getting a grip october 2007
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Get a GRIP Get a GRIP
Getting Research Into Getting Research Into PracticePractice
Sue Lacey BryantSue Lacey BryantWhittlebury HallWhittlebury Hall October 2007 October 2007
Getting research into Getting research into practice practice
““Health professionals and policy Health professionals and policy makers have access to a large makers have access to a large volume of research evidence and volume of research evidence and guidance relevant to clinical guidance relevant to clinical effectiveness”effectiveness”
Getting a GRIP on the Getting a GRIP on the evidenceevidence
1.1. The challengeThe challenge2.2. BarriersBarriers3.3. Tools we can Tools we can
useuse4.4. Success factorsSuccess factors5.5. Implications for Implications for
Quality: MKQuality: MK
1. THE CHALLENGE1. THE CHALLENGE
Courtesy of Bill Runciman, APSF; Data extracted from AHRQ 2006 report
Wrong plan nearly 50% of the timeWrong plan nearly 50% of the timeHarm a patient with 10% of admissionsHarm a patient with 10% of admissions
The harm is permanent or severe with 2% The harm is permanent or severe with 2% of admissionsof admissions
Death is associated with the harm in Death is associated with the harm in 1/300 patients1/300 patients
This amounts to 100,000 preventable This amounts to 100,000 preventable deaths since 1995 (Australia alone)deaths since 1995 (Australia alone)Costs as much as $1 million /hour Costs as much as $1 million /hour
(Australia alone)(Australia alone)
Data courtesy of Professor Jeff Richardson, CHE, Monash University Data courtesy of Professor Jeff Richardson, CHE, Monash University and Professor Runciman, Professorial Research Fellow, Patient Safety, and Professor Runciman, Professorial Research Fellow, Patient Safety,
University of AdelaideUniversity of Adelaide
UK and AustraliaUK and Australia
Put another wayPut another way
50% more deaths than annual 50% more deaths than annual combined total from:combined total from:
AIDS +AIDS +
Suicide +Suicide +
Motor vehicle accidents +Motor vehicle accidents +
Homicide +Homicide +
Drowning +Drowning +
Falls +Falls +
PoisoningsPoisonings
OR – put another wayOR – put another way
The equivalent of a jumbo jet The equivalent of a jumbo jet crashing every week with over crashing every week with over 300 UK citizens on board300 UK citizens on board
2.BARRIERS2.BARRIERS
• Information and technology Information and technology overloadoverload
Growing information baseGrowing information base• Specialty silosSpecialty silos
Communication issuesCommunication issues• Clinical governanceClinical governance
Plethora of guidelinesPlethora of guidelinesTrainees, locum and agency staffTrainees, locum and agency staff
• Increasing patient safety issues Increasing patient safety issues Less patient time, more referralsLess patient time, more referralsMedical errorsMedical errorsRising cost of claimsRising cost of claims
Reasons for resisting Reasons for resisting changechange
• Information problems Information problems • Individual decision-Individual decision-
makingmaking• Effects of stressEffects of stress• Getting the right people Getting the right people
togethertogether• The The status quostatus quo
Getting evidence into Getting evidence into practicepractice
Main difficulties No.
Evidence based practice 13
Time 12
Access to information 8
Resources 7
Guidelines - overload 5
Changing practice 4
Costs 4
Patient expectations 2
Other 4
AdoptingAdopting research research evidenceevidence
BaselineBaselinesurveysurvey
Information’s just Information’s just landing on us!landing on us!
““Robin weighed the NSF for the Robin weighed the NSF for the elderly, measured its height and elderly, measured its height and found it had a found it had a BMIBMI of 86” of 86”
View from the frontlineView from the frontline1. 1. AccessAccess• Inadequate Inadequate
access to access to informationinformation
• Lack of relevant Lack of relevant evidenceevidence
2. Skills2. Skills• Low levels of Low levels of
baseline skills in baseline skills in using ITusing IT
• Low levels of Low levels of baseline skills in baseline skills in critical appraisal critical appraisal
• Insufficient time Insufficient time for clinicians to for clinicians to acquire new acquire new skillsskills
View from the frontlineView from the frontline
3. Funding3. Funding
Insufficient money Insufficient money to help clinicians to help clinicians to acquire new to acquire new skillsskills
4. Hierarchy4. Hierarchy
Problems Problems relating to relating to medical and medical and nursing nursing hierarchieshierarchies
5. Autonomy5. Autonomy Perceived Perceived threats to threats to medical medical autonomyautonomy
3. TOOLS WE CAN USE3. TOOLS WE CAN USE
1. All groups involved 1. All groups involved
2. Characteristics of the change2. Characteristics of the change
that might influence its adoptionthat might influence its adoption
3. Readiness of health professionals3. Readiness of health professionals
in the target group to changein the target group to change
4. Potential external barriers to 4. Potential external barriers to changechange
5. Likely enabling factors 5. Likely enabling factors
(including resources and skills)(including resources and skills)
Tools we can use: Tools we can use: Barriers scaleBarriers scale
• Benefits of changeBenefits of change• Quality of Quality of
researchresearch• Access to research Access to research • ResourcesResources• Organisational Organisational
cultureculture• Staffing issuesStaffing issues• Personal feelingsPersonal feelings
• AdopterAdopter• OrganizationOrganization• InnovationInnovation• Communication Communication processprocess
Tools we can use: Survey Tools we can use: Survey monkeymonkey• Online surveyOnline survey• Different types of question Different types of question
- single answer, multiple - single answer, multiple answers, or a matrix answers, or a matrix
• Mandatory questionsMandatory questions• Conditional logic to direct Conditional logic to direct
usersusers• View results online View results online • Download as a *.csv file Download as a *.csv file • Make results available Make results available
onlineonline
•80% of physicians changed their care 80% of physicians changed their care as a result of evidence* - as a result of evidence* - as follows:as follows:
•Avoided hospitalisation in 12%Avoided hospitalisation in 12%•Reduced overall length of stay in hospital Reduced overall length of stay in hospital in 19%in 19%
•Changed diagnostic tests in 51% and drug Changed diagnostic tests in 51% and drug choices in 45%choices in 45%
•AvoidedAvoided additional tests or procedures in additional tests or procedures in 49%49%
•Adhering to evidence-based guidelines for Adhering to evidence-based guidelines for treating hypertension alone could save at treating hypertension alone could save at least $1.2 billion annually in US**least $1.2 billion annually in US**
•Marshall J G. …. The Rochester study. •** Fischer MA, Avorn J. Economic implications of E-B-based prescribing for hypertension:
Tools we can use: the Tools we can use: the power of Evidencepower of Evidence
Tools we can use:Tools we can use: Knowledge managementKnowledge management• Public Public HealthHealth professionals professionals
are the ‘pumping stations’ are the ‘pumping stations’
that drive the ‘that drive the ‘waterwater’ ’
(knowledge) through (knowledge) through
the organisationthe organisation• The librarians are the ‘treatment The librarians are the ‘treatment
works’ that ensure that the knowledge works’ that ensure that the knowledge is fit for purpose and available in the is fit for purpose and available in the right quantities to be consumed’right quantities to be consumed’
Tools we can use:Tools we can use: Information teamInformation team• Suppporting journal clubs Suppporting journal clubs • Supporting service review and developmenSupporting service review and developmen• Supporting patient engagement workstreamSupporting patient engagement workstream• Best evidence, best practice, models of Best evidence, best practice, models of
serviceservice• Information skills trainingInformation skills training• ““Alerts”Alerts”• Access to resourcesAccess to resources• Promoting use of the Map of medicinePromoting use of the Map of medicine• Sharing information: intranet / internetSharing information: intranet / internet
•Framework for sharing clinical knowledge across care settings
•Evidence based care pathways available to clinicians at the point of care
•Localizable benchmark for clinical processes
4. SUCCESS FACTORS4. SUCCESS FACTORS
Resources Resources
BenefitsBenefits
CollaborationCollaboration
Relevance Relevance
Getting better with evidence
Influencing behaviourInfluencing behaviour
Identifying local priorities for changeIdentifying local priorities for change Exploring barriers to changeExploring barriers to change Gaining commitment, building Gaining commitment, building
coalitionscoalitions Incentives for changeIncentives for change Effective communicationEffective communication Supporting/managing changeSupporting/managing change Monitoring changeMonitoring change
Experience, evidence and everyday practice. King’s Fund
Getting the message Getting the message acrossacross Information Information Context:Context: Local priorities, Local priorities,
Involvement, Involvement, Overcoming Overcoming barriersbarriers
Process:Process:Leadership,Leadership,
CollaborationCollaboration CommunicationCommunication
Key questions for Key questions for managersmanagers Who wants the change?Who wants the change? Why?Why? What is its importance for the What is its importance for the
service and for the organization?service and for the organization? What are the measures of success?What are the measures of success? Which staff groups are to be Which staff groups are to be
involved with this change?involved with this change?
How to put evidence into How to put evidence into practicepractice• What is the purpose?What is the purpose?• Who can help?Who can help?• What is the situation?What is the situation?• Who should be Who should be
involved?involved?• What are the key What are the key
messages?messages?• What is the aim?What is the aim?• Is the available Is the available
information suitable?information suitable?
• What are the barriers?What are the barriers?• Are things on track?Are things on track?• What are the options?What are the options?• Which strategies Which strategies
should be used?should be used?• Is support available?Is support available?• What would it cost, What would it cost,
and is it worth doing?and is it worth doing?• Has it worked?Has it worked?
Research-to-practice Research-to-practice pipeline pipeline
By clinicians:By clinicians:1.1. Awareness Awareness 2.2. Acceptance Acceptance 3.3. Applicable Applicable 4.4. Available and Available and
able able 5.5. Acted on Acted on
By patients:By patients:1.1. Agreed to Agreed to 2.2. Adhered toAdhered to Taking the paths from research to improved health outcomes
5. LESSONS FOR 5. LESSONS FOR QUALITY:MKQUALITY:MK Analyse the local situationAnalyse the local situation There will always be unplanned There will always be unplanned
consequencesconsequences Getting evidence into practice is a Getting evidence into practice is a
lengthy and complicated businesslengthy and complicated business Change must offer benefits to Change must offer benefits to
frontline stafffrontline staff
No magic bulletsNo magic bullets
• ““A multi-faceted approach using a A multi-faceted approach using a range of techniques can be range of techniques can be successful”.successful”.
• ““A costly and messy process”A costly and messy process”• “ “ A group of complex inter-related A group of complex inter-related
tasks.”tasks.”
Experience, evidence and everyday practice
Changing clinical Changing clinical behaviourbehaviour
Be flexibleBe flexible Tailor the approachTailor the approach Start smallStart small Build incrementallyBuild incrementally Use existing channelsUse existing channels Build on previous workBuild on previous work Target enthusiasts Target enthusiasts
first first AND it takes several AND it takes several
yearsyears
Reality checkReality check
Implementation is the real work Implementation is the real work
While some teams focus on developing While some teams focus on developing guidelines the “much harder task of guidelines the “much harder task of implementation was sometimes implementation was sometimes under-prioritised”under-prioritised”
Use the evidence we have Use the evidence we have Getting better with evidence
The challenge for The challenge for Quality: MK Quality: MK • ““the field of quality improvement is the field of quality improvement is
broadly accepted and institutionalised now broadly accepted and institutionalised now and is highly politically correct.” and is highly politically correct.”
• ““What is left is the question whether it What is left is the question whether it really contributes to a better, a more really contributes to a better, a more effective, efficient and patient centred effective, efficient and patient centred care.care.
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