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Application of research to quality improvement Helen CrispThe Health Foundation, London UK
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Being ‘scientific’ about health care improvement
Improvement needs to be as ‘evidence-based’ as any other aspect of health care provision
Effective, theory-based interventions using tested methods
Change demonstrated by robust measures: • process• clinical outcomes• patient experience
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Why is research important for improvement?
To understand what we’re trying to do
To measure what we are doing and if it’s working
To report our work so others can learn
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Understanding what we’re trying to doTo boost chances of getting desired results - improvement interventions need to:
be focused on a well-defined issue
use research evidence on approaches that have been tried
build on previous work that showed good results
and
learn from interventions demonstrated as ineffective
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E.g. You want to improve hand washing rates
What approaches have been tried elsewhere?
What has shown little effect?
What works?
Where did it work?
Is it likely to work for us?
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Finding relevant research
It can overwhelming!
Refine your search terms
Look for:
systematic reviews
meta analyses
Work with your local research leads
Sign up for regular research up-dates:
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Health Systems EvidenceMcMaster University - Canada
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Other sources
Good practice repositories
Examples:
NICE Quality and Productivity proven case studies
BMJ Quality Reports
Other national patient safety and quality improvement agencies
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PollTo date, has your improvement work been based on research evidence?
• YES, TOTALLY
• YES, TO SOME EXTENT
• NO, WE GENERATE OUR OWN IDEAS
• NOT SURE
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Benefits of research-based improvement
Not starting from scratch
Benchmark your results against reported findings
Counters the inevitable question from clinicians when introducing a change:
“What’s the evidence for this?”
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THE EVIDENCE IS OUT THERE
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Using research methods to do improvement work
To improve effectiveness of implementation; improvement programmes need to be based on evaluated methods, based on explicit theories about how and why the intervention is expected to work.
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Introducing ‘Theory of change’
Image credit: Sidney Harris
“I think you should be more explicit here in step two”
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What is a ‘Theory of change?A comprehensive description and illustration of how and why a desired change is expected to happen in a particular context.
The theory of change sets out explicit statements on the components of an improvement programme (its activities or interventions) and how these are expected to lead to achieving the desired goals.
First identifying the desired long-term goals, the theory of change works back from these to identify all the conditions (outcomes) that must be in place (and how these related to one another causally) to reach the goals.
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Behaviour change:- Chronic conditions more effectively managed
OUTPUTS
Fewer visits to surgery
ACTIVITIES OUTCOMESGOAL
Advertising campaign
Equitable access to resources
and interventions
Pain clinics
Reduction in medications
over time
# Self Referrals
Recognising & reporting of adverse
effects
Physical activity
workshops
ENABLING FACTORS
Interventions targeted at specific population; Local stakeholders buy-in to champion, Funding continues to sustain, Effective monitoring and evaluation
THEORY OF CHANGE : Managing chronic conditions; pain, fatigue, shortness of breath
Dietary and
Nutritional advice
Lower BMI
Individuals feel more
empowered
Accuracy in self
administering
Reduction in pain
< Negative emotion
s
Psychotherapy
Smoking cessation
workshops
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Developing a theory of change
Keep it simple • Use language that’s easy to understand• Keep your diagram on one side of paper/screen view
Keep it relevant • Focus on the key elements of the intervention • Explore the assumptions linking action and expected
outcomesKeep it updated
• Return to the theory of change at regular intervals• What has changed during the implementation?• Does the theoretical link between actions and outcomes
hold up in practice?
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Measurement is key to quality improvement research
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Measuring improvementUnless you measure you do not know if there has been an improvement
What to measure and how to measure it?
Measure key elements of the intervention
Use routinely collected data where possible
Be precise about data definitions
Measure over time
Use robust techniques such as statistical process control charts
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Typical measuresProcess measures• error rates e.g. prescription errors• compliance rates e.g. completing a checklist
Clinical outcome measures• complication rates e.g. of a surgical procedure• infection rates – healthcare associated infections
Resource use • length of hospital stay• number of medications prescribed
Patient experience• involved in decisions about care• treated with dignity and respect
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Evaluating improvement interventions
Key evaluation question:
Did the improvement intervention fulfil its intended objectives?
Sub-questions:
How was this achieved?
What resources did it take?
What unintended results were there?
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Evaluation approaches
Summative• Summarises the intervention effect at the end
Formative• Findings shared and help to shape the intervention
Rapid cycle• Frequent review of effectiveness of intervention
Developmental • Intervention is still developing, all aspects reviewed
and changes made in response
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External evaluation
Often part of large scale, national or multi-site change programmes
Independently commissioned from specialist teams
Great learning opportunity (NOT a threat!)
Share experience - the good and the challenging
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PollDo you think it is important that quality improvement work is written up for publication?
• YES
• NO
• NOT SURE
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Helping to build the evidence base
This section based on presentations by Dr Kaveh Shojania, Editor in Chief, BMJ Quality and Safety
Better reporting of improvement work will:
Help spread successful improvement interventions
Prevent wasted effort on repeating interventions that don’t work
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Sharing and learning moreReports on improvement work need not only results but also:• how the initiative was designed• the setting where it was implemented• detail on the core components• measures and data used to measure the change• challenges overcome along the way• how they were overcome• what the team would do differently in the future
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Reporting bias
When reporting a successful intervention many improvement reports amount to:
“See, we did X!”
versus
“Here’s what we had to do to
achieve X”
Higher tendency to write up reports and submit papers and abstracts when the improvement is ‘successful’ We can a lot from what didn’t work
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Reporting to facilitate spread
Improvement reports need to provide enough detail:
to convey credibly that something worked
to give insight on the action needed to replicate the results in another clinical setting
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Credibility and replication• Too often improvement reports lack important
details about key components of intervention and
institutional context
− Readers cannot know if it’s worth trying in their setting
• No information is given on barriers or problems to
implementation
− No improvement effort works immediately, this
absence decreases credibility
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A typical QI reportIntroduction
Hospital infections affect thousands each year
Hospital staff do not wash their hands consistently
We implemented a multi-faceted strategy:
• Staff education
• Clinical champions
• Empowering patients to ask staff if they have washed their hands
Methods
Briefly stated design, data collection strategy and main outcomes, plus some mention of PDSA
Results
We improved hand hygiene by 50%
Discussion
Patient empowerment can be effective
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What is lacking here?Introduction
Hospital infections affect thousands each year
Hospital staff do not wash their hands consistently
We implemented a multifaceted strategy:• Staff education
• Clinical champions
• Empowering patients to ask staff if they have washed their hands
No connection between the introduction material and specific features of the intervention
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A better approachIntroductionCommonly identified barriers to hand hygiene compliance include A, B, and C
Staff education, clinical champions, and empowering patients address A, B, and C by doing X, Y, and Z
• This introduction makes clear what factors explain poor hand hygiene
• And, it makes explicit why the intervention includes these ingredients
• This “theory for the intervention” will pay off in writing the report and interpreting the results
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Is it clear what you did?Methods
Briefly stated design, data collection strategy and main outcomes, plus some mention of PDSA
Results
We improved hand hygiene by 50%
Discussion
Patient empowerment can be effective
‘PDSA’ needs context to make sense!
Simply saying; ‘We carried out three PDSA cycles’ is not informative. What did the ‘study’ of what you had ‘done’ reveal and how did you ‘act’ as a result?
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A better approachMethodAfter the first round of staff education we reviewed the delivery mechanism and feedback from participants, using PDSA methodology. It was reported that timing of training sessions was an issue in getting staff attendance, so the next sessions were planned with ward managers.
Participants wanted more visual material to illustrate key points - these were designed with staff and used in subsequent sessions.
• This provides more detail which makes the report credible
• Others are likely to have the same issues and could avoid making the same mistakes
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Points to consider:
When do you start ‘writing up’?
How to capture the key components of the improvement initiative?
When barriers arise - how do you record these- and the action to overcome
them?
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Some tips for writing up
Writing always takes longer than you think – don’t leave it to the last few weeks
Robust data collection from the outset is vital
Keep an ‘improvement diary’ to help capture information as you go along, particularly the adjustments
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Involve others
Include different perspectives in your write up;
not just the improvement lead
other staff involved
staff not involved but affected by the change
service users
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Consider the audience and where to publish
Core information remains but different emphasis for:
A report to the funder
Academic publication in a peer reviewed journal
Publication in a professional practice magazine
Beyond text:
Photos, videos, animations - bring the work to life
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A tool to help
SQUIRE guidelines
Standards for Quality Improvement Reporting Excellence
Checklist of points to consider when writing up improvement work
BUT• Don’t leave it until you’ve completed the work• Use guidelines to consider what data to capture as you go
along
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Download SQUIRE guidelines from:
http://www.squire-statement.org/
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Spreading the word
Professionals listen to their peers
Think of a range of approaches - and use every opportunity:
Professional seminars
Conferences
E-mail bulletins and newsletters
Blogs
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Conclusion
Find and use existing evidence
Actively use robust research methods
Contribute to building the evidence
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Conclusion
Find and use existing evidence
Actively use robust research methods
Build the evidence