Improving Patient Care E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Strategies for successfully updating and improving health care organizations of all kinds Health care is always evolving and improving. However, the rapid speed of medical advancement can make the adoption of new technologies and practices a challenging process - particularly in large organizations and complex networks. Any projected impact upon quality and outcomes of care must be carefully evaluated so that changes may be implemented in the most efficacious and efficient manner possible. Improving Patient Care equips professionals and policymakers with the knowledge required to successfully optimize health care practice. By integrating scientific evidence and practical experience, the text presents a cohesive and proven model for practice change and innovation, complete with analysis of innovation, target group and setting; selection and application of strategies; and evaluation of process, outcomes and costs. This new third edition also includes: * Newly written chapters on clinical performance feedback, patient engagement, patient safety, evaluation designs, and methods for process evaluation * Increased emphasis on the role of contextual influences in implementation and improvement * New research examples from across the world and updated scientific literature throughout Designed to help promote safer and more efficient, patient-centered care and better outcomes, Improving Patient Care is an essential resource for healthcare providers, quality assessors, and students of health services research, health management, and health policy.
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Veröffentlichungsjahr: 2020
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Table of Contents
Cover
List of Contributors
Introduction
I.1 Which Changes?
I.2 Evidence‐Based Practice and Evidence‐Based Implementation
I.3 The Book's Messages
I.4 The Book's Basic Principles
I.5 The Organization of the Book
I.6 Changes from the Previous Edition
References
Part I: Principles of the Implementation of Change
1 Implementation of Change in Healthcare
1.1 Introduction
1.2 The Implementation Problem
1.3 Various Approaches to the Implementation of Change in Patient Care
1.4 What Is Implementation?
1.5 Which Recommended Practices Should Be Adopted?
1.6 A Systematic Approach to “Sustainable Change”
References
2 Theories on Implementation of Change in Healthcare
2.1 Introduction
2.2 Theories on Factors Related to Individual Professionals
2.3 Theories on Social Processes
2.4 Theories on Organizational Systems
2.5 Theories on Economic and Societal Structures
2.6 Conclusions
References
3 Effective Implementation of Change in Healthcare
3.1 Elements of Effective Implementation
3.2 The Implementation of Change Model
3.3 Developing a Proposal and Targets for Change
3.4 Assessment of Performance
3.5 Analysis of the Target Group and Setting
3.6 Selection and Development of Improvement Strategies
3.7 Development, Testing, and Execution of an Implementation Plan
3.8 Sustainable Change: Integration of Change into Practice Routines
3.9 Evaluation and (Possible) Adaptations to the Plan
3.10 Planning of the Implementation Process
3.11 Conclusions
References
4 Planning and Organizing the Change Process
4.1 Introduction
4.2 A Motivated Team Comprising All Relevant Expertise
4.3 Creating a Context for Change
4.4 Involving the Target Group and Stakeholders in the Plan
4.5 Leaders and Key Figures
4.6 Project Management: Time Schedule and Responsibilities
4.7 Resources and Support
4.8 Conclusions
References
Part II: Guidelines and Innovations
5 Characteristics of Successful Innovations
5.1 Introduction
5.2 Various Types of Improvements Require Various Types of Change Proposals
5.3 Characteristics of Innovations That Promote Implementation
5.4 Format and Presentation
5.5 Involvement of the Target Group and Local Adaptation
5.6 Conclusions
References
6 Clinical Practice Guidelines as a Tool for Improving Patient Care
6.1 Introduction
6.2 Aims of Guidelines
6.3 Potential Benefits and Limitations of Guidelines
6.4 Development of Effective Guidelines
6.5 Quality of Guidelines and Guideline Development Programs
6.6 International Collaboration in Guideline Development
6.7 Conclusion
References
Part III: Assessment of Performance
7 Indicators for Quality and Safety of Care
7.1 Introduction
7.2 Indicators for Quality and Safety of Care
7.3 Methods to Develop a Set of Indicators
7.4 Selecting or Developing a Preliminary Set of Indicators
7.5 Finding Consensus among Target Users
7.6 Testing the Indicators Empirically
7.7 Create a Feedback Report
7.8 Use and Effect of Quality Indicators
7.9 Conclusion
References
Part IV: Problem Analysis
8 Determinants of Implementation
8.1 Introduction
8.2 Analysis of Stakeholders
8.3 Determinants of Change
8.4 Subgroups in the Target Population
8.5 Conclusions
References
9 Methods to Identify and Analyze Determinants of Implementation
9.1 Introduction
9.2 Interviews
9.3 Surveys
9.4 Observation
9.5 Data Analysis
9.6 Prioritization and Goal Setting
9.7 Conclusions
References
Part V: Strategies for Change
10 Selection of Strategies for Improving Patient Care
10.1 Introduction
10.2 Methods to Select and Develop Implementation Strategies
10.3 Classification of Implementation Strategies
10.4 Implementation Strategies in the Different Phases of Change
10.5 Subgroups within the Target Group
10.6 The Effectiveness of Different Strategies and Interventions
10.7 Conclusions
References
11 Dissemination of Innovations
11.1 Introduction
11.2 Mass Media Approach
11.3 Personalized Approaches
11.4 Conclusion
References
12 Educational Implementation Strategies
12.1 Introduction
12.2 Types of Educational Strategies
12.3 Effectiveness of Education
12.4 Determinants of the Effectiveness of Education
12.5 Discussion and Conclusions
References
13 Clinical Performance Feedback and Decision Support
13.1 Introduction
13.2 Definitions, Characteristics, and Components
13.3 Effectiveness of Feedback and Decision Support
13.4 Factors Associated with Effects
13.5 Discussion and Conclusions
References
14 Engaging Patients in Healthcare Improvement and Innovation
14.1 Introduction
14.2 Impact of Patient Engagement on Direct Care
14.3 Impact of Patient Engagement on Organizational Design and Governance
14.4 Impact of Patient Engagement in Policy Making
14.5 Conclusion
References
15 Organizational Implementation Strategies
15.1 Introduction
15.2 Revision of Professional Roles
15.3 Enhanced Patient Care Teams
15.4 Knowledge Management (Use of IT)
15.5 Integrated Care Systems
15.6 Quality and Safety Management
15.7 Conclusions
References
16 Patient Safety Strategies
16.1 Introduction
16.2 Definition of Patient Safety Concepts
16.3 Strategies to Measure Patient Safety
16.4 Patient Safety Improvement Strategies
16.5 Strategies to Assure Patient Safety
16.6 Conclusions
References
17 Health System Strategies for Implementation
17.1 Introduction
17.2 Strategies to Enhance Evidence‐Based Policy Making
17.3 Scaling Up Interventions and Practices
17.4 Changes in the Financial Reimbursement of Healthcare Providers
17.5 Changes in the Financial Risk for Patients
17.6 Changes in the Healthcare System
17.7 Conclusions
References
18 Multifaceted Implementation Strategies
18.1 Introduction
18.2 Strategies in Multifaceted Implementation Strategies
18.3 Effectiveness of Multifaceted Implementation Strategies
18.4 Tailoring in Multifaceted Strategies
18.5 Volume and Classification of Strategies
18.6 Combinations of Specific Strategies
18.7 Conclusions
References
Part VI: Organization and Evaluation
19 Planning of Implementation
19.1 Introduction
19.2 Development of the Plan According to Phases in the Change Process
19.3 Planning of Activities for Different Levels of Care
19.4 Planning of Activities over Time
19.5 Incorporating the Implementation Plan into Existing Activities
19.6 Testing of the Implementation Strategies
19.7 Setting Goals for Evaluation
19.8 Integration and Embedding of New Practice into Routines and Organization
19.9 Conclusions
References
20 Experimental Designs for Evaluation of Implementation Strategies
20.1 Introduction
20.2 Experimental Study Designs
20.3 Outcome Measures and Data‐Collection Methods
20.4 Statistical Power and Data Analysis
20.5 Regulatory and Ethical Considerations
20.6 Conclusion
References
21 Observational Evaluation of Implementation Strategies
21.1 Introduction
21.2 Designs for Observational Evaluations
21.3 Cross‐Sectional Studies
21.4 Before–After Comparisons
21.5 Controlled Before–After Comparisons
21.6 Multiple Case Studies
21.7 Developmental Research
21.8 Data Analysis in Observational Evaluation Designs
21.9 Conclusions
References
22 Process Evaluation of Implementation Strategies
22.1 Introduction
22.2 Frameworks for Process Evaluation
22.3 Process Evaluation and Implementation Strategies
22.4 Assessing the Fidelity of Implementation Strategies
22.5 Framing Process Evaluations
22.6 A Practical, Step‐wise Approach to Process Evaluation
22.7 Conclusions
References
23 Economic Evaluation of Implementation Strategies
23.1 Introduction
23.2 The Basics of Economic Evaluation
23.3 Types of Economic Evaluation
23.4 Policy Cost‐Effectiveness
23.5 Framing Economic Evaluations
23.6 Cost Analysis
23.7 Sensitivity Analysis, Quantitative Modeling, and Budget Impact
23.8 Ex Post Evaluation of the Efficiency of Implementation
23.9 Conclusions
References
Index
End User License Agreement
List of Tables
Chapter 1
Table 1.1 Approaches aimed at the implementation of improved care.
Chapter 2
Table 2.1 Lessons from theory for planned improvement in healthcare.
Chapter 3
Table 3.1 Steps in the process of change.
Table 3.2 A step‐by‐step approach to implementation of a blood transfusion pr...
Chapter 4
Table 4.1 The competencies of medical leadership.
Chapter 5
Table 5.1 Implementation of various innovations (Cretin 1998).
Table 5.2 Characteristics of innovations that might promote or hinder their i...
Chapter 6
Table 6.1 Steps and activities in guideline development in the context of imp...
Table 6.2 Examples of non‐specific and specific questions.
Table 6.3 GRADE rating system of the quality of evidence.
Table 6.4 Framework of types of tools for guideline implementation.
Chapter 7
Table 7.1 Clinimetrics of nine indicators for integrated head and neck cancer...
Table 7.2 Measurement characteristics according to their aim.
Table 7.3 Framework of quality domains.
Table 7.4 Examples of indicators.
Table 7.5 Possible factors influencing the quality of indicators.
Table 7.6 Adherence to quality indicators for non‐Hodgkin lymphoma (NHL) care...
Chapter 8
Table 8.1 Phases in a process of change.
Chapter 9
Table 9.1 Perceived barriers to change in three studies.
Table 9.2 Methods to identify determinants of implementation in healthcare.
Chapter 10
Table 10.1 Implementation strategies in different phases of the change proces...
Table 10.2 Approach to different groups in the introduction of innovations.
Chapter 11
Table 11.1 Examples of mass media and personalized methods for dissemination.
Chapter 12
Table 12.1 Overview of reviews on continuing professional education.
Chapter 13
Table 13.1 Overview of reviews on performance feedback.
Table 13.2 Overview of reviews on computerized decision support systems (
CDSS
)...
Table 13.3 Suggestions for optimizing the effectiveness of audit and feedback...
Chapter 15
Table 15.1 Overview of reviews on revision of professional roles.
Table 15.2 Overview of reviews on enhanced patient care teams and team‐orient...
Table 15.3 Overview of reviews on the use of information technology in health...
Table 15.4 Overview of reviews on integrated care programs.
Chapter 16
Table 16.1 Incidence of in‐hospital adverse events across the world.
Table 16.2 Methods for measuring incidents and adverse events.
Table 16.3 Factors influencing incidents.
Table 16.4 Overview of reviews on strategies to improve patient safety.
Chapter 17
Table 17.1 Overview of reviews on strategies to enhance evidence‐based policy...
Table 17.2 Overview of reviews on changes in financial reimbursement of healt...
Chapter 18
Table 18.1 Overview of reviews on multifaceted improvement strategies.
Chapter 19
Table 19.1 Introducing changes on multiple levels.
Chapter 23
Table 23.1 Criteria for a complete economic evaluation.
Table 23.2 Classification of the outcomes of economic evaluations that compar...
Table 23.3 Types of economic evaluations.
Table 23.4 Hypothetical example of a cost–consequence analysis of implementin...
Table 23.5 Costs in the different stages of implementation strategies.
Table 23.6 Costs of the outreach visitor intervention (in euros) per practice...
List of Illustrations
Introduction
Figure I.1 The Grol and Wensing implementation of change model.
Chapter 3
Figure 3.1 The Grol and Wensing implementation of change model.
Chapter 4
Figure 4.1 The Grol and Wensing implementation of change model.
Chapter 5
Figure 5.1 The Grol and Wensing implementation of change model.
Chapter 7
Figure 7.1 The Grol and Wensing implementation of change model.
Chapter 8
Figure 8.1 The Grol and Wensing implementation of change model.
Chapter 9
Figure 9.1 Paretogram on determinants of dissatisfaction (proportion of answ...
Figure 9.2 Fishbone diagram of figures identified as causing delays to treat...
Chapter 10
Figure 10.1 The Grol and Wensing implementation of change model.
Figure 10.2 Methods for implementing change.
Chapter 13
Figure 13.1 Clinical performance feedback intervention theory (
CP‐FIT
)...
Chapter 14
Figure 14.1 A framework for patient and family engagement.
Chapter 19
Figure 19.1 The Grol and Wensing implementation of change model.
Chapter 20
Figure 20.1 The Grol and Wensing implementation of change model.
Chapter 21
Figure 21.1 Hypothetical example of an interrupted time‐series study.
Guide
Cover
Table of Contents
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Improving Patient Care
The Implementation of Change in Health Care
Third Edition
Edited by
Michel Wensing
Faculty of Medicine, Health Services Research and Implementation Science University of Heidelberg, Heidelberg, Germany;Department of General Practice and Health Services Research Heidelberg University Hospital, Heidelberg, Germany;Department IQ healthcare, Radboud Institute for Health Sciences Radboud University Medical Center, Nijmegen, The Netherlands
Richard Grol
Radboud University, Nijmegen, The Netherlands;Maastricht University, Maastricht, The Netherlands
Jeremy Grimshaw
Clinical Epidemiology Program, Ottawa Hospital Research Institute Ottawa, Ontario, Canada;Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada;Health Knowledge Transfer and Uptake, Ottawa, Ontario, Canada
This edition first published 2020© 2020 John Wiley & Sons Ltd
Edition HistoryWiley‐Blackwell (2e, 2013)
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
The right of Michel Wensing, Richard Grol, and Jeremy Grimshaw to be identified as the author(s) of the editorial material in this work has been asserted in accordance with law.
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Library of Congress Cataloging‐in‐Publication Data
Names: Wensing, Michel, editor. | Grol, Richard, editor. | Grimshaw, Jeremy, editor.Title: Improving patient care : the implementation of change in health care / edited by Michel Wensing, Richard Grol, Jeremy Grimshaw.Description: Third edition. | Hoboken, NJ : Wiley-Blackwell 2020. | Includes bibliographical references and index.Identifiers: LCCN 2019055404 (print) | LCCN 2019055405 (ebook) | ISBN 9781119488590 (cloth) | ISBN 9781119488613 (adobe pdf) | ISBN 9781119488606 (epub)Subjects: MESH: Patient Care | Quality of Health Care | Health Care Reform | Organizational Innovation | Health Plan ImplementationClassification: LCC RA395.A3 (print) | LCC RA395.A3 (ebook) | NLM W 84.1 | DDC 362.1/0425–dc23LC record available at https://lccn.loc.gov/2019055404LC ebook record available at https://lccn.loc.gov/2019055405
Cover Design: WileyCover Image: © mythja/Shutterstock
List of Contributors
Eddy AdangDepartment for Health EvidenceRadboud Institute for Health SciencesRadboud University Medical CenterNijmegen, The Netherlands
Jozé BraspenningDepartment IQ healthcareRadboud Institute for Health SciencesRadboud University Medical CenterNijmegen, The Netherlands
Benjamin BrownCentre for Primary Care and Centre for Health InformaticsUniversity of ManchesterManchesterUK
Jako BurgersDutch College of General Practitioners (NHG)Utrecht;Department of Family MedicineCare and Public Health Research Institute (CAPHRI), Maastricht UniversityMaastricht, The Netherlands
Hilly CalsbeekDepartment IQ healthcareRadboud Institute for Health SciencesRadboud University Medical CenterNijmegen, The Netherlands
Stephen CampbellSchool of Health Sciences and NIHRGreater Manchester Patient SafetyTranslational Research CentreUniversity of ManchesterManchesterUK
Glyn ElwynDartmouth Institute for Health Policy and Clinical PracticeGeisel School of Medicine at Dartmouth CollegeLebanon, NHUSA
Cornelia FluitDepartment for Research in Learning and EducationRadboudumc Health AcademyRadboud University Medical CenterNijmegen, The Netherlands
Jeremy GrimshawClinical Epidemiology ProgramOttawa Hospital Research InstituteOttawa, Ontario;Department of MedicineUniversity of OttawaOttawa, OntarioCanada
Richard GrolRadboud UniversityNijmegen;Maastricht UniversityMaastricht, The Netherlands
Mirelle Hanskamp‐SebregtsInstitute for Quality Assurance RadboudInstitute for Health SciencesRadboud University Medical Center Nijmegen;Department IQ healthcareRadboud Institute for Health SciencesRadboud University Medical CenterNijmegen, The Netherlands
Rosella HermensDepartment IQ healthcareRadboud Institute for Health SciencesRadboud University Medical CenterNijmegen, The Netherlands
Ties HoomansCare Policy and Evaluation CentreLondon School of Economics and Political ScienceLondonUK
Marlies HulscherDepartment IQ healthcareRadboud Institute for Health SciencesRadboud University Medical CenterNijmegen, The Netherlands
Noah IversWomen’s College Research Institute and Family Practice Health CentreWomen’s College HospitalToronto, Ontario;Department of Family and Community Medicine, University of TorontoToronto, Ontario;Dalla Lana School of Public HealthUniversity of TorontoToronto, OntarioCanada
Miranda LaurantUniversity of Applied Sciences Arnhem‐NijmegenNijmegen;Department IQ healthcareRadboud Institute for Health SciencesRadboud University Medical CenterNijmegen, The Netherlands
Holger PfaffInstitute of Medical SociologyHealth Services Researchand Rehabilitation Science (IMVR)University of CologneCologne, Germany
Amy PriceStanford Medicine XStanford University School of MedicineStanford, CAUSA
Johan L. SeverensErasmus School of Health Policy & Management and Institute of Medical Technology AssessmentErasmus University RotterdamRotterdam, The Netherlands
Charles VincentDepartment of Surgery and CancerImperial CollegeLondonUK
Philip van der WeesDepartment IQ healthcareRadboud Institute for Health SciencesRadboud University Medical CenterNijmegen, The Netherlands
Trudy van der WeijdenDepartment of Family MedicineCare and Public Health Research Institute (CAPHRI)Maastricht UniversityMaastricht, The Netherlands
Michel WensingFaculty of MedicineUniversity of HeidelbergHeidelberg;Department of General Practice and Health Services ResearchHeidelberg University HospitalHeidelberg, Germany;Department IQ healthcareRadboud Institute for Health SciencesRadboud University Medical CenterNijmegen, The Netherlands
Hub WollersheimDepartment IQ healthcareRadboud Institute for Health SciencesRadboud University Medical CenterNijmegen, The Netherlands
Marieke ZegersDepartment Intensive Care;Department IQ healthcareRadboud Institute for Health SciencesRadboud University Medical CenterNijmegen, The Netherlands
Introduction
Richard Grol1,2 and Michel Wensing3,4,5
1 Radboud University, Nijmegen, The Netherlands
2 Maastricht University, Maastricht, The Netherlands
3 Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
4 Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
5 Department IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
Friesland – a province of the Netherlands – is the homeland of the famous black and white Friesian cows, and the land of milk and cheese. For centuries these cows were milked by hand, which meant the famer and his family awoke at 4 or 5 o'clock in the morning. Around 1890, reports of successful experiments with a milking machine appeared in the regional newspapers; according to the experts this machine had been shown to be both efficient and cost‐effective. It milked cows with udders of different sorts very well. How quickly would this new technique spread among Friesian farmers?
The first machines were introduced in 1910, but it was not until the 1950s that they were adopted widely (Mak 1996). Why did farmers prefer to rise at the crack of dawn, even though everyone knew about the new machine? That it was the personal relationship they maintained with their cows is probably too romantic. The way to understand the reasons for this, and what a successful implementation program should have been directed toward, is to examine the farmers' motives and their living and working conditions at that time. One of the main reasons for non‐adoption was that the milking machine costed money, whereas manpower provided by the family was free. At that time farmers were, for the most part, self‐sufficient and their work involved little exchange of money. Perhaps equally important was their system of standards and values: the most important aim of a farming enterprise was to guarantee the continuity of the family business, not to make a profit. Taking risks was therefore at odds with their mission; following a set routine developed by their forefathers was seen as a guarantee of success. According to Mak (1996), it was not until World War II, when these standards were subjected to enormous modification, that farming practices in Friesland changed. An earlier effective introduction of milking machines would have required changes at different levels: changes in standards and values, greater skill in dealing with money, increase in farm size, and changes to milk and cheese production in factories. In short, changes in the entire process from cow to consumer, a complete change in culture at all levels.
This example demonstrates that if one wants to implement an innovation successfully, it is crucial to have a clear understanding of, and insight into, the target group's living and working conditions and standards and values, as well as of the issues involved in the implementation of an innovation itself. Simply publishing the effects or efficiency (or otherwise distributing information on the innovation's usefulness) is usually not enough to guarantee successful adoption. The real obstacles must be sought and tackled in a systematic way with a variety of appropriate methods and measures that have proven to be effective in practice. This is the message being delivered in this book.
In the field of healthcare an enormous number of valuable insights, technologies, and practices become available each year. They derive from well‐planned scientific research or from careful experiments and evaluation in everyday practice. Only a small proportion of these methods and technologies are, in the short term, adopted into the daily practice of patient care. Thus patients, clients, and care users could be needlessly deprived of effective care or receive unnecessary, outdated, or, even worse, harmful care. Of course, not all innovations are improvements, but it is a general observation that in healthcare the situation is often one of “underuse, overuse and misuse of care” (Bodenheimer 1999). Therefore, it is important that great care be taken not only to develop innovations and scientific insights, but also to take care that valuable insights and procedures are adopted into daily practice; in doing so, an important contribution can be made to the improvement of the quality of patient care and public health.
Adopting valuable insights and procedures frequently occurs with difficulty and incompletely. Implementation of new insights or improvements in healthcare may be only partially successful and at times completely unsuccessful. Consequently, the intended results for the patients – recovery from an illness, improvement in health, better quality of life, more efficient procedures, or better collaboration between providers – are often not realized. There are many possible reasons for this, such as the nature, the effectiveness, or the applicability of the (new) proposed method of working, the professionals who need to change, or the setting in which the intended change is to take place. However, there may also be structural, financial, or organizational obstacles. Equally, the way in which the change is implemented may be ineffective. Given that scientific knowledge on effective implementation and change in the practice of healthcare is still limited, but growing all the time, it is important to bring together this knowledge and to distill recommendations from it to aid implementation in routine patient care. That is, in sum, the purpose of this book.
The book is meant for healthcare providers, healthcare managers, staff involved in quality assessment, policy makers, and researchers in healthcare who are concerned with the question of how best to design the implementation of valuable (new and existing) insights and procedures so that they contribute to optimal patient care. This book tries to answer that question by combining the now available scientific knowledge and practical experience.
I.1 Which Changes?
The book is directed at the implementation of various changes and improvements in healthcare, including:
adoption of practices, technologies, and healthcare delivery models, which have been well researched and found to have a proven value;
adoption of well‐developed practice guidelines in practice, both those developed centrally and those developed within a local area or institution;
preventing, stopping, or reducing unnecessary, expensive, unsafe, or harmful practices;
reducing undesirable variations in the care provided.
In this book, we will use words such as innovations, new procedures, new insights, and changes in care provision. What we mean by this is the introduction of improvements in healthcare. Therefore, we make no distinction between quality improvements and the implementation of new insights.
I.2 Evidence‐Based Practice and Evidence‐Based Implementation
It is certainly not true to say that all new technologies, procedures, guidelines, or recommendations from scientific research signify real improvements in patient care. Nor is it the case that the improvement of care provision can arise only from scientific information being made available. In this book we concentrate on practices, technologies, and healthcare delivery models based on scientific evidence, on careful evaluation, and thus on innovations that are firmly established as being able to contribute to better, more effective, safer, more efficient, and patient‐friendly care or better healthcare outcomes for patients and populations.
That does not mean that these innovations would be able to find their way into practice on their own, without further adaptation. In many cases active contributions from the target groups will be necessary to adapt an innovation to their own setting and experiences. The importance of such “two‐way traffic between practice and science” (Health Council of the Netherlands 2000), involving users and other stakeholders in the implementation of innovations, will be often emphasized in this book.
I.3 The Book's Messages
The messages delivered in this book can be summarized as follows:
Take into account when developing a new working method, procedure, clinical guideline, or care protocol, from the outset, how it is to be implemented.
Know and understand as completely as possible the target group and the setting in which implementation is to take place. Put yourself in the target group's position, try to see their perspective, and involve them in both the development and the implementation of the innovation.
Employ a well‐planned change intervention with a diversity of cost‐effective and well‐tested strategies and measures. A well‐organized implementation process will contribute to successful implementation, overcoming many barriers to change.
Careful, continuous evaluation of the actual care process and monitoring of the changes are also crucial in the ensuing success of the implementation activities.
I.4 The Book's Basic Principles
It is important for readers to keep in mind a number of principles that underpin this book:
The book is about
optimizing patient care and prevention
; thus, it is about the quality and safety of care and about quality improvement. However, it is not a “manual for quality improvement.”
The emphasis lies on the improvement of the
primary processes in care provision
by physicians, nurses, and allied health professionals and the teams they work in. The patient is at center stage. Changes in the organization of institutions or practices can be very important, but are discussed here predominantly in terms of what they contribute to the improvement of direct patient care. Prevention of disease that is independent of patient care (e.g. control of air pollution or poverty in the population) is not covered.
The immediate reasons for implementation may be the availability of new scientific insights and/or the availability of valuable procedures, as well as experiences from daily practice that a specific care process is not effective, efficient, or patient friendly.
Changes may be initiated and realized in a guided process, with the emphasis on practical support for targeted individuals (
top
‐
down
), or adaptive, with the emphasis on stakeholder involvement and needs (
bottom‐up
). We advocate a mix of these approaches.
The book largely takes the
perspective of the implementer
, meaning the
agent of change
, the person or team who is, or who feels, responsible for the implementation of improvements in care provision. Through the book, however, processes and implementation are often also looked at through the eyes of the target group (professionals, teams, patients).
Our
target group
for this book comprises healthcare providers, executive staff, staff involved in quality assessment, healthcare managers, and policy makers. The book also offers an introduction to and overview of the field to researchers in the field.
Not only recommended practices, technologies, and healthcare delivery models should have “proven” value. It is equally important that the strategies for their implementation have been based as much as possible on robust research and are carefully evaluated. In this book we will show which approaches to implementation are evidence based and which have been based on experience.
I.5 The Organization of the Book
The book is organized into a number of parts, each of which contains several chapters. With this organization, the book largely follows the model that will be discussed in greater detail in Chapter 3 (see Figure I.1):
Part I
provides a general introduction, presents a set of theories on implementation and change in healthcare, describes a model for implementation (
Figure I.1
) that is used throughout the rest of the book, and ends with recommendations for the planning and preparation of the implementation project.
Part II
discusses the characteristics of new insights, guidelines, and procedures that can contribute to their ultimate implementation. The development of effective guidelines is then examined extensively.
Part III
is about measuring actual care provision as a basis for setting up concrete targets for improvement. It deals primarily with the development of good indicators.
Part IV
deals with the analysis of the target group and the setting, and discusses the range of factors that may play a role in implementation. Methods to carry out a “diagnostic analysis” are also presented.
Part V
describes existing dissemination and implementation strategies and current scientific knowledge of their effectiveness.
Part VI
outlines the design of an effective implementation plan, organizing its implementation in daily practice and evaluating the effects.
I.6 Changes from the Previous Edition
Compared to the previous edition of the book, which was published in 2013, the overall structure and approach have remained the same. Jeremy Grimshaw joined Michel Wensing and Richard Grol as co‐editors of the book, while Martin Eccles and David Davis retired. As a substantial body of relevant new research has become available since 2013, all chapters have been updated with respect to the published literature. Several chapters (Chapters 13, 14, 16, 20, and 21) have been newly written by (largely) different author teams. In Chapters 11–18 on strategies for quality improvement and implementation of innovations, we have focused more strongly on the role of contextual factors and intervention components that are associated with effects. In Chapters 20–23 on evaluation methods, we have reduced the information on advanced methods, sample size calculation, and statistical aspects of data analysis (for which we refer to other sources).
Figure I.1 The Grol and Wensing implementation of change model.
References
Bodenheimer, T. (1999). The American health care system. The movement for improved quality in health care.
N. Engl. J. Med.
340: 488–492.
Health Council of the Netherlands (2000).
Van implementeren naar leren. Het belang van tweerichtingsverkeer tussen praktijk en wetenschap in de gezondheidszorg. [From implementation to learning. The importance of two‐way traffic between practice and science in healthcare.]
. The Hague: Gezondheidsraad; publ. 2000/18.
Mak, G. (1996).
Toen God verdween uit Jorwerd. [When God disappeared from Jorwerd.]
. Amsterdam: Atlas.
Part IPrinciples of the Implementation of Change
1Implementation of Change in Healthcare: A Complex Problem
Richard Grol1,2 and Michel Wensing3,4,5
1 Radboud University, Nijmegen, The Netherlands
2 Maastricht University, Maastricht, The Netherlands
3 Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
4 Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
5 Department IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
SUMMARY
Substantial numbers of patients do not receive high‐quality care: care that is accessible, safe, effective, patient centered, well‐coordinated, and efficient.
Changes in practice are often required to improve patient care and prevention. It may also demand changes in healthcare organizations and healthcare systems to facilitate practice changes.
Different approaches to the implementation of change in patient care can be observed, each based on different assumptions and theories of human and organizational behavior.
A combination of structured guidance (“top‐down”) and participation of target populations and stakeholders (“bottom‐up”) is often needed to achieve real and sustainable changes in practice.
Different innovations and proposals for change demand different implementation strategies.
1.1 Introduction
The number of new insights, procedures, programs, and technologies that have become available as a result of careful development and/or scientific research is enormous. For instance, the number of clinical trials added to Medline, a large database of journals in the field of medicine, is gigantic. Subsets of this database – systematic literature analyses of clinical research studies or that portion of the literature capturing clinical guidelines – are growing at significant rates. For many problems and questions that emerge in healthcare practice and policy, a search in the research literature would identify many relevant publications.
As a consequence, knowledge about optimal patient care quickly becomes obsolete, affected by both scientific and social developments. An example of quality problems in modern times is presented in Box 1.1. A great deal of knowledge that one absorbs over the years of training to become a doctor, nurse, or paramedic is obsolete by the time training is completed. This is not a new observation (see Box 1.2). It reflects the importance of health professionals' ability to scan, absorb, and use the medical literature, described in subsequent chapters (Candy 2000). The legitimate concerns about the validity and relevance of published research and technologies (leading to “research waste”) imply a need for careful selection of items for implementation into practice.
Box 1.1 Unsafe Cardiac Surgery: The Radboud Cardiac Surgery Case
In September 2005, details about the mortality rates at the Cardiac Surgery department of the Radboud University Nijmegen Medical Center got into the newspapers. The post‐surgery mortality rate in 2004 was 6.7%, compared to 2.7% in other cardiac centers in the Netherlands. This situation initiated a process which led to major improvements in clinical practice within a few years. The Board of Directors initially denied the problem, stating that the high mortality rates were caused by the patient case mix. However, after the situation had been intensively analyzed, by both an internal committee and an external committee (appointed by the Health Care Inspectorate), the conclusion was reached that in fact these high mortality rates reflected serious problems. The high mortality and complication rates could not be attributed to more seriously ill patients (in fact, the situation was quite the opposite). Instead it was discovered that staff did not work according to prevailing clinical research evidence and protocols; there was little or no cooperation between the disciplines involved (for example, everyone used his/her own patient record); departments did not collaborate with each other; there were conflicts among cardiac surgeons; the management of the department had lost control of the situation; and little effort was invested in quality improvement. The Board of Directors of the hospital was aware of the problem, but left it to the physicians to solve it. For a long time, the national Inspectorate relied on the department's explanations.
These findings led the Inspectorate to close the department. The Board of Directors was dismissed. The management of the medical staff and the head of the department resigned. Meanwhile, many patients looked for treatment elsewhere, resulting in many empty beds. This initiated a reorganization of the Radboud University Nijmegen Medical Center in general and the cardiac surgery department in particular. The reorganization led to operations being restarted after six months. A year later, the department's mortality and complication rates were far below the national average (around 1%). The question is: What was the real cause of this change? Several hypotheses can be formulated:
Transparency
: publicizing the data and validating them provided both the public at large and the medical center with an insight into the fact that a real problem did exist. Good objective data on performance can contribute to the sense of urgency that something really needs to be done. This information prompted the Inspectorate as well as the patients to take measures.
National Inspectorate
: the decision of the Inspectorate to close the center and to demand radical changes put the organization under great pressure to implement improvements in a quick and thorough way.
Leadership
: the new management of the department, the medical staff, and the medical center made high quality and patient safety into an absolute priority and supervised the implementation of many changes to achieve this, including, among other actions, a revised and more intensive internal audit method.
Organization of care processes
: the surgical process was redesigned with the help of all disciplines involved, daily consultation on the patients as well as a joint medical file were introduced, and cooperation with the aim of a safer surgical process became a core objective.
Competency and motivation of professionals
: less than competent or dysfunctional surgeons were suspended, new surgeons who were prepared to work in the new system were appointed, and competencies were brought up to the required standard.
We would suggest that these changes all contributed to the improved quality and outcomes of care, probably in concert to achieve the complex change needed at Radboud. However, they represent hypotheses which need to be tested. This book presents the available scientific knowledge in this field.
Box 1.2 Development of Knowledge, a Not So Recent Example
In 1348, King Philip VI of France asked the medical faculty of the University of Paris for a scientific explanation of the plague epidemic, known as the Black Death, which killed about a third of the population of Europe. After extensive research, the Sorbonne came up with the cause – a threefold conjunction of Saturn, Jupiter, and Mars in the 14th grade of Aquarius. For a long time, this was generally accepted as being the definitive explanation in both Europe and the Arab world (Achterhuis 1998). What will we make of our explanations of the most important diseases of our time and the effectiveness of certain treatments 100 years from now?
The store of new knowledge about good patient care is growing at an ever‐increasing pace, but the percentage of valuable insights subsequently introduced into routine patient care and prevention is considerably lower. Taken at face value, this fact would imply that investing resources in research, guidance, and technology would seem to be a useless exercise. This was the case in the past; it may still be the case today. Although Semmelweis had demonstrated the importance of antiseptics in the nineteenth century, many surgeons operating after 1900 still used their bare hands, with adverse consequences. Even today, many institutions pay too little attention to washing and disinfecting hands before and after medical or nursing interventions, with huge consequences for patients and healthcare costs (Teare et al. 2001; Bolon 2011).
1.2 The Implementation Problem
The spread of information in the current information age, with new media and tools to transfer knowledge, is probably taking place faster than it did in the past. Nevertheless, clinicians, researchers, and policy makers have noticed that it takes a long time before research results or insights find their way into daily practice. In many cases healthcare professionals only learn and adopt new information gradually. To some extent this is understandable, considering the high workload of most of them, and even positive given the need for a careful assessment of recommended practices. It was estimated that a healthcare professional faces 75 trials and 11 new systematic reviews a day (Bastian et al. 2010), which is substantially more than a decade earlier (Haines 1996).
Even if clinicians are informed about new insights on optimal patient care, changes do not necessarily take place within their daily routines. The same applies to decision makers in prevention programs and healthcare systems. The scientific literature is replete with examples from which it would appear that patients are not given the care that, according to recent scientific or professional insights, is desirable. For instance, a representative analysis of clinical care given to almost 7000 patients in the USA showed that on average less than 60% of the patients received the care they should receive, based on best evidence (McGlynn et al. 2003; Asch et al. 2006; Runciman et al. 2012). Even after successful implementation of improvements, professionals' adherence to clinical practice guidelines was proven to decrease after a year in about half of the cases (Ament et al. 2015; see Box 1.3).
Box 1.3 Adherence to Guidelines in Primary Care in the Netherlands
In a National Study of Primary Care, 104 primary care practices collected data to determine their adherence to prevailing clinical guidelines developed by the Dutch College of General Practitioners (Braspenning et al. 2004). In total, data were compiled for 58 indicators. Although the average overall score for the indicators was 74%, wide variations existed between clinical problems, the nature of the performance (for example, the score for medication prescription was 62% and for referral 89%), and among primary care practices.
In what follows you will find some data from studies, which will give you an idea of the nature and the extent of the implementation problem in specific fields of healthcare.
1.2.1 Effective Care
Worldwide, there are many examples of the need for improvement of healthcare practice. In the USA, for example, the overall acute myocardial infarction 30‐day mortality rates remain high, having only declined from 18.8% in 1995 to 15.8% in 2006 (Krumholz et al. 2009), while Canadian rates have decreased from 13.5% in 1995 to 10.6% in 2003 (Johansen et al. 2010). While demonstrating significant reductions, a portion of these deaths remains preventable. In 2001 11% of patients in the Netherlands with an acute myocardial infarction died within 30 days following hospital admission; in 2013 this was 7.6%, similar to Switzerland and the UK, but worse than Australia (4.1%). The percentages for cerebral infarction were 16% in 2001 and 9% in 2013. The five‐year survival rates for various types of cancer are better in countries such as Finland, Norway, and Switzerland than in the Netherlands. The five‐year survival rate for colon cancer was on average 63% (range 51–71%) in the OECD (Organisation for Economic Co‐operation and Development) countries in recent years (OECD 2017).
Improvements are also possible in the treatment of the chronically ill. For example, a study among diabetes patients at outpatient clinics of internal medicine showed that only 23% of the patients managed to have the target value of HbA1c. The average score for a set of process indicators was 64% (Dijkstra et al. 2004). In this study, care and care outcomes improved considerably when the clinic provided structured multidisciplinary care and (specialized) nurses. Similarly, in 2007, a US study found that only 34% of hypertensive patients received adequate treatment to maintain the recommended blood pressure (Ardery et al. 2007). Hospital admissions for asthma and chronic obstructive pulmonary disorder (COPD) ranged from 58/100 000 in Japan to 427/100 000 in Hungary, with an average in the OECD countries of 236/100 000 in 2015 (OECD 2017).
1.2.2 Safe Care
Patients may be unnecessarily harmed by such inadequate care, not to mention the frustrations or costs that are incurred. Figures from the USA reveal a high number of deaths (45–99 000 deaths per year) as a result of poor practice and medical (mis)management (AHRQ 2010). Studies have been performed in various countries investigating adverse events for patients in hospitals. A systematic analysis of the results of those studies showed an average of 9.2% of patients suffering from adverse events, of which more than 40% were estimated to be preventable (De Vries et al. 2008). Medical records of patients in 19 hospitals in the Netherlands were studied in 2016 (Wagner 2017). The study showed that 3.1% (1035) of the patients who died in hospital suffered a potentially avoidable death.
Medication is an important cause of unsafe care. The HARM study indicated that there are 40 000 hospital admissions every year through medication errors in ambulatory patients in the Netherlands (Van den Bemt 2002). Furthermore, 5.5% of patients contracted an infection in hospital in 2016 (RIVM 2017). The scope of this problem is global. For example, 7.5% of Canadian patients contract a nosocomial infection (Baker et al. 2004); between 3 and 20% of US patients suffer some form of hospital‐related adverse event (Institute of Medicine 2000). Similar results are found in Australia and New Zealand (Wilson et al. 1995; Davis et al. 2002). A study found about 380 000 opioid‐related hospital admissions in 13 states in the USA in a three‐year period (2013–2015), suggesting overprescribing of these strong analgesics (Blanchard et al. 2018).
Insufficient hand hygiene in hospital is a classic example of a safety problem. Although clear evidence exists in this area, stipulating when hands need to be cleaned, compliance – most notably by physicians – is known to be poor. For instance, a study of 47 wards in three hospitals, in which nursing performance was closely observed (3500 observations), showed average rates of adherence per hospital to the infection prevention guidelines of 37, 33, and 19% (Brink‐Huis et al. 2010). Erasmus et al. conducted a systematic review of 96 studies on compliance with hand hygiene guidelines in hospital care. The overall median compliance rate was 40%, with lower rates for doctors (32%) than for nurses (48%; Erasmus et al. 2010). Needless to say, there is a lot of room for improvement.
There is also room for improvement to avoid other aspects of unsafe care, for example patient falls and nutrition. A study in 10 hospitals and 10 nursing homes in the Netherlands showed that an incident or error in the area of pressure ulcers, falling, or urinary tract infections happened every week in 9% of the patients (Van Gaal et al. 2014). Similar figures can be found in almost all developed countries. In 2004, 11% of nursing home residents in the USA had pressure ulcers (Park‐Lee and Caffrey 2009). The Australian Institute of Health and Welfare (2018) reported that in 2015–2016 there were 3.2 falls per 1000 hospitalizations; fall rates were higher in public hospitals than in private hospitals.
1.2.3 Efficient Care
While it is true that best evidence care is occasionally not offered to patients, it is frequently the reverse that holds true: unnecessary, expensive, and out‐of‐date care is also offered or provided. These inefficient clinical actions have considerable consequences in terms of personal and societal costs. Null et al. (2005) indicated that 7.5 million unnecessary surgical procedures were undertaken yearly in the USA, a country which sees approximately 53.3 million procedures annually (Cullen et al. 2009). In about 20% of their decisions, physicians in the Netherlands took unnecessary actions (Braspenning et al. 2004), including, for example, inappropriately prescribing antibiotics for acute ear infections (30%), referral to a physiotherapist for acute back pain (20%), not prescribing the first‐choice medicine for stomach complaints (25%), or unnecessary prostate‐specific antigen (PSA) testing for men with micturition problems (71%). Analyses of medical records in hospitals showed large numbers of “low value actions” that contribute little to health outcomes in patients (Colla et al. 2014). Examples were X‐rays in case of low back pain (22%) or anti‐psychotic medication as treatment for problematic behavior in case of dementia (31%). Stopping practices with unproven or low value for patients is just as important as the implementation of valuable innovations (Prasad and Ionnidis 2014).
1.2.4 Access to Care
Access to care implies the absence of financial, geographical, or time barriers to care as required. Waiting times and times for diagnosis or treatment are important indicators of timely access to care. For instance, a study by El Sharouni et al. (2003) about waiting time outcomes for radiotherapy for cancer patients showed that the average waiting time was 80 days in the Netherlands. This resulted in 41% of the patients going from having a possibly curable illness to having a possibly incurable illness. Waiting times for cataract surgery ranged from 464 days in Poland to 37 days in the Netherlands, with an average of 121 days in the OECD countries in 2015 (OECD 2017). Box 1.4 provides another example.
1.2.5 Patient‐Centered Care
Patient centeredness is about the delivery of treatments and communication in a manner which involves patients in decision making and puts them at center stage when dealing with their problems. In a study in 10 European countries, 17 400 patients from primary care were asked for their experiences of care, using a validated questionnaire (EUROPEP; Grol et al. 2000). Scores were collated on two dimensions: communication and information from the physician, and organization of care. On average, patients were very positive about their primary care practices: 80% were positive or very positive about treatment, communication, information, and organization of care, with substantial variation between countries (Petek et al. 2011). The judgment of the waiting times before a consultation with the general practitioner (GP), however, was much more negative. Compared to a similar study in 1998, the evaluations were more or less the same (Petek et al. 2011).
1.2.6 Variation in the Provision of Care
Studies often point to an enormous variation in performance. In some regions or hospitals, patients are more likely to undergo surgery for back pain, removal of the uterus, or surgical reduction of the prostate than in other regions or hospitals. While variation is not necessarily problematic, it is plausible that a considerable number of patients do not receive the recommended care, or, worse, receive unnecessary or possibly even damaging care. A survey of 276 patients suffering from lung cancer in hospitals in the east of the Netherlands measured the organizational quality of care on the basis of carefully constructed indicators (using scientific literature, guidelines, expert panels, and patient panels). Considerable variation was noted in patient throughput among the participating hospitals. For example, regarding finalizing the diagnosis within the recommended 21 days, the scores among hospitals varied between 58 and 73%. Regarding the start of the therapy as recommended (within 35 days after the first visit), scores varied between 38 and 66% (Ouwens et al. 2007).
Box 1.4 Organization of Care for Patients Suffering from Breast Cancer
Quick diagnosis and treatment of breast cancer can prevent aggravation of the situation. Schouten et al. (2010) mapped the times to treatment of 1600 breast cancer patients, who were treated by 20 different teams:
Average
Spread
(
standard deviation
)
Admission time for the first appointment (advice max. 5 days)
6.8 days
6.2 days
Time between first outpatient visit and diagnosis (advice max. 1 day)
5.4 days
8.6 days
Time between diagnosis and operation (advice max. 21 days)
18.5 days
16.5 days
Apart from the fact that diagnoses can be made much quicker in many places, the huge variety among institutions is remarkable. Also, much can be gained by multidisciplinary deliberation on patients (average 25%) and preoperative counseling of patients (average 55%).
Variation is also found between healthcare systems in different countries. In 2008, a survey among nearly 10 000 chronically ill patients in 8 countries showed that the percentage of diabetic patients that received recommended care (regular HbA1c measurement, examination of feet and fundi, and blood pressure measurement) varied between an average 35% in France and up to 60–65% in England and the Netherlands (Schoen et al. 2009). Likewise, the percentages of adults in the USA who had received an HbA1c measurement, retinal eye examination, and foot examination in the past year were 79.4, 66.7, and 64.6%, respectively (Coffey et al. 2004).
1.3 Various Approaches to the Implementation of Change in Patient Care
Partly on the basis of the figures presented so far, there is agreement between all parties involved in healthcare that care given could be improved in a number of ways: offering safer, more effective, more patient‐centered, better‐coordinated, and more efficient care. However, when it comes to how this can be achieved, opinions differ. Various stakeholders and disciplines have proposed a variety of approaches (Grol 1997; Grol 1999):
Healthcare professionals
are often inclined to take improvements into their own hands and to promote continuing professional development and achieve consensus on recommended practice for and among themselves. Professional hierarchies may support the adoption of chosen practices.
Biomedical researchers
more frequently classify, rate, and catalogue scientific developments within a field, making this information available to professionals through systematic reviews, rigorously developed clinical guidelines, and computerized decision support systems.
Healthcare researchers
, who may work for or on behalf of the government, map out health system and professional performance, indicating variations between care providers, institutions, and regions. Quality of care is measured with the help of “performance indicators”; this information is then channeled back to care providers as feedback or “mirrored information” and is increasingly made public.
Organizational and management experts
study how care processes can be optimized and how organizational conditions for optimal care can be created. They advise managers in healthcare organizations on organizational processes and leadership.
Patient representatives
,
ethicists
,
and lawyers
argue for the central role of patients, defending their right to better information provision and a more influential role in decisions about their illness. In addition, patients can be involved in the planning and design of healthcare services.
Health insurers and governments
, frequently assisted by
health economists
, are accountable for improving the overall quality of care, while at the same time controlling its costs. This is often done by selectively budgeting, financial incentives, or regulations, and by making rules for tariffs and volume.
Thus, in the daily practice of optimizing patient care, different parties are inclined to opt for different strategies to improve care.
