Sue Dopson

No Magic Targets! Changing Clinical Practice to Become More Evidence Based.

This article focuses on the diffusion and adoption of innovations in clinical practice. The authors are specifically interested in underresearched questions concerning the latter stages of the creation, diffusion, and adoption of new knowledge, namely: What makes this information credible and therefore utilized? Why do actors decide to use new knowledge? And what is the significance of the social context of which actors are a part? This article first appeared in Health Care Management Review, 27(3), 35-47.

Understanding the role of opinion leaders in improving clinical effectiveness.

We present findings from evaluations of two government-funded initiatives exploring the transfer of research evidence into clinical practice--the PACE Programme (Promoting Action on Clinical Effectiveness), and the Welsh Clinical Effectiveness Initiative National Demonstration Projects. We situate the findings within the context of available research evidence from healthcare and other settings on the role of opinion leaders or product champions in innovation and change--evidence which leaves a number of problems and unanswered questions. A major concern is the difficulty of achieving a single replicable description of what opinion leaders are and what they do--subjective understandings of their role differ from one setting to another, and we identify a range of very different types of opinion leadership. What makes someone a credible and influential authority is derived not just from their own personality and skills and the dynamic of their relationship with other individuals, but also from other context-specific factors. We examine the question of expert versus peer opinion leaders, and the potential for these different categories to be more or less influential at different stages in the innovation process. An often neglected area is the impact of opinion leaders who are ambivalent or hostile to an innovation. Finally, we note that the interaction between individual opinion leaders and the collective process of negotiating a change and reorienting professional norms remains poorly understood. This raises a number of methodological concerns which need to be considered in further research in this area.

Muddle in the Middle: Organizational Restructuring and Middle Management Careers

Considers the extent to which one organization through rationalization and redundancy programmes has violated its psychological contracts with its middle manager employees by removing the prospect of a traditional career. Offers a review of the issues raised in the literature on careers and the psychological contract and a case study of the impact of change on individual middle managers. Describes the empirical work carried out in British Telecom on which the article is based. Concludes that both the nature of middle management jobs and the career opportunities available have changed considerably, resulting in breaches of the psychological contract. However, individual managers have reacted differently to the changes, depending on their ability and willingness to pursue informal networks and personal contacts.

Implementation of evidence-based medicine: evaluation of the Promoting Action on Clinical Effectiveness programme

Objectives: To evaluate the Promoting Action on Clinical Effectiveness (PACE) programme, which sought to implement clinically effective practice in 16 local sites. Methods: 182 semi-structured interviews, usually by telephone, with project team members, clinicians, and senior managers and representatives from the Department of Health and the Kings Fund. Results: The most influential factors were strong evidence, supportive opinion leaders and integration within a committed organization; without these factors, projects had little chance of success. Other factors (context analysis, professional involvement and good project management) emerged as important, supporting processes; their presence might be an additional help, but on their own they would not be enough to initiate change. A serious problem with any of them could have a strong adverse impact. Conclusions: Although there is no simple formula for the factors that ensure successful implementation of research-based improvements to clinical practice, certain principles do seem to help. Time and resource need to be devoted to a period of local negotiation and adaptation of good research evidence based on a careful understanding of the local context, in which opinion leader influence is an important component of a well managed and preferably well integrated process of change.

When Policy meets Practice: Colliding Logics and the Challenges of ‘Mode 2’ Initiatives in the Translation of Academic Knowledge

Institutional change has been characterized as the outcome of a dialectical process whereby different constituent communities within an organizational field promote competing institutional logics (Seo and Creed 2002). However, the dynamics of this dialectical process are poorly understood. In this paper, we examine this dialectical process by drawing upon a longitudinal study of a policy intervention in the UK aimed at promoting a logic of knowledge production in genetics science (termed here as ‘Mode 2’; cf. Nowotny et al. 2001) that was co-present, and competing, with the dominant logic surrounding the production of academic science (‘Mode 1’). We highlight the tensions and interplays that occurred between these competing institutional logics by examining the rhetoric that was propounded, and the actions incurred, and their effects, amongst constituent communities of policy makers and scientists. Our findings demonstrate, first, that tensions can exist within as well as across constituent communities within the organizational field; and, second, how mobilizing a new institutional logic related to knowledge production may produce its own contradictions that can, paradoxically, lead to the simultaneous resurrection (and reinforcement) of the old logic. We discuss the implications for managing projects where these different logics are co-mingled.

The role of the middle manager in the implementation of evidence‐based health care

The present study reflects on the role of the middle manager in the implementation of what has become known as evidence-based health care. This movement advocates that clinical practice is continually informed by the results of robust research and evidence. In our work exploring the complexity of ensuring that practice is informed by evidence we have found that general managers have relatively little influence when compared with clinicians especially doctors. We argue that local professional groups work together in communities of practice, which are frequently uniprofessional. These boundaries affect the motivations for seeking improvement and upgrading and the way evidence and knowledge is perceived and interpreted. We argue that if the quality of health care is to be improved, we need to understand the complex historically and contextually informed interactions between different professional groups and to design diffusion strategies that acknowledge this complexity.

The role of hospital managers in quality and patient safety: a systematic review

Objectives To review the empirical literature to identify the activities, time spent and engagement of hospital managers in quality of care. Design A systematic review of the literature. Methods A search was carried out on the databases MEDLINE, PSYCHINFO, EMBASE, HMIC. The search strategy covered three facets: management, quality of care and the hospital setting comprising medical subject headings and key terms. Reviewers screened 15 447 titles/abstracts and 423 full texts were checked against inclusion criteria. Data extraction and quality assessment were performed on 19 included articles. Results The majority of studies were set in the USA and investigated Board/senior level management. The most common research designs were interviews and surveys on the perceptions of managerial quality and safety practices. Managerial activities comprised strategy, culture and data-centred activities, such as driving improvement culture and promotion of quality, strategy/goal setting and providing feedback. Significant positive associations with quality included compensation attached to quality, using quality improvement measures and having a Board quality committee. However, there is an inconsistency and inadequate employment of these conditions and actions across the sample hospitals. Conclusions There is some evidence that managers’ time spent and work can influence quality and safety clinical outcomes, processes and performance. However, there is a dearth of empirical studies, further weakened by a lack of objective outcome measures and little examination of actual actions undertaken. We present a model to summarise the conditions and activities that affect quality performance.

The Diffusion of Medical Innovations: Can Figurational Sociology Contribute?

This article seeks to present and explore the relevance of a figurational, or process sociological approach, as developed by Norbert Elias, to the investigation of innovation and change. It is argued that Elias’s work offers a theoretically robust framework for exploring such issues. Applications of the principles of his work, in particular the emphasis on an understanding of longer-term unplanned processes, are a potential help to those charged with planning and managing complex change, such as the introduction of innovation. The example of health policy-makers’ attempts to use the principles of evidence-based medicine (EBM) to change clinical practice is used to explore these claims.

Understanding Change and Innovation in Healthcare Settings: Reconceptualizing the Active Role of Context

This article discusses the ways in which ‘context’ has been formulated and explored in healthcare settings. We contend that context is an important, but poorly understood mediator of change and innovation and that there is a dearth of empirical work in healthcare studies that adequately deals with context. Drawing on extensive empirical data exploring the career of ‘evidence based’ healthcare innovations, we illustrate that context should not be seen as a backcloth to action but as an interacting element in the change process.

The Changing Role of the Middle Manager in the United Kingdom

The article examines the changing role of the middle manager in Great Britain, including the changes affecting middle managers and of their reactions to the changes. Middle managers were defined very broadly in the six-country study to include all those below the small group of top strategic managers and above first-level supervision. The British legal tradition, which relies heavily on precedent, has no legal definition of management, let alone lower and middle management, that satisfactorily describes their status and responsibilities. The absence of a definition of what constitutes management in the country has in part, led to blurred management categories. Despite the many drawbacks of definition and on the assumption that a middle-management category can only logically exist in larger organizations, quantitative data are available from the 1981 official census figures concerning managers in central and local government, industry and commerce, who generally plan and supervise in non-agricultural enterprises employing 25 persons or over. Approximately 82 percent of the managers in large establishments at the time of the census were male, and approximately 18 percent were female, with females being more concentrated at the junior and lower-middle levels.