”There is nothing so practical as a good theory”

Management research in the improvement of health services

Mats BrommelsMedical Management Centre

Karolinska Institutet15 June 2012

”There is nothing so practical as a good theory”

• Medical management …

• … research …

• … in the spectrum of health research …

• … requires a change of paradigm …

• … shows its value by its usefulness …

• … by virtue of application

Medical Management Centre Mission

• Improve health care as a contribution to KI’s mission to improve people’s health

• More specifically, by developing useful knowledge on organising and managing health care, to promote safe, high-quality and cost-effective medical services

Medical Management CentreGoal

• Establish management knowledge as an academic discipline in its own right at the medical university

• Make a management career legitimate, visible and attractive among health professionals

Medical ManagementValue

• Through collaborative research and knowledge transfer create space and give legitimacy to managers of professional organisations acting in a political environment

• ”We have solid evidence ….”• ”We have a useful theory (palusible hypothesis)

that we intend to test and evaluate …”

Medical Management Research• “Medically informed research on the organisation and

management of health services”

• Health services research (AcademyHealth): “the multi-disciplinary field of scientific investigation that studies how social factors, financing systems, organisational structures and processes, health technologies, and personal behaviours affect access to health care, the quality and cost of health care, and ultimately, our health and well-being”

• More focus on “organisations, institutions and communities” than on “individuals, families and populations”,

Brommels M. Management and medicine: odd couple no more. Bonding through medical management research. Scand J Public Health 2010;38(7):673-7.

Why Medical Management?

• MMC’s medically qualified staff has unrestricted access to clinical settings and the substance knowledge needed to develop successful practice change strategies and methods

• Implementation research is done in close cooperation with clinical practitioners

• All biomedical research, education and practice will need the know-how thus acquired to handle change successfully

Medical ManagementSpecial contribution: What

• Generally applicable methods for the implementation of medical research into real-world practice – ”translational research, part II”, ”from bedside to transformed practice”– The challenge: “Translating basic discoveries

into clinical trials and studies, followed by implementation of the results into the real-world practice of medicine” (NIH 2005, 2007)

The 3T’s road map

Dougherty D, Conway PH. The ”3T’s” road map to transform US health care: the ”how” of high-quality care. JAMA 2008; 299:2319-21.

From translational to implementation research

Application on human being

Translation

Implentation in clinical practice

Transformation

Cell and molecularbiologyresearch

Translationalresearch

Clinical trials

Implementationresearch

Observational and action research

Improvedhealth

Diagnostic methodswith assessedaccuracy

Efficacious therapies

Knowledge transfer and professionalbehaviour change

New work practices and procedures

Brommels M. Time for the third step? Implementation is the greatest challenge for clinical research. Swedish Med J;2006:103:2223-6. Brommels M. Management and medicine: odd couple no more. Bonding through medical management research. Scand J Public Health 2010;38(7):673-7.

Basic research Clinical (applied) research

Implementation of inventions and new knowledge

Organisational (process) development

Governance, stewardship, management, follow-up

Data sources Biobanks Patient databases Empirical observations on practice

Administrative databases

Practical experience

Focus Biological mechanisms

Indications for treatment and treatment effects

Changes in struc-tures, organisa-tions, processes

Improved safety and quality

Efficiency

Needs, resources and performance

Approaches and methods

Cell and molecular biology

Clinical trials Observational and action oriented studies

Locally organised improvement

Objectives, resource allocation, follow-up

Contribution to practice

Diagnostic and therapeutic methods

Patterns, Methods support

mechanisms, Knowledge and decision support models, theories,

strategies

Actors Pre-clinical researchers

Clinical researchers

Health services/ care sciences researchers

Practitioners Decision-makers

Medical Management Centre, Karolinska Institutet 2012

Studies of organisational change

• Programme evaluation (assessment of effects) combined with descriptive case study

• Frame of reference - Strategic change management model (Pettigrew & Whipp 1991): Analyse programme content, extarenal and internal context, change process and outcomes (intended and unintended)

Studies of organisational change

• Look for patterns and explanatory models• Establish ”programme theory” (about what works

and under which circumstances), formulate hypotheses and collect data to assess those (realist evaluation, Pawson & Tilley 1997)

• Feed back observations and interpretations to the organisation (leadership) to enable modifications of the programme and further monitoring (action research)

• ”Generalise to theory”

Realist evaluation (Pawson & Tilley 1997)

Plan

Do

Study

Act