There has been a lot of interest in the academic literature over the last decade or more in how best to evaluate complex interventions designed to improve health systems. This paper arose from a recent international summit which aimed to create a bit of order in the messy world of health service evaluation. It provides a useful general overview of some of the key issues.
Tara Lamont, Nicholas Barber, John de Pury, Naomi Fulop, Stephanie Garfield-Birkbeck ,Richard Lilford, Liz Mear ,Rosalind Raine ,Ray Fitzpatrick. BMJ 2016; 352 doi: http://dx.doi.org/10.1136/bmj.i154 (Published 01 February 2016)
Measurement is a key element of improvement but all that matters cannot be measured and focusing on the measurable distracts attention from the more complex elements of professional practice. In this paper I explore some of the areas in general practice where there is no right answer, or where there are competing right answers, and suggest how these might be valued despite the lack of valid and reliable metrics.
Martin Marshall, DOI: 10.3399/bjgp16X683773 Published 1 February 2016
- Application of simplified Complexity Theory concepts for healthcare social systems to explain the implementation of evidence into practice Theory is increasingly being used to help develop a better understanding of why implementation of research evidence is so rife with problems. This paper explores the potential utility of complexity theory to explain why guidelines for pre-operative fasting (2 hours, rather than the 9 hours so often seen in practice) are usually ignored. It is a good example of how retrospective data analysis can contribute to the development of deeper understandings
J , Rycroft-Malone J , Hawkes C. & Noyes J . (2015) Application of
simplified Complexity Theory concepts for healthcare social systems to explain
the implementation of evidence into practice. Journal of Advanced Nursing
00(0), 000–000. doi: 10.1111/jan.12815
- Understanding quality improvement at scale in general practice: a qualitative evaluation of a COPD improvement programme. Large scale improvement is hard work, particularly when carried out in the general practice sector. This paper describes a project undertaken by colleagues within UCLPartners which aimed to improve care for people with COPD registered with practices in North East London. We used an analytical framework developed by the Health Foundation which allowed us to explore how and why improvement in general practice is different from that in the hospital sector. There are some important lessons for clinicians, managers and policy makers interested in large scale improvement in General Practice.
" Martin Marshall, James Mountford, Kirsten Gamet, Gulsen Gungor, Conor Burke, Robyn Hudson, Steve Morris, Nishma Patel, Phil Koczan, Rob Meaker, Cyril Chantler, Christopher Michael Roberts. DOI: 10.3399/bjgp14X682801Published 1 December 2014
- Moving Improvement research closer to practice: the Researcher-in-Residence model. The emerging ‘Researcher-in-Residence’ model which attempts to break down the traditional barriers between researchers (traditionally seen as the producers of scientific knowledge) and practitioners (traditionally regarded as recipients and users of that knowledge).
" Marshall, M, Pagel, C, French, C, Utley, M, Allwood, D, Fulop, N, Pope, C, Banks, V and Goldman, A. 3rd June 2014
- Bridging the ivory towers and the swampy lowlands; increasing the impact of health services research on quality improvement. This latest article explores how the disconnect between the traditional ‘producers’ of research evidence in academia, and the managerial and clinical ‘consumers’ of that evidence, has contributed to the challenge of embedding an evidence-informed approach to service improvement. It challenges the academic and health service sector to work more closely together for the benefit of patients.
" Marshall, M, (2013). Bridging the ivory towers and the swampy lowlands; increasing the impact of health services research on quality improvement. Int J Qual Health Care (2013) doi: 10.1093/intqhc/mzt076
- How staff at a ‘failing’ trust are leading its turnaround. An example of how a Rapid Response Evaluation Team can undertake a small scale pragmatic evaluation to help a struggling hospital to deliver change.
" Marshall, M, Miani, C, Nolte, E and Gill, M. HSJ, 7the October 2013
- More dialogue, more learning, more action. The authors discuss what is required for the growing jigsaw of empirical research and investigative reports into the UK’s health system in order to lead to change at scale for the lasting benefit of patients and the population..
" Mountford J and Marshall, M, (2013). More dialogue, more learning. BMJ Qual Saf 2013;0:1-3. doi:10.1136/bmjqs-2013-002471.
- Promotion of improvement as a science A paper that positions and frames the science of improvement and calls for greater scientific rigour in the practice of improvement.
" Marshall M, Pronovost P, et al. (2013). Promotion of improvement as a science. The Lancet; 2 February 2013 ( Vol. 381,Issue 9864,Pg 419-421)
Below is a selection of publications which have helped to stimulate our thinking about the science of improvement
- Recommendations for Evaluation of Health Care Improvement Initiatives. This paper challenges traditional approaches to the evaluation of improvement initiatives. It identifies 3 different stages in the life of improvement work – innovation, testing and scale up/spread – differentiated by what the authors call the ‘degree of belief’ of the stakeholders in the possible effectiveness of their work. Recognising the inherent uncertainty in improvement work shifts the evaluation question from ‘does it work’ to ‘How and in what contexts does a new model work or can be amended to work’. It’s a model that is work testing
" Parry,G.J; Carson-Stevens, A; Luff;D.F; McPherson, M.E; Goldmann, D.A (2013) Academic Pediatrics Vol13, Issue 6, Supplement , Pg. S23-S30
- Reducing central line infections in intensive care units. A much quoted example of pragmatic science, rigorously evaluating a complex intervention to reduce central line infections in ICUs. This study initiated a number of similar large scale programmes around the world, including the UK’s ‘Matching Michigan’ programme.
" Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al., (2006). An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355(26):2725-32.
- Increasing the identification and referral of victims of domestic violence in primary care. This paper uses a rigorous RCT design to evaluate a complex community intervention aiming to improving the identification and referral of victims of domestic violence. Who says improvement science is only relevant to hospitals and that RCTs can’t be used to evaluate complex interventions?!
" Feder G, Davies RA, Baird K, Dunne D, Eldridge S, Griffiths C, et al. (2011). Identification and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: a cluster randomised controlled trial. Lancet 2011. Nov 19;378(9805):1788-95.
- Re-designing stroke services along the patient pathway. This case study outlines the role of scientific evidence in making a case for radical redesign of stroke services across London.
" Porter M, Mountford J, Ramdas K (2010). Reconfiguring Stroke Care in North Central London. Special Version, for UCLP Value in Health Care Delivery Programme June 2011, London
- Reducing emergency admissions: are we on the right track? A good example of how research evidence can be used to challenge commonly held beliefs – in this case, the approaches used to managing the rapid rise in emergency admissions. Surely targeting people at high risk of admission makes sense? Well, not really…
" Roland M, Abel G. (2012). Reducing emergency admissions: are we on the right track? BMJ 2012;345:23-25
- The Behaviour Change Wheel A review of behaviour change models which results in a sophisticated and multi-dimensional model designed primarily to influence changes in individual behaviour to improve public health but highly applicable to changes in organisational behaviour for service improvement.
" Michie S, van Stralen M, et al. (2011). The Behaviour Change Wheel: A new method for characterising and designing behaviour change interventions. Implement Science 6(42).
- Collaborative Care for Patients with Depression and Chronic Disease. We are increasingly recognising that focusing on single disease improvement programmes in a world where a high proportion of patients have multi-morbidity is at best unhelpful. This ambitious study uses a single blind RCT to evaluate an intervention to improve outcomes for patients with both depression and diabetes and/or cardiovascular disease. The strategy to analyse outcomes across the three conditions is complex and ambitious but the bottom line is that coordinated care across all conditions is associated better outcomes than conventional single disease-focused care.
" Katon WJ, Lin EHB, Von Korff M et al., Collaborative Care for Patient with Depression and Chronic Disease. N Eng J Med 2010;363:2611-20.
- The Science of Improvement. A typically thoughtful paper from one of the fathers of the quality improvement movement in health care, challenging traditional approaches to evaluating improvement interventions.
" Berwick DM. (2008). The Science of Improvement. JAMA. 2008;299(10):1182-1184.
- Evidence Based Quality Improvement. An entertaining paper which compares and contrasts Evidence Based Management with Evidence Based Medicine. You can imagine which comes of worst.
" Shojania K. and Grimshaw J (2005). Evidence Based Quality Improvement: The state of the science. Health Affairs 24(1).
- Research designs for studies evaluating the effectiveness of change and improvement strategies. An interesting paper from some of the leading proponents of quantitative and positivist approaches to evaluating improvement interventions. This paper is 10 years old but the arguments go on about how to evaluate complex social interventions.
" Eccles M, Grimshaw J, Campbell M, Ramsay C, (2003). Research designs for studies evaluating the effectiveness of change and improvement strategies. Qual Saf Health Care 2003;12:47-52
- Evidence-based management: From theory to practice in health care. A classic paper with its analysis of why manager encourage evidence based clinical practice but sometimes struggle with evidence based management practice.
" Walshe K, Rundall TG. (2001). Evidence-based management: From theory to practice in health care. The Milbank Quarterly 2001; 79:429-457
- Make a WISH - working for the long term sustainability of healthcare. The English NHS is one of its periodic financial crises. In this it is like all health care systems in the world. In fact, Jim Easton, who was once responsible for trying to drive £20b of efficiency savings across the NHS, argues that this is because all healthcare systems are steadily becoming unaffordable, and that sustaining universal healthcare will require solutions which look at best radical and maybe even bizarre.
- Why quality improvement in healthcare is hard. Quality improvement methods, even according to their advocates, do not seem to have had as much impact internationally in healthcare are in other industries. Perhaps this is something to do with the deep structure and methods of healthcare? In this piece Jim Easton, who was once responsible for trying to support Quality Improvement across the English NHS reflects on this, and possible solutions.