Ensuring your clinical audit leads to changes in practice —Overcoming the barriers and challenges to changing clinical practice

• • • •

• • • • The barriers and challenges

• • • • New thinking about implementingchange in clinical settings

• • • • Practical suggestions

• • • • Practical suggestions

• • • • The barriers and challenges

• • • • New thinking about implementingchange in clinical settings

Misunderstanding of the clinical audit process — The traditional model of audit and feedback

Re-audit

Decide on —ReasonWho is involvedCases

Let’s do aclinical audit

on a subject!

Definequality and formulatemeasures

Collect data to

measureday-to-day

practice

Present data

Recommend action

Set (or adjust)standards

Re-evaluatepractice

Makechanges

Measurepractice

Compare currentpractice against

standards

Identify areafor change

TheClinicalAuditcycle

No

Yes

Laterask: Have

things changedor need to

monitor?

Feed back tothose involved

— celebrate and maintain good practice

Yes

Identify —Shortcomings or problems Causes Improvements

As rapidly as possible

Devise an improvement

plan and implement it

No

Ask:Does

day-to-daypractice meetbest practice

?

Decide on —ReasonWho is involvedCases

Let’s do aclinical auditon a subject!

Measureday-to-day

practice

Refer toevidence

Define —Best practice How to measure if best practice

Clinical audit as aquality improvement process

The challenges in achieving changeNew evidence, best practices or new procedures don’t implement themselves

A change in practice is not automatically continued over time

The impact of change can be highly variable

People select weak actions that depend on people’s memory and good will

People ‘take action’ rather than plan the change process

The even bigger challenges in sustaining change over time

The change intervention itself didn’t really work —something else caused the improvement

The change intervention is changed from one setting to another

The context affects the impact of the change

What can happen —

• • • • The barriers and challenges

• • • • Practical suggestions

• • • • New thinking about implementingchange in clinical settings

A ‘theory of change’ for improvement defines exactly what will be achieved through a change process and how the process will work to produce the

intended improvement

The ‘theory’ explains —

What

How and Why

When and Where

‘Training’ the staff will work because…• They aren’t doing what they should be doing versus• There is evidence that they don’t have the knowledge

and skills needed to do what they should be doing

… is to be changed

… it works

… under what conditions

Success depends on —

Appropriate decision-making

Choosing the right strategy/ies

Effective implementationDoing the right strategy/ies the right way

Theory asks —

Is there a cause-and-effect relationship between action and the effect of action?

Was the action the right action?

Was the right action implemented the right way?

Key concepts

Confirm the IMPROVEMENT —the exact OUTCOME to be achieved

ImprovementChange versus

An improvement is the exact outcome to be achieved through the change process, preferably expressed in measurable terms

Number or percentage or ratio of time or patients the desired outcome will happen

How to figure out what’s neededProblem

What isn’thappening

now?

the baseline findings

Cause

Why isn’t it happening?

the findingsof analysis

Action

What do we haveto do to

achieve it?

the processof making

change

Improvement

What dowe want to achieve –

the level of patient care

we want?

the result or outcome

Who or what has to change — Factors involved in theories

Individual professionals — attitudes, beliefs, knowledge, skills

Social interaction — communication, networking, team work, leadership

Financial or economic — funding, contracting

Organizational — roles, staff, environment, policies, procedures, processes, systems, culture

Individual professionals — why don’t they do what we expect them to do

They don’t want to

It goes againstthe grainWhat’s in it for me It’s more

work

It’s not worth it

I don’t seethe point

People don’t believe in the change

They can’t do it — the organizational factor

My managersays to ignore it

I don’t havewhat I need

It doesn’t match‘the system’

I don’t know how

People don’t have what it takes to make the change

I don’t really knowwhat you want

To increase the uptake and sustainability of change by individual professionals, they need —

Scientific evidence of what is the right or best way

Belief in the value of the evidence

A feasible way to implement the evidence

SocialInformation from a credible source

Teams of professionals working together

Professional linkages

Leadership

Organizational

Teams are enabled to change things on their own

Strategy, structure, culture, support

Process and systems redesign

Continuous learning

Financial

Pay-for-performance or other targets

Financial rewards or penalties

Contractual arrangements

Regulator influences

€

Other considerations

Context

Dose of change to achieve improvement

All the factors that are not part of the improvement process —simple, complicated, complex or chaotic

The quantity, intensity, duration, scope and comprehensiveness of the actions in the change process

• • • • The barriers and challenges

• • • • New thinking about implementingchange in clinical settings

• • • • Practical suggestions

Match change strategies to types of change

Reaffirm or amend improvement

State benefits and barriers and investigate barriers

Reaffirm or amend factors and who will be involved

Consider context

Know the causes

Possible strategiesEducationConsensus-buildingOpinion leaderAudit and feedbackPatient feedbackReminder systemMarketing Communication and mediaProfessional linkagesRole revision

Use as manystrategies as

possible

Possible strategies

Use as manystrategies as

possible

Skill mix changesClinical teams and processesReorganization of servicesContinuity of careWorkplace satisfactionChanges in structureIT systemsFinancial incentivesRegulatory influences

Types of actions healthcare organizations can take

WEAK

Raise staff awarenessRemind staffProvide trainingWrite a new policy

STRONG

Remove barriers to doing the work effectivelyRedesigning the workMonitor and feed backSuperviseUse IT or technology

Hughes D. Root cause analysis: bridging the gap between ideas and execution. National Center for Patient Safety Topics in Patient Safety 2006;6(5):1–2

Setting priorities among actions

Use a 7–point scale to rate —1

How effective will the action be in addressing the causes of the breakdowns

2 Multiply the ratings

3 Find and implement the priority actions (top priority = 49)

Make a list of actions to address the causes ofbreakdowns in quality

How strongly do you believe that the action can be implemented in your organization

• • • • The barriers and challenges

• • • • New thinking about implementingchange in clinical settings

• • • • Practical suggestions

Nancy.Dixon@hqq.co.uk

www.hqq.co.uk

@hqq_uk

References

1. Grol R, Wensing M, Bosch M, Hulscher M, Eccles M. Theories on implementation of change in healthcare. In: Grol R,Wensing M, Eccles M, David D, editors. Improving Patient Care. The Implementation of Change in Health Care. 2nd ed.Chichester: Wiley Blackwell BMJ Books; 2013, p. 18–39.

2. Davidoff F, Dixon-Woods M, Leviton L, Michie S. Demystifying theory and its use in improvement. BMJ Qual Saf2015;24(3)228–38.

3. Wiltsey Stirman S, Kimberly J, Cook N. Calloway A, Castro F, Charns M. The sustainability of new programs and innovations:a review of the empirical literature and recommendations for future research. Implement Sci 2012;7:17.

4. Dixon-Woods M, Bosk CL, Aveling EL, Goeschel CA, Pronovost PJ. Explaining Michigan: developing an ex post theory ofa quality improvement program. Milbank Q 2011;89(2):167–205.

5. Hovlid E, Bukve O, Haug K, Aslaksen AB, von Plessen C. Sustainability of healthcare improvement: what can we learnfrom learning theory? BMC Health Serv Res 2012;12:235.

6. Evaluating healthcare quality improvement. Event report. A summary of learning from a Health Foundation roundtable,6 June 2011. The Health Foundation. Available at: https://www.health.org.uk/publications/evaluating-healthcare-quality-improvement. Last accessed 1 October 2019.

7. McDonald KM, Graham ID, Grimshaw J. Toward a theoretical basis for quality improvement interventions. In ShojaniaKG, McDonald KM, Wachter RM, Owens DK, editors. Closing the Quality Gap: A Critical Analysis of Quality ImprovementStrategies, Volume 1—Series Overview and Methodology. Technical review 9 (Contract No. 290-02-0017) to the StanfordUniversity–UCSF Evidence-based Practice Center). AHRQ Publication No. 04-0051-1. Rockville MD: Agency for HealthcareResearch and Quality. August 2004. Available at: https://www.ncbi.nlm.nih.gov/books/NBK43908/. Last accessed 1October 2019.

8. Reed JE, McNicholas C, Woodcock T, Issen L, Bell D. Designing quality improvement initiatives: the actioneffect method, a structured approach to identifying and articulating programme theory. BMJ Qual Saf 2014;23(12):1040–8.

9. Doyle C, Howe C, Woodcock T, Myron R, Phekoo K, McNicholas C, Saffer J, Bell D. Making change last: applying theNHS institute for innovation and improvement sustainability model to healthcare improvement. Implement Sci 2013 Oct26;8:127.

10. Hayes CW, Goldmann D. Highly adoptable improvement: a practical model and toolkit to address adoptability andsustainability of quality improvement initiatives. Jt Comm J Qual Patient Saf 2018;44(3):155–63.

11. Lennox L, Maher L, Reed J. Navigating the sustainability landscape: a systematic review of sustainability approaches inhealthcare. Implement Sci 2018;13:27.

12. Ramaswamy R, Reed J, Livesley N, Boguslavsky V, Garcia-Elorrio E, Sax S, Houleymata D, Kimble L, Parry G. Unlocking theblack box of improvement. Int J Qual Health Care 2018;30(S1):15–9.

13. Rangachari P. Innovation implementation in the context of hospital QI: lessons learned and strategies for success. InnovEntrep Health 2018;5:1–14.

14. Grol R. Beliefs and evidence in changing clinical practice. BMJ 1997;315:418–21.15. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of changes in patients’ care. Lancet

2003;362(9391)125–30.

16. Perla RJ, Parry GJ. The epistemology of quality improvement: it’s all Greek. BMJ Qual Saf 2011;20(Suppl 1):i24–7.17. Øvretveit J, Garofalo L, Mittman B. Scaling up improvements more quickly and effectively. Int J Qual Health Care

2017;29(8):1014–19.18. Øvretveit J. Understanding the conditions for improvement: research to discover which context influences affect

improvement success. BMJ Qual Saf 2011;20 Suppl 1:i18–23.19. Snowden DJ, Boone ME. A leader’s framework for decision making. Harv Bus Rev 2007;85;69–76.20. Grol R, Bosch M, Wensing. Development and selection of strategies for improving patient care. In: Grol R, Wensing M,

Eccles M, David D, editors. Improving Patient Care. The Implementation of Change in Health Care. 2nd ed. Chichester:Wiley Blackwell BMJ Books; 2013, p. 167–84.

21. Shojania KG, Grimshaw JM. Evidence-based quality improvement: the state of the science. Health Aff (Millwood)2005;24(1):138–50.

22. Mills PD, Neily J, Luan D, Osborne A, Howard K. Actions and implementation strategies to reduce suicidal events in theVeterans Health Administration. Jt Comm J Qual Patient Saf 2006;32(3):130–41.

23. Pham JC, Kim GR, Natterman JP, Cover RM, Goeschel CA, Wu AW, Pronovost PJ. ReCASTing the RCA: an improved modelfor performing root cause analysis. Am J Med Qual 2010;25(3):186–91.

24. McHugh M, Harvey JB, Kang R, Shi Y, Scanlon DP. Measuring the dose of quality improvement initiatives. Med Care ResRev 2016;73(2):227–46.