalized their commitment to the goal of zero preventable harm. Also, leaders created an enabling infrastructure in the way of a coordinating team to support the improvement work to prevent infections. The team of hospital quality improvement and infection prevention staff provided project management, analytics, improvement science support, and expertise on evidence-based infection prevention practices. A third intervention assembled Comprehensive Unit-based Safety Program teams in ICUs to foster local ownership of the improvement work. The coordinating team also linked unit-based safety teams in and across hospital organizations to form clinical communities to share information and disseminate effective solutions. Practical implications This framework is a feasible approach to drive local efforts to reduce bloodstream infections and other preventable healthcare-acquired harms. Originality/value Implementing this framework could decrease the significant morbidity, mortality, and costs associated with preventable harms.
Collapse
Affiliation(s)
- Peter J Pronovost
- Armstrong Institute for Patient Safety and Quality , Johns Hopkins Medicine, Baltimore, Maryland, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland, USA.,Department of Surgery, Johns Hopkins University , Baltimore, Maryland, USA.,Department of Health Policy and Management, Johns Hopkins University , Baltimore, Maryland, USA
| | - Sally J Weaver
- Armstrong Institute for Patient Safety and Quality , Johns Hopkins Medicine, Baltimore, Maryland, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland, USA
| | - Sean M Berenholtz
- Armstrong Institute for Patient Safety and Quality , Johns Hopkins Medicine, Baltimore, Maryland, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland, USA.,Department of Surgery, Johns Hopkins University , Baltimore, Maryland, USA.,Department of Health Policy and Management, Johns Hopkins University , Baltimore, Maryland, USA
| | - Lisa H Lubomski
- Armstrong Institute for Patient Safety and Quality , Johns Hopkins Medicine, Baltimore, Maryland, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland, USA
| | - Lisa L Maragakis
- Armstrong Institute for Patient Safety and Quality , Johns Hopkins Medicine, Baltimore, Maryland, USA.,Department of Medicine, Division of Infectious Diseases, Johns Hopkins University , Baltimore, Maryland, USA
| | - Jill A Marsteller
- Armstrong Institute for Patient Safety and Quality , Johns Hopkins Medicine, Baltimore, Maryland, USA.,Department of Health Policy and Management, Johns Hopkins University , Baltimore, Maryland, USA
| | - Julius Cuong Pham
- Armstrong Institute for Patient Safety and Quality , Johns Hopkins Medicine, Baltimore, Maryland, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland, USA.,Queens Medical Center, Honolulu, Hawaii, USA
| | - Melinda D Sawyer
- Armstrong Institute for Patient Safety and Quality , Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - David A Thompson
- Armstrong Institute for Patient Safety and Quality , Johns Hopkins Medicine, Baltimore, Maryland, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland, USA.,Johns Hopkins School of Nursing, Division of Acute and Chronic Care, Johns Hopkins University , Baltimore, Maryland, USA
| | - Kristina Weeks
- Armstrong Institute for Patient Safety and Quality , Johns Hopkins Medicine, Baltimore, Maryland, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland, USA
| | - Michael A Rosen
- Armstrong Institute for Patient Safety and Quality , Johns Hopkins Medicine, Baltimore, Maryland, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University , Baltimore, Maryland, USA.,Department of Health Policy and Management, Johns Hopkins University , Baltimore, Maryland, USA
| |
Collapse
|
19
|
Cairney P, Oliver K. Evidence-based policymaking is not like evidence-based medicine, so how far should you go to bridge the divide between evidence and policy? Health Res Policy Syst 2017; 15:35. [PMID: 28446185 PMCID: PMC5407004 DOI: 10.1186/s12961-017-0192-x] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 03/12/2017] [Indexed: 11/10/2022] Open
Abstract
There is extensive health and public health literature on the ‘evidence-policy gap’, exploring the frustrating experiences of scientists trying to secure a response to the problems and solutions they raise and identifying the need for better evidence to reduce policymaker uncertainty. We offer a new perspective by using policy theory to propose research with greater impact, identifying the need to use persuasion to reduce ambiguity, and to adapt to multi-level policymaking systems. We identify insights from secondary data, namely systematic reviews, critical analysis and policy theories relevant to evidence-based policymaking. The studies are drawn primarily from countries such as the United States, United Kingdom, Canada, Australia and New Zealand. We combine empirical and normative elements to identify the ways in which scientists can, do and could influence policy. We identify two important dilemmas, for scientists and researchers, that arise from our initial advice. First, effective actors combine evidence with manipulative emotional appeals to influence the policy agenda – should scientists do the same, or would the reputational costs outweigh the policy benefits? Second, when adapting to multi-level policymaking, should scientists prioritise ‘evidence-based’ policymaking above other factors? The latter includes governance principles such the ‘co-production’ of policy between local public bodies, interest groups and service users. This process may be based primarily on values and involve actors with no commitment to a hierarchy of evidence. We conclude that successful engagement in ‘evidence-based policymaking’ requires pragmatism, combining scientific evidence with governance principles, and persuasion to translate complex evidence into simple stories. To maximise the use of scientific evidence in health and public health policy, researchers should recognise the tendency of policymakers to base judgements on their beliefs, and shortcuts based on their emotions and familiarity with information; learn ‘where the action is’, and be prepared to engage in long-term strategies to be able to influence policy; and, in both cases, decide how far you are willing to go to persuade policymakers to act and secure a hierarchy of evidence underpinning policy. These are value-driven and political, not just ‘evidence-based’, choices.
Collapse
Affiliation(s)
- Paul Cairney
- Politics and Public Policy at the University of Stirling, Stirling, United Kingdom. .,Division of History and Politics, University of Stirling, Stirling, FK9 4LA, United Kingdom.
| | - Kathryn Oliver
- Departmental Lecturer in Evidence-Based Social Intervention and Policy Evaluation, Oxford University, Oxford, United Kingdom.,Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
20
|
Fulop NJ, Ramsay AIG, Vindrola-Padros C, Aitchison M, Boaden RJ, Brinton V, Clarke CS, Hines J, Hunter RM, Levermore C, Maddineni SB, Melnychuk M, Moore CM, Mughal MM, Perry C, Pritchard-Jones K, Shackley DC, Vickers J, Morris S. Reorganising specialist cancer surgery for the twenty-first century: a mixed methods evaluation (RESPECT-21). Implement Sci 2016; 11:155. [PMID: 27884193 PMCID: PMC5123291 DOI: 10.1186/s13012-016-0520-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 11/11/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are longstanding recommendations to centralise specialist healthcare services, citing the potential to reduce variations in care and improve patient outcomes. Current activity to centralise specialist cancer surgical services in two areas of England provides an opportunity to study the planning, implementation and outcomes of such changes. London Cancer and Manchester Cancer are centralising specialist surgical pathways for prostate, bladder, renal, and oesophago-gastric cancers, so that these services are provided in fewer hospitals. The centralisations in London were implemented between November 2015 and April 2016, while implementation in Manchester is anticipated in 2017. METHODS/DESIGN This mixed methods evaluation will analyse stakeholder preferences for centralisations; it will use qualitative methods to analyse planning, implementation and sustainability of the centralisations ('how and why?'); and it will use a controlled before and after design to study the impact of centralisation on clinical processes, clinical outcomes, cost-effectiveness and patient experience ('what works and at what cost?'). The study will use a framework developed in previous research on major system change in acute stroke services. A discrete choice experiment will examine patient, public and professional preferences for centralisations of this kind. Qualitative methods will include documentary analysis, stakeholder interviews and non-participant observations of meetings. Quantitative methods will include analysis of local and national data on clinical processes, outcomes, costs and National Cancer Patient Experience Survey data. Finally, we will hold a workshop for those involved in centralisations of specialist services in other settings to discuss how these lessons might apply more widely. DISCUSSION This multi-site study will address gaps in the evidence on stakeholder preferences for centralisations of specialist cancer surgery and the processes, impact and cost-effectiveness of changes of this kind. With increasing drives to centralise specialist services, lessons from this study will be of value to those who commission, organise and manage cancer services, as well as services for other conditions and in other settings. The study will face challenges in terms of recruitment, the retrospective analysis of some of the changes, the distinction between primary and secondary outcome measures, and obtaining information on the resources spent on the reconfiguration.
Collapse
Affiliation(s)
- Naomi J. Fulop
- Department of Applied Health Research, University College London, 1-19 Torrington Place, London, WC1E 7HB UK
| | - Angus I. G. Ramsay
- Department of Applied Health Research, University College London, 1-19 Torrington Place, London, WC1E 7HB UK
| | - Cecilia Vindrola-Padros
- Department of Applied Health Research, University College London, 1-19 Torrington Place, London, WC1E 7HB UK
| | | | - Ruth J. Boaden
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | | | - Caroline S. Clarke
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - John Hines
- University College London Hospitals NHS Foundation Trust, London, UK
- Barts Health NHS Trust, London, UK
| | - Rachael M. Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Claire Levermore
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Mariya Melnychuk
- Department of Applied Health Research, University College London, 1-19 Torrington Place, London, WC1E 7HB UK
| | - Caroline M. Moore
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Muntzer M. Mughal
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Catherine Perry
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | | | | | | | - Stephen Morris
- Department of Applied Health Research, University College London, 1-19 Torrington Place, London, WC1E 7HB UK
| |
Collapse
|