Robyn Clay-Williams

Positive deviance: a different approach to achieving patient safety

Patient safety management within healthcare systems globally can feel like a relentlessly negative treadmill. Mortality reviews, incident reporting systems and audits all focus attention on what goes wrong and how often, why errors occur, and who or what is at the root of the problem. Sometimes these methods help us to understand why patients are harmed. However, such ‘find and fix’ approaches tell us little about the presence of patient safety, alerting us instead to its absence . These efforts aim to prevent harm by striving to reduce the number of things that go wrong,1 as opposed to identifying instances when—often despite challenging circumstances and limited resources—things go right. The focus on error detection and its management has not produced the expected gains in patient safety,2 primarily because these methods are not well suited to a complex adaptive system such as healthcare.3 Behaviours that produce errors are variations on the same processes that produce success, so focusing on successful practices may be a more effective tactic.4nnOne approach to focusing on success is positive deviance. While positive deviance can be used to describe the behaviour of an exemplary individual, the term can also be extended to describe the behaviours of successful teams and organisations. Originating in international public health projects,5 positive deviance has recently been embraced to improve quality and safety of healthcare delivered in organisations.6 ,7 The premise is that solutions to common problems mostly exist within clinical communities rather than externally with policy makers or managers, and that identifiable members of a community have tacit knowledge and wisdom that can be generalised. Moreover, because the solutions have been generated within a community, they tend to be more readily accepted and feasible within existing resources, thus increasing the likelihood of success and, …

Where the rubber meets the road: using FRAM to align work-as-imagined with work-as-done when implementing clinical guidelines

BackgroundUptake of guidelines in healthcare can be variable. A focus on behaviour change and other strategies to improve compliance, however, has not increased implementation success. The contribution of other factors such as clinical setting and practitioner workflow to guideline utilisation has recently been recognised. In particular, differences between work-as-imagined by those who write procedures, and work-as-done—or actually enacted—in the clinical environment, can render a guideline difficult or impossible for clinicians to follow. The Functional Resonance Analysis Method (FRAM) can be used to model workflow in the clinical setting. The aim of this study was to investigate whether FRAM can be used to identify process elements in a draft guideline that are likely to impede implementation by conflicting with current ways of working.MethodsDraft guidelines in two intensive care units (ICU), one in Australia and one in Denmark, were modelled and analysed using FRAM. The FRAM was used to guide collaborative discussion with healthcare professionals involved in writing and implementing the guidelines and to ensure that the final instructions were compatible with other processes used in the workplace.ResultsProcesses that would have impeded implementation were discovered early, and the guidelines were modified to maintain compatibility with current work processes. Missing process elements were also identified, thereby, avoiding the confusion that would have ensued had the guideline been introduced as originally written.ConclusionsUsing FRAM to reconcile differences between work-as-imagined and work-as-done when implementing a guideline can reduce the need for clinicians to adjust performance and create workarounds, which may be detrimental to both safety and quality, once the guideline is introduced.

The impact of clinical leadership on health information technology adoption: systematic review.

PURPOSEnTo conduct a systematic review to examine evidence of associations between clinical leadership and successful information technology (IT) adoption in healthcare organisations.nnnMETHODSnWe searched Medline, Embase, Cinahl, and Business Source Premier for articles published between January 2000 to May 2013 with keywords and subject terms related to: (1) the setting--healthcare provider organisations; (2) the technology--health information technology; (3) the process--adoption; and (4) the intervention--leadership. We identified 3121 unique citations, of which 32 met our criteria and were included in the review. Data extracted from the included studies were assessed in light of two frameworks: Bassellier et al.s IT competence framework; and Avgar et al.s health IT adoption framework.nnnRESULTSnThe results demonstrate important associations between the attributes of clinical leaders and IT adoption. Clinical leaders who have technical informatics skills and prior experience with IT project management are likely to develop a vision that comprises a long-term commitment to the use of IT. Leaders who possess such a vision believe in the value of IT, are motivated to adopt it, and can maintain confidence and stability through the adversities that IT adoptions often entail. This leads to proactive leadership behaviours and partnerships with IT professionals that are associated with successful organisational and clinical outcomes.nnnCONCLUSIONSnThis review provides evidence that clinical leaders can positively contribute to successful IT adoption in healthcare organisations. Clinical leaders who aim for improvements in the processes and quality of care should cultivate the necessary IT competencies, establish mutual partnerships with IT professionals, and execute proactive IT behaviours to achieve successful IT adoption.

Determination of health-care teamwork training competencies: a Delphi study

OBJECTIVEnThe purpose of this study was to determine the optimum content of a 1-day classroom-based crew resource management (CRM) course for health-care personnel working in ad hoc teams in complex, time-critical hospital departments such as surgery, intensive care or emergency.nnnDESIGNnA two-round modified Delphi panel.nnnPARTICIPANTSnselected teamwork competency components suitable for inclusion in 1 day of training from a list developed via literature review. Participants Fifteen experts in health care, CRM and training.nnnMAIN OUTCOME MEASUREnKnowledge, skill and attitude competency components for a 1-day CRM course.nnnRESULTSnOf the 110 knowledge, skill and attitude CRM competency components, 40 components were selected by greater than 70% of respondents, whereas the remaining 62 components were selected by fewer than 55% of respondents. These 40 competency components ranged across five competency domains: communication, task management, situational awareness, decision-making and leadership, and provided a consensus on the most critical areas for inclusion in training for health-care personnel.nnnCONCLUSIONSnThis new competency model is now available for use. Although the sample size was limited, a high degree of consensus was reached after only two rounds. A modified Delphi technique within the context of competencies first refined from the literature was a useful and cost-effective method for determining the content of a 1-day CRM training course for health-care workers.

An action research protocol to strengthen system-wide inter-professional learning and practice [LP0775514]

BackgroundInter-professional learning (IPL) and inter-professional practice (IPP) are thought to be critical determinants of effective care, improved quality and safety and enhanced provider morale, yet few empirical studies have demonstrated this. Whole-of-system research is even less prevalent. We aim to provide a four year, multi-method, multi-collaborator action research program of IPL and IPP in defined, bounded health and education systems located in the Australian Capital Territory (ACT). The project is funded by the Australian Research Council under its industry Linkage Program.Methods/DesignThe program of research will examine in four inter-related, prospective studies, progress with IPL and IPP across tertiary education providers, professional education, regulatory and registration bodies, the ACT health systems streams of care activities and teams, units and wards of the provider facilities of the ACT health system. One key focus will be on push-pull mechanisms, ie, how the education sector creates student-enabled IPP and the health sector demands IPL-oriented practitioners. The studies will examine four research aims and meet 20 research project objectives in a comprehensive evaluation of ongoing progress with IPL and IPP.DiscussionIPP and IPL are said to be cornerstones of health system reforms. We will measure progress across an entire health system and the clinical and professional education systems that feed into it. The value of multi-methods, partnership research and a bi-directional push-pull model of IPL and IPP will be tested. Widespread dissemination of results to practitioners, policymakers, managers and researchers will be a key project goal.

High performing hospitals: a qualitative systematic review of associated factors and practical strategies for improvement

BackgroundHigh performing hospitals attain excellence across multiple measures of performance and multiple departments. Studying high performing hospitals can be valuable if factors associated with high performance can be identified and applied. Factors leading to high performance are complex and an exclusive quantitative approach may fail to identify richly descriptive or relevant contextual factors. The objective of this study was to undertake a systematic review of qualitative literature to identify methods used to identify high performing hospitals, the factors associated with high performers, and practical strategies for improvement.MethodsMethods used to collect and summarise the evidence contributing to this review followed the ‘enhancing transparency in reporting the synthesis of qualitative research’ protocol. Peer reviewed studies were identified through Medline, Embase and Cinahl (Jan 2000-Feb 2014) using specified key words, subject terms, and medical subject headings. Eligible studies required the use of a quantitative method to identify high performing hospitals, and qualitative methods or tools to identify factors associated with high performing hospitals or hospital departments. Title, abstract, and full text screening was undertaken by four reviewers, and inter-rater reliability statistics were calculated for each review phase. Risk of bias was assessed. Following data extraction, thematic syntheses identified contextual factors important for explaining success. Practical strategies for achieving high performance were then mapped against the identified themes.ResultsA total of 19 studies from a possible 11,428 were included in the review. A range of process, output, outcome and other indicators were used to identify high performing hospitals. Seven themes representing factors associated with high performance (and 25 sub-themes) emerged from the thematic syntheses: positive organisational culture, senior management support, effective performance monitoring, building and maintaining a proficient workforce, effective leaders across the organisation, expertise-driven practice, and interdisciplinary teamwork. Fifty six practical strategies for achieving high performance were catalogued.ConclusionsThis review provides insights into methods used to identify high performing hospitals, and yields ideas about the factors important for success. It highlights the need to advance approaches for understanding what constitutes high performance and how to harness factors associated with high performance.

Do large-scale hospital- and system-wide interventions improve patient outcomes: a systematic review

BackgroundWhile health care services are beginning to implement system-wide patient safety interventions, evidence on the efficacy of these interventions is sparse. We know that uptake can be variable, but we do not know the factors that affect uptake or how the interventions establish change and, in particular, whether they influence patient outcomes. We conducted a systematic review to identify how organisational and cultural factors mediate or are mediated by hospital-wide interventions, and to assess the effects of those factors on patient outcomes.MethodsA systematic review was conducted and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Database searches were conducted using MEDLINE from 1946, CINAHL from 1991, EMBASE from 1947, Web of Science from 1934, PsycINFO from 1967, and Global Health from 1910 to September 2012. The Lancet, JAMA, BMJ, BMJ Quality and Safety, The New England Journal of Medicine and Implementation Science were also hand searched for relevant studies published over the last 5xa0years. Eligible studies were required to focus on organisational determinants of hospital- and system-wide interventions, and to provide patient outcome data before and after implementation of the intervention. Empirical, peer-reviewed studies reporting randomised and non-randomised controlled trials, observational, and controlled before and after studies were included in the review.ResultsSix studies met the inclusion criteria. Improved outcomes were observed for studies where outcomes were measured at least two years after the intervention. Associations between organisational factors, intervention success and patient outcomes were undetermined: organisational culture and patient outcomes were rarely measured together, and measures for culture and outcome were not standardised.ConclusionsCommon findings show the difficulty of introducing large-scale interventions, and that effective leadership and clinical champions, adequate financial and educational resources, and dedicated promotional activities appear to be common factors in successful system-wide change.The protocol has been registered in the international prospective register of systematic reviews, PROSPERO (Registration No. CRD42103003050).

Scoping Meta‐Review: Introducing a New Methodology

For researchers, policymakers, and practitioners facing a new field, undertaking a systematic review can typically present a challenge due to the enormous number of relevant papers. A scoping review is a method suggested for addressing this dilemma; however, scoping reviews present their own challenges. This paper introduces the “scoping meta‐review” (SMR) for expanding current methodologies and is based on our experiences in mapping the field of consumer engagement in healthcare. During this process, we developed the novel SMR method. An SMR combines aspects of a scoping review and a meta‐review to establish an evidence‐based map of a field. Similar to a scoping review, an SMR offers a practical and flexible methodology. However, unlike in a traditional scoping review, only systematic reviews are included. Stages of the SMR include: undertaking a preliminary nonsystematic review; building a search strategy; interrogating academic literature databases; classifying and excluding studies based on titles and abstracts; saving the refined database of references; revising the search strategy; selecting and reviewing the full text papers; and thematically analyzing the selected texts and writing the report. The main benefit of an SMR is to map a new field based on high‐level evidence provided by systematic reviews.

Classroom and simulation team training: a randomized controlled trial

OBJECTIVEnTo test the hypotheses that classroom and simulation-based crew resource management (CRM) training interventions improve teamwork attitudes and behaviours of participants and that classroom training combined with simulation-based training provide synergistic improvements.nnnDESIGNnA randomized controlled trial.nnnSETTINGnArea Health Service in New South Wales, Australia.nnnPARTICIPANTSnA total of 157 doctors, nurses and midwives randomized into one of four groups, consisting of three intervention groups and a control group.nnnINTERVENTIONnOne-day CRM-based classroom course; one-day CRM style simulation-based training or classroom training followed by simulation-based training.nnnMAIN OUTCOME MEASURESnPre- and post-test quantitative participant teamwork attitudes, and post-test quantitative trainee reactions, knowledge and behaviour.nnnRESULTSnNinety-four doctors, nurses and midwives completed pre-intervention attitude questionnaires and 60 clinicians completed post-intervention assessments. No positive changes in teamwork attitudes were found associated with classroom or simulation training. Positive changes were found in knowledge (mean difference 1.50, 95% confidence interval (CI) 0.58-2.43, P = 0.002), self-assessed teamwork behaviour (mean difference 2.69, 95% CI 0.90-6.13, P = 0.009) and independently observed teamwork behaviour (mean difference 2.30, 95% CI 0.30-4.30, P = 0.027) when classroom-only trained group was compared with control; however, these changes were not found in the group that received classroom followed by simulation training.nnnCONCLUSIONSnClassroom-based training alone resulted in improvements in participant knowledge and observed teamwork behaviour. The study found no additional impact of simulation training.

The struggle of translating science into action: Foundational concepts of implementation science

Abstract Rationale, aims, and objectives “Implementation science,” the scientific study of methods translating research findings into practical, useful outcomes, is contested and complex, with unpredictable use of results from routine clinical practice and different levels of continuing assessment of implementable interventions. The authors aim to reveal how implementation science is presented and understood in health services research contexts and clarify the foundational concepts: diffusion, dissemination, implementation, adoption, and sustainability, to progress knowledge in the field. Method Implementation science models, theories, and frameworks are critiqued, and their value for laying the groundwork from which to implement a studys findings is emphasised. The paper highlights the challenges of turning research findings into practical outcomes that can be successfully implemented and the need for support from change agents, to ensure improvements to health care provision, health systems, and policy. The paper examines how researchers create implementation plans and what needs to be considered for study outputs to lead to sustainable interventions. This aspect needs clear planning, underpinned by appropriate theoretical paradigms that rigorously respond to a studys aims and objectives. Conclusion Researchers might benefit from a return to first principles in implementation science, whereby applications that result from research endeavours are both effective and readily disseminated and where interventions can be supported by appropriate health care personnel. These should be people specifically identified to promote change in service organisation, delivery, and policy that can be systematically evaluated over time, to ensure high‐quality, long‐term improvements to patients health.