How to Read a Paper: The Basics of Evidence-Based Medicine (43 page)

Another paper that's worth looking up is Gustafson's [37] quasi-systematic review of the determinants of successful change projects in health care organisations. The 18 items in Gustafson's final model include:

• tension for change (staff feel that current practice is sub-optimal and want things to be different);
  
• balance of power (staff supporting the change outnumber, and are more strategically placed in the organisation, than staff opposing it);
  
• perceived advantages (everyone understands the change and believes its advantages outweigh the disadvantages);
  
• flexibility (the new practice can be adapted to fit local needs and ways of working);
  
• time and resources (the change is adequately funded and people have protected time to work on it).
  

If this sounds like a recipe your organisation can't follow in relation to EBM, read the next section (and if that doesn't help, consider changing jobs!).

For those with an appetite for ‘hard core’ management and organisation studies papers, I recommend Ferlie's [38] team's recent summary of the literature on such topics as knowledge as a resource in organisations (known in the jargon as the ‘resource-based view of the firm’) and critical management studies (a field of research that asks questions such as ‘who holds the power in this organisation?’ and ‘whose interests does this change serve?’), applied to the question of whether and how quickly organisations adopt evidence-based practices and policies. Their findings are diverse, hence difficult to summarise, but it is clear that the EBM community has much to learn from our colleagues in management disciplines.

How can we help organisations develop the appropriate structures, systems and values to support evidence-based practice?

Whilst there is a wealth of evidence on the sort of organisation that supports evidence-based practice, there is much less evidence on the effectiveness of specific interventions to
change
an organisation to make it more ‘evidence based’—and it is beyond the scope of this book to address this topic comprehensively. Much of the literature on organisational change is in the form of practical checklists or the ‘ten tips for success’ type format. Checklists and tips can be enormously useful, but such lists tend to leave me hungry for some coherent conceptual models on which to hang my own real-life experiences.

The management literature offers not one but several dozen different conceptual frameworks for looking at change—leaving the non-expert confused about where to start. It was my attempt to make sense of this multiplicity of theories that led me to write a series of six articles published a few years ago in the
British Journal of General Practice
entitled ‘Theories of change’. In these articles, I explored six different models of professional and organisational change in relation to effective clinical practice [39–44]:

1.
Adult learning theory
: the notion that adults learn via a cycle of thinking and doing explains why instructional education is so consistently ineffective, and why hands-on practical experience with the opportunity to reflect and discuss with colleagues is the fundamental basis for both learning and change.

2.
Psychoanalytic theory
: Freud's famous concept of the unconscious, which influences (and sometimes overrides) our conscious, rational self. People's resistance to change can sometimes have powerful and deep-rooted emotional explanations.

3.
Group relations theory
: based on studies by specialists at London's Tavistock clinic on how teams operate (or fail to operate) in the work environment. Relationships both within the team and between the team and its wider environment can act as barriers to (or catalysts of) change.

4.
Anthropological theory
: the notion that organisations have cultures—that is, ways of doing things and of thinking about problems—that are, in general, highly resistant to change. A relatively minor proposed change towards evidence-based practice (such as requiring consultants to look up evidence routinely on the Cochrane database) may in reality be highly threatening to the culture of the organisation (in which, for example, the ‘consultant opinion’ has traditionally carried an almost priestly status).

5.
Classical management theory
: the notion that ‘mainstreaming’ a change within an organisation requires a systematic plan to make it happen. The vision for change must be shared amongst a critical mass of staff, and must be accompanied by planned changes to the visible structures of the organisation, to the roles and responsibilities of key individuals, and to information and communication systems.

6.
Complexity theory
: the notion that large organisations (such as the UK National Health Service) depend critically on the dynamic, evolving, and local relationships and communication systems between individuals. Supporting key interpersonal relationships, and improving the quality and timeliness of information available locally are often more crucial factors in achieving sustained change than ‘top-down’ directives or overarching national or regional programmes.

There are, as I have said, many additional models of change that might come in useful when identifying and overcoming barriers to achieving evidence-based practice. The above-mentioned list is not intended to be exhaustive—and given the complex nature of health care organisations, none of them will provide a simple formula for successful change.

I would certainly add a seventh theoretical model to the list—that of change as a
social movement
—that is, as a powerful groundswell of activity that is bound up with individuals' identity as part of the movement for change [45]. If you've ever been on a protest march, or joined a residents' initiative to improve some local service or other, you'll know what it feels like to be part of a social movement. I was once on a high-level committee that tried to close the little-used casualty department of a small hospital on the grounds that there was no evidence that it was either effective or cost-effective—but I bargained without the input of the ‘Hands Off Our Hospital’ campaign. Indeed, many successful changes in clinical practice towards evidence-based care (e.g. the abolition of routine episiotomy in obstetric care) were achieved primarily through patient pressure groups operating in ‘social movement’ mode.

The interesting thing about social movements for change is that as Bate and colleagues [45] emphasise, while they can achieve profound and widespread change, they cannot be planned, controlled or their behaviour predicted in the same way as a conventional management model. You might also like to check out Pope's [46] sociological analysis of the rise of EBM as a social movement!

Whatever theoretical approach you take to change, converting your theories into practice will be a tough challenge. A publication by the UK National Association of Health Authorities and Trusts (NAHAT), entitled ‘Acting on the Evidence’, emphasises that the task of supporting and empowering managers and clinical professionals to use evidence as part of their everyday decision making is massive and complex [47]. An action checklist for health care organisations working towards an evidence-based culture for clinical and policymaking decisions, listed at the end of Appendix 1, is adapted from the NAHAT report.

First and foremost, key players within the organisation, particularly chief executives, board members and senior clinicians, must create an evidence-based culture where decision-making is
expected
to be based on the best available evidence. High-quality, up-to-date information sources (such as the Cochrane electronic library and the Medline database) should be available in every office, and staff given protected time to access them. Ideally, users should only have to deal with a single access point for all available sources. Information on the clinical and cost-effectiveness of particular technologies should be produced, disseminated and used together. Individuals who collate and disseminate this information within the organisation need to be aware of who will use it and how it will be applied—and tailor their presentation accordingly. They should also set standards for, and evaluate, the quality of the evidence they are circulating. Individuals on the organisation's internal mailing list for effectiveness information need training and support if they are to make the best use of this information.

This sound advice from NAHAT is based (implicitly if not explicitly) on the notion of the
learning organisation
. As Davies and Nutley [48] have pointed out, ‘Learning is something achieved by individuals, but “learning organisations” can configure themselves to maximise, mobilise, and retain this learning potential’. Drawing on the work of Senge [49], they offer five key features of a learning organisation.

1.
People are encouraged to move beyond traditional, professional or departmental boundaries (an approach Senge called ‘open systems thinking’).

2.
Individuals' personal learning needs are systematically identified and addressed.

3.
Learning occurs to some extent in teams, because it is largely through teams that organisations achieve their objectives.

4.
Efforts are made to change the way people conceptualise issues—thus allowing new, creative approaches to old problems.

5.
Senior clinicians and managers provide leadership to drive through a shared vision with coherent values and clear strategic direction, so that staff willingly pull together towards a common goal.

Turning a traditional organisation into a learning organisation is a tough task, which often involves a major shift in organisational culture (the unwritten rules, assumptions and expectations that make up ‘how things are done around here’). Whilst it's not possible for any single individual to turn an organisation around, if you're sufficiently senior to write the job description of a new member of staff, or to decide how a training budget is spent, or to choose who is involved in a key decision, you can start to move your organisation in the right direction (
Table 15.2
).

Table 15.2
Key differences between a traditional organisation and a learning organisation

Source: Senge [49]. Reproduced with permission of Emerald Group Publishing Limited.

A core principle in developing a learning organisation is
invest in people
. In addition to strong leadership form the top, there are some particular roles that you might think of supporting in relation to EBM [25].

1.
Knowledge managers
: These are senior people hired not just to get the information systems right but to encourage the rest of us to use them. They make the decisions about what software licences to purchase for the organisation and which members of staff are allowed to access which knowledge sources. When I wrote the first edition of this book in 1995, a minority of hospitals had a rule that staff nurses couldn't go into the medical library or dial up an Internet connection. The role of the knowledge manager is to blow this sort of nonsense away and ensure that (in the case of EBM) everyone who needs to practice it has links to the relevant knowledge base, protected time to access it and appropriate training.

2.
Knowledge workers
: These individuals have it on their job description to help the rest of us find and apply knowledge. The person on the computer helpdesk is a kind of knowledge worker, as is a librarian or a research assistant. To use some contemporary jargon, the tools of EBM should be offered as an ‘augmented product’ with designated members of staff hired to provide flexible support to individuals as and when they ask for it.

3.
Champions
: Adoption of a new practice by individuals in an organisation or professional group is more likely if key individuals within that group are willing to back the innovation. ‘Backing’ an evidence-based innovation might include, for example, talking enthusiastically about it, showing people how to use it, getting it on the agenda of key committees, giving staff protected time to learn about it and try it out, and rewarding people who take it up. Whilst there's remarkably little research evidence about what champions actually do (or what's the most effective way of championing an evidence-based change), the principle is pretty simple: designate particular individuals at every level in your organisation to back it.