I read the paper by Ovretveit and Gustafsen with interest, as I
believe that this is a neglected area. I found their paper admirably clear
and concise, and I would agree with many of their points. However, I feel
that they have neglected one important area.
In their discussion of the
ways in which this kind of research could be improved, they discuss the
need for empirically based explanatory theo...
I read the paper by Ovretveit and Gustafsen with interest, as I
believe that this is a neglected area. I found their paper admirably clear
and concise, and I would agree with many of their points. However, I feel
that they have neglected one important area.
In their discussion of the
ways in which this kind of research could be improved, they discuss the
need for empirically based explanatory theories about what helps and what
hinders quality improvement programme implementation, and mention the
theories of innovation adoption and diffusion as potential candidates
under this heading. I would suggest that in looking for theories to aid
understanding of observed phenomena it is also worth considering health
care providers as organisations, and looking to the literature of
organisational studies. Even the smallest primary care providers can be
said to be organisations, employing considerable numbers of ancillary
staff as well as doctors and nurses. This fact is often barely
acknowledged in the literature relating to behavioural change in response
to quality improvement programmes; if it is considered, authors tend to
talk vaguely about the need to change “organisational culture”, without
clearly defining what this might be[1,2] Whilst some authors define
organisations in terms of making rational decisions in pursuit of goals,[3,4] others argue that the reality is much more complex than this, involving
social interactions between organisation members, and often-incompatible
goals.[5-7] Taking this approach, it can be seen that any attempt to
implement a quality improvement programme will come up against the nature
of the organisation in which implementation is to occur. Particularly, the
nature of the social interactions taking place, the “accommodations” [5]
that take place to allow the definition of a programme of organisational
activity in the face of those incompatible goals, and the distribution of
power within the organisation will all affect what happens. If we want to
understand what is happening during the implementation of quality
improvement programmes, research should therefore be directed at these
factors, using the methodologies developed by those who have spent many
years doing this kind of research in other fields.[8]
Personally, I would go further, and argue that given the complex
nature of health care organisations, it is strange to assume that any kind
of proscriptive “quality programme” will succeed in more than one site,
and that it is somehow possible to derive sets of “essential conditions”
that will ensure successful implementation. Rather than expending large
sums on designing such programmes and evaluating them, may be the time has
come to approach the problem differently. It should be possible to define
sets of desirable outcomes, and give these to health care organisations.
These organisations could then be enabled, using action research
methodology, to work to understand their own internal dynamics, and in
reaching that understanding, go on to make any changes necessary to reach
the desirable outcomes. The resulting processes would not be uniform
across providers, but if the desirable outcomes were achieved, this would
not matter. This, of course, goes against the government’s stated aim that
a patient’s experience of the health service should be the same all across
the country. However, as others have argued,[9] this drive for uniformity
cannot necessarily be defended in an increasingly plural world. Some
authors [10,11] have described work that takes elements of this approach.
The time has come to stop using ideas borrowed from the more formal
sciences, looking for the quality improvement equivalent of a “new drug”
that will somehow improve quality across many different contexts, and
concentrate on understanding the uniqueness of health care organisations,
allowing that “uniqueness” to become a strength.
References
(1) Halligan A and Donaldson L. Implementing clinical governance:
turning vision into reality. British Medical Journal 2001; 322(7299):1413-1417.
(2) Marshall M et al. A qualitative study of the cultural changes
in primary care organisations needed to implement clinical governance. Br
J Gen Pract 2002; 52(481):641-5.
(4) Simon HA. Decision making and organizational design. In Organization theory: selected writings, Pugh DS (Ed). 1984, Penguin
Books: London. Pp. 202-223.
(5) Checkland PB. Information, systems and information systems.
1998, Chichester: John Wiley.
(6) Vickers G. The art of judgement. 1995, Thousand Oaks: Sage.
(8) Checkland PB and Scholes J. Soft systems methodology in
action. 1999, Chichester: Wiley.
(9) Loughlin M. 'Quality' and 'excellence': meaning versus
rhetoric. In NICE, CHI and the NHS reforms: enabling excellence or
imposing control? Miles A, Hampton JR and Hurwitz B. (Eds). 2000, Aesculapius Medical Press: London.
(10) Atkins EM, Duffy MC and Bain DJ. The practice
characterization model: the importance of organizational life cycles and
targeted interventions in general medical practice. International Journal
of Health Planning & Management 2001; 16(2):125-38.
(11) Cretin, S., et al., Evaluating an integrated approach to clinical
quality improvement: clinical guidelines, quality measurement, and
supportive system design. Medical Care 2001; 39(8 Suppl 2):II70-84.
Milne and Hill raise an interesting hypothesis - that the decline in
surgical rates may have been due to a programme of Getting Research Into
Practice. We intend to test this hypothesis by comparing our data with
that for the whole of England and, within the area of our study, to
compare the two Berkshire districts with districts in the former East
Anglian region. We will report the results on this site...
Milne and Hill raise an interesting hypothesis - that the decline in
surgical rates may have been due to a programme of Getting Research Into
Practice. We intend to test this hypothesis by comparing our data with
that for the whole of England and, within the area of our study, to
compare the two Berkshire districts with districts in the former East
Anglian region. We will report the results on this site as soon as
possible.
Black and Hutchings present an intriguing account of the rise and
fall of glue ear surgery in two English regions.[1] They speculate that
the acceleration of the decline from 1992 may have been due to the
Effective Health Care bulletin on glue ear, helped by five "contextual
features". One of these was the concurrent structural change to the NHS,
arising from the introduction of health care commis...
Black and Hutchings present an intriguing account of the rise and
fall of glue ear surgery in two English regions.[1] They speculate that
the acceleration of the decline from 1992 may have been due to the
Effective Health Care bulletin on glue ear, helped by five "contextual
features". One of these was the concurrent structural change to the NHS,
arising from the introduction of health care commissioning.
We write to suggest another possible contextual feature, a project
entitled "Getting Research into Practice (GRiP). GRiP was a project that
started in 1992, initially within the Oxford region, that aimed to help
the new purchasing health authorities find and apply evidence of
effectiveness in their work.[2,3] One of the four topics chosen for GRiP
was surgery for children with suspected glue ear. This was first taken
forward in Berkshire and later in the other three counties of the region.
From 1995 GRiP (and successor programmes) was generalised to the whole of
the Anglia and Oxford regions. GRiP took a multifaceted approach to
implementing change. There is evidence that multi-faceted interventions
targeting different barriers to change are more likely to be effective
than single interventions.[4] In addition surgery for glue ear became a
topic for performance management in the Anglia and Oxford Region before
other regions.
There would be several ways of exploring the specific contribution of
GRiP to the decline of glue ear surgery. One would be to see if the
decline was faster in Berkshire, or in the rest of the Oxford region, or
in the Anglia and Oxford regions, than elsewhere. Another would be to
compare the rate of decline of topics of low appropriateness covered in
Effective Health Care bulletins but not in the GRiP project with those
that were.
We are not aware of any quantitative evaluation of GRiP, although
there has been a qualitative analysis of the process.[5]
Ruairidh Milne
Senior Lecturer in Public Health Medicine
Wessex Institute for Health Research and Development Mailpoint 728
Boldrewood
University of Southampton
Southampton SO16 7PX
Alison Hill
Director
Public Health Resource Unit
Institute of Health Sciences
Old Road
Headington
Oxford OX3 7LF
References
(1) Black N, Hutchings A. Reduction in the use of surgery for glue
ear: did national guidelines have an impact? Qual Saf Health Care
2002;11(2):121-4.
(2) Needham G. A GRiPPing yarn-getting research into practice: a case
study. Health Libraries Review 1994;11:269-77.
(3) Dunning M, McQuay H, Milne R. Getting a GRiP. Health Service
Journal 1994;April:24-6.
(4) NHS Centre for Reviews and Dissemination. Getting Evidence into
Practice. Effective Health Care Bulletin . 1999;5(1) York:
University of York.
(5) Dopson SE, Gabbay J. Getting research into practice and
purchasing: issues and lessons from the four counties. Winchester: Wessex
Institute of Public Health Medicine 1996.
Dr Shojania raises important issues that must be solved before
widespread implementation of many decision-support tools is possible. I
appreciate his letter. Dr Shojania and I, however, have been addressing
different kinds of decision-support. The tools my colleagues and I have
implemented, both locally and at external sites, are explicit tools that
generate specific instructions, in contrast to...
Dr Shojania raises important issues that must be solved before
widespread implementation of many decision-support tools is possible. I
appreciate his letter. Dr Shojania and I, however, have been addressing
different kinds of decision-support. The tools my colleagues and I have
implemented, both locally and at external sites, are explicit tools that
generate specific instructions, in contrast to the suggestions to the
clinician that are generated by most guidelines. Our tools are
computerized protocols that could function as closed-loop instruments.
(We use them in the open-loop mode with the bedside clinician always
reading the instruction(s) before executing the change in therapy.)
In my opinion, the important issues raised by Dr Shojania will be
most productively addressed when clear distinctions are made between
different strategies of decision-support and the different tools that
could be used to achieve those strategies. One important distinction is
that between diagnostic and therapeutic decision-support tools.
We have limited our work since 1985 to therapeutic protocols. Within
the therapeutic protocol domain, explicit computerized protocols have been
successfully implemented and exported by us, for clinical trial purposes,
with a clinician compliance of 95 %. We do not yet know if similar success
will be found with application of these tools within clinical practice. A
number of concerns with clinical practice use are apparent to us. They
include the issues raised by Dr Shojania.
I very much agree with the authors concerning the role of Risk
Management in the Patient Safety arena. In fact, as a Director of Risk
Managment in an integrated delivery system in Dayton, Ohio, I have been
very involved in the patient safety efforts of our two acute care
organizations, as well as the other entities within our system. My
concern for the past few months has been how to best focus the ri...
I very much agree with the authors concerning the role of Risk
Management in the Patient Safety arena. In fact, as a Director of Risk
Managment in an integrated delivery system in Dayton, Ohio, I have been
very involved in the patient safety efforts of our two acute care
organizations, as well as the other entities within our system. My
concern for the past few months has been how to best focus the risk
manager role with safety. It is virtually impossible for the risk manager
to be involved at the level that I would like to see, and still maintain
all the other functions of a professional risk manager, ie; insurance
renewal, claims management, etc. We are struggling with reorganization in
our department and the authors have greatly assisted me in my belief that
we need to chart a new future and not stand on the sidelines when safety
initiatives are proposed. We also need not to feel guilty as Risk
Managers if our role is not the model that we have been traditionally
taught!
I share much of Dr Morris' enthusiasm for decision support. While
involved in an evaluation of a decision support targeting vancomycin
ordering practice,[1] I had the opportunity to observe the potential
impact of this approach. However, as a clinician using the same
computerized order entry system in daily practice, I also recognized the
major limitation of this approach: users will not tolerate many...
I share much of Dr Morris' enthusiasm for decision support. While
involved in an evaluation of a decision support targeting vancomycin
ordering practice,[1] I had the opportunity to observe the potential
impact of this approach. However, as a clinician using the same
computerized order entry system in daily practice, I also recognized the
major limitation of this approach: users will not tolerate many such
interventions at any given time.
Too many alarms can contribute to a sense of general noise, so that
they lose their value.[2] Similarly, too many triggers for guidelines, or
even alerts such as potential drug-drug interactions, will result in users
clicking past all such screens, so that in the end, none of the screens
will work. Forcing users to follow a given guideline or respond to a
particular alert runs the risk of adding an intolerable time burden to
frequent users of the system – e.g., interns and residents who write
multiple orders a day.
Consider the admission orders for even a routine medical admission.
Possible guidelines might relate to many medications (e.g., choices of
antibiotics), diagnostic orders ('does this patient really need a KUB –
the yield of plain abdominal radiographs is known to be low in most
clinical situations'[3]), various prophylactic strategies (“do you want to
order DVT prophylaxis?' '...stress ulcer prophylaxis?' etc.)
Elderly patients will trigger even more guidelines - does the patient
need fall precautions? How about a soft matteress or other decubitus ulcer
precautions? Pneumococcal vaccination prior to discharge?[4] Vlu vaccine?
[4] Does the patient have an advanced directive?[5]
The list goes on, and this does not even include guidelines triggered
by specific admitting diagnoses e.g., guidelines for treatment of
community acquired pneumonia, acute coronary syndrome, hip fracture,
gastrointestinal bleeding, stroke, etc. etc, not to mention important
secondary diagnoses – 'This patient has diabetes: do you want to add an
angiotensin converting enzyme inhibitor.' 'This patient has a diagnosis of
congestive heart failure, but there is no record of an echocardiogram or
other assessment of ejection fraction.' 'This patient is on prednisone;
would you like to add a bisphosphonate to protect against osteoporosis?'
Thus, computerized systems offer a greater chance of success for
implementation of a single guideline, it is unlikely that this benefit
will generalize to more than a handful of such protocols at any given
time. Further research will need determine optimal strategies for
harnessing the potential of computerized decision support. Currently,
though, it is unrealistic to think that an institution acquiring an order
entry system could expect to impact practice in more than a few areas
using this approach.
References
(1) Shojania KG, Yokoe D, Platt R, Fiskio J, Ma'luf N, Bates DW.
Reducing vancomycin use utilizing a computer guideline: results of a
randomized controlled trial. J Am Med Inform Assoc 1998;5:554-562.
(2) Cropp AJ, Woods LA, Raney D, Bredle DL. Name that tone. The
proliferation of alarms in the intensive care unit. Chest 1994;105:1217-
1220.
(3) Harpole LH, Khorasani R, Fiskio J, Kuperman GJ, Bates DW.
Automated evidence-based critiquing of orders for abdominal radiographs:
impact on utilization and appropriateness. J Am Med Inform Assoc
1997;4:511-521.
(4) Dexter PR, Perkins S, Overhage JM, Maharry K, Kohler RB, McDonald
CJ. A computerized reminder system to increase the use of preventive care
for hospitalized patients. N Engl J Med 2001;345:965-970.
(5) Heffner JE, Barbieri C, Fracica P, Brown LK. Communicating do-not-
resuscitate orders with a computer-based system. Arch Intern Med
1998;158:1090-1095.
As a member of the professional organisation for nurses in Ontario, I
would like to direct nurses and other interested readers to the web page
of the Registered Nurses Association of Ontario, www.rnao.org
This site has a wealth of position statements, policies, submissions
to a variety of health stakeholders and other documents relating to
providing...
As a member of the professional organisation for nurses in Ontario, I
would like to direct nurses and other interested readers to the web page
of the Registered Nurses Association of Ontario, www.rnao.org
This site has a wealth of position statements, policies, submissions
to a variety of health stakeholders and other documents relating to
providing quality health care as well as nursing.
Adding the element of safety to medical education can not be effected
unless the institutions supplement their systems with program of outcomes
assesment.
While all that Dr Stevens describes is of interest, only when it is
established that the medical safety material that has been presented is
absorbed and put into practice will the validity of the suggestions be
established.
Adding the element of safety to medical education can not be effected
unless the institutions supplement their systems with program of outcomes
assesment.
While all that Dr Stevens describes is of interest, only when it is
established that the medical safety material that has been presented is
absorbed and put into practice will the validity of the suggestions be
established.
This requires testing of competence at completion of the program and
evaluation of performance,with remediation as required, thereafter.
I will call the work of giving Medicine to poor countries, a Great English
men do this beautiful things. From a Professor of internal medicine -
Jorge H Jimenez.
This scholarly article has been a fine example of what a fresh
approach and interdisciplinary overview can do.
We work with illness explanatory models of patients from various
outpatient clinics who suffer from biomedically unexplained fatigue and
weakness for six months or more. Also, in private practice of clinical
psychiatry compliance is the pivotal issue. We find that cultural
epide...
This scholarly article has been a fine example of what a fresh
approach and interdisciplinary overview can do.
We work with illness explanatory models of patients from various
outpatient clinics who suffer from biomedically unexplained fatigue and
weakness for six months or more. Also, in private practice of clinical
psychiatry compliance is the pivotal issue. We find that cultural
epidemiology plays a significant role in understanding and managing
patients' compliance and outcome. Either intentional error or violation,
or unintentional slip or lapse, patients do always have subjective
explanation for their behaviour. The antecedents of compliance or non-
compliance can be found:
(1)in patient's illness experience, different
variables of which include stigma of illness or treatment, anticipated
outcome, perceived seriousness of the symptoms, and many other
sociocultural contextual factors;
(2)in subjective meaning of the illness
as exemplified by the perceived causes of the illness and their linkages
among each other; and
(3)his experiences with the help seeking behaviour
and the agencies of help, with their meeting patient's perceived needs.
Patient's explanatory models (emic) and its match or otherwise with
the explanatory models of the professional care giving agencies (etic) is
an important determinant of the patient's compliance toward the prescribed
treatment. Careful attention to the patient's emic is facilitated by
cultural epidemiological approach with the use of Explanatory Model
Interview Catalogue(EMIC), a tool that can be used in research as well as
in clinical practice. It focuses on patient's experience, meaning, and
behaviour while retaining the qualitative as well as the quantitative
aspects. Ratings on predetermined codes facilitate comparison and analysis
apart from crystallizing the salient features of the explanatory model.
Reliability of this effective tool has been documented in studies on
leprosy and depression.
Dear Editor
I read the paper by Ovretveit and Gustafsen with interest, as I believe that this is a neglected area. I found their paper admirably clear and concise, and I would agree with many of their points. However, I feel that they have neglected one important area.
In their discussion of the ways in which this kind of research could be improved, they discuss the need for empirically based explanatory theo...
Dear Editor
Milne and Hill raise an interesting hypothesis - that the decline in surgical rates may have been due to a programme of Getting Research Into Practice. We intend to test this hypothesis by comparing our data with that for the whole of England and, within the area of our study, to compare the two Berkshire districts with districts in the former East Anglian region. We will report the results on this site...
Dear Editor
Black and Hutchings present an intriguing account of the rise and fall of glue ear surgery in two English regions.[1] They speculate that the acceleration of the decline from 1992 may have been due to the Effective Health Care bulletin on glue ear, helped by five "contextual features". One of these was the concurrent structural change to the NHS, arising from the introduction of health care commis...
Dear Editor
Dr Shojania raises important issues that must be solved before widespread implementation of many decision-support tools is possible. I appreciate his letter. Dr Shojania and I, however, have been addressing different kinds of decision-support. The tools my colleagues and I have implemented, both locally and at external sites, are explicit tools that generate specific instructions, in contrast to...
Dear Editor
I very much agree with the authors concerning the role of Risk Management in the Patient Safety arena. In fact, as a Director of Risk Managment in an integrated delivery system in Dayton, Ohio, I have been very involved in the patient safety efforts of our two acute care organizations, as well as the other entities within our system. My concern for the past few months has been how to best focus the ri...
Dear Editor
I share much of Dr Morris' enthusiasm for decision support. While involved in an evaluation of a decision support targeting vancomycin ordering practice,[1] I had the opportunity to observe the potential impact of this approach. However, as a clinician using the same computerized order entry system in daily practice, I also recognized the major limitation of this approach: users will not tolerate many...
Dear Editor
As a member of the professional organisation for nurses in Ontario, I would like to direct nurses and other interested readers to the web page of the Registered Nurses Association of Ontario, www.rnao.org
This site has a wealth of position statements, policies, submissions to a variety of health stakeholders and other documents relating to providing...
Dear Editor
Adding the element of safety to medical education can not be effected unless the institutions supplement their systems with program of outcomes assesment.
While all that Dr Stevens describes is of interest, only when it is established that the medical safety material that has been presented is absorbed and put into practice will the validity of the suggestions be established.
This req...
Dear Editor
I will call the work of giving Medicine to poor countries, a Great English men do this beautiful things. From a Professor of internal medicine - Jorge H Jimenez.
Thanks
Dear Editor
This scholarly article has been a fine example of what a fresh approach and interdisciplinary overview can do.
We work with illness explanatory models of patients from various outpatient clinics who suffer from biomedically unexplained fatigue and weakness for six months or more. Also, in private practice of clinical psychiatry compliance is the pivotal issue. We find that cultural epide...
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