Evidence-informed Improvement Research Articles

“I would have to walk around to find the best Wi-Fi connection…”: qualitatively exploring challenges associated with rapid rollout of telehealth in Canadian long-term care homes

BackgroundEarly in the COVID-19 pandemic, long-term care (LTC) homes in British Columbia, Canada, restricted visitation to ensure the safety of their residents against transmission of the novel coronavirus. As such, these LTC homes had to quickly implement a rapid rollout of telehealth services to maintain physician care for residents while avoiding the infection risk of in-person visits amidst lockdown measures. The abrupt transition from traditional in-person physician care to telehealth presented significant challenges. Investigating these challenges is pivotal to the development of strategies for sustained telehealth use for physician services in LTC homes. This analysis is part of a broader qualitative, utilization-focused evaluation study of telehealth services rapidly implemented for physician care in LTC homes within the Fraser Health Authority region of British Columbia. The evaluation has aimed to consider integral factors such as telehealth challenges, facilitators, preferences, and continued use. Semi-structured interviews and focus groups were conducted with 70 physicians, staff, residents, and family caregivers across 27 different LTC homes in the region. All interviews and focus groups were transcribed verbatim and were analyzed using a thematic approach to identify common barriers surrounding the rapid rollout of telehealth in LTC across relevant groups.ResultsFrom the data, four challenges were identified: connectivity challenges (e.g., inconsistent or no Wi-Fi or cellular connectivity), device challenges (e.g., lack of accessible devices and software issues), privacy challenges (e.g., lack of private space to support telehealth use), and informational challenges (e.g., lack of electronic medical record access). All challenges posed barriers to telehealth access for both care provider and recipient groups in LTC settings.ConclusionsThe challenges identified in this analysis are supported by existing literature, which is significant given the different contexts within which such research has been undertaken. Collectively, this knowledge base can support evidence-informed improvements to telehealth for physician care in LTC settings. Future research should capture the perspectives of diverse cultural groups, LTC residents with cognitive impairments, and those who provide and receive care in rural settings.

The Use of Research in Schools: Principals’ Capacity and Contributions

Policy expectations for the role of research evidence in educational decision-making have grown exponentially in the U.S. and globally, yet there has been limited attention to school capacity to engage in evidence-informed improvement. In this paper, I address this gap by first conceptualizing principal leadership for evidence use and, second, use this conceptual lens to examine large-scale survey data about school evidence use practices and capacity. Drawing on data from a national survey of more than 4000 educators in 134 schools in the US, I explore school practices and capacity to use research and surface opportunities and needs for principal leadership in evidence-informed improvement. Findings suggest that there is an opportunity to improve the role of research in school improvement decision-making, and that principals may contribute to school capacity in specific ways that relate to developing human capital, influencing culture, leveraging resources, and shaping decision-making. Data reveal moderate evidence of research use in agenda setting and of organizational routines that support research use, but lack of uptake of those routines for research use as well as limited investment in resources (e.g., time). Further, decision-making was distributed across a wide range of improvement initiatives, with evidence of a lack of clarity about goals. Although principals report confidence and experience with using research, overall school staff also reported limited experience with prior research, including coursework or participation in research, and low confidence in critically consuming research. Implications point to the need to strengthen principals’ own evidence use capacity as well as focus on dimensions school capacity as part of evidence use initiatives. Recommendations suggest strategies for developing principals’ knowledge and skills around leadership for evidence-informed improvement.

An Application of the Social-ecological Systems Framework to Promoting Evidence-informed Policy and Practice

ABSTRACT Education policy continues to press for increased use of research evidence in decision-making, yet decades of research point to weak links between research and practice. We see evidence-informed improvement not as a problem with schools, but with a larger evidence-use ecosystem. As a step toward building and strengthening multidirectional paths between research, practice, and policy, we explore three overlapping research contexts: production, practice, and mediation. Despite the importance of each of these contexts in evidence-infor5med policy and practice, they are rarely considered together. In this paper, we seek to understand the social-ecological systems in which these contexts are situated and to identify problematic disconnects and promising similarities. This study draws on case studies of research production in institutions of higher education, knowledge mobilization by an intermediary organization, and school-based decision-making. We use Elinor Ostrom’s Social-ecological Systems Framework as a lens on each case, attending to resource systems, resource units, governance systems, actors, and the interactions that coordinate and align those systems to achieve positive outcomes. We then look across cases to identify barriers and opportunities to restructure and reorganize the evidence-use ecosystem in order to redesign and strengthen research-practice infrastructure and more effectively promote evidence-informed policy and practice.

Contextual factors and mechanisms that influence sustainability: a realist evaluation of two scaled, multi-component interventions

BackgroundIn 2012, Alberta Health Services created Strategic Clinical NetworksTM (SCNs) to develop and implement evidence-informed, clinician-led and team-delivered health system improvement in Alberta, Canada. SCNs have had several provincial successes in improving health outcomes. Little research has been done on the sustainability of these evidence-based implementation efforts.MethodsWe conducted a qualitative realist evaluation using a case study approach to identify and explain the contextual factors and mechanisms perceived to influence the sustainability of two provincial SCN evidence-based interventions, a delirium intervention for Critical Care and an Appropriate Use of Antipsychotics (AUA) intervention for Senior’s Health. The context (C) + mechanism (M) = outcome (O) configurations (CMOcs) heuristic guided our research.ResultsWe conducted thirty realist interviews in two cases and found four important strategies that facilitated sustainability: Learning collaboratives, audit & feedback, the informal leadership role, and patient stories. These strategies triggered certain mechanisms such as sense-making, understanding value and impact of the intervention, empowerment, and motivation that increased the likelihood of sustainability. For example, informal leaders were often hands-on and influential to front-line staff. Learning collaboratives broke down professional and organizational silos and encouraged collective sharing and learning, motivating participants to continue with the intervention. Continual audit-feedback interventions motivated participants to want to perform and improve on a long-term basis, increasing the likelihood of sustainability of the two multi-component interventions. Patient stories demonstrated the interventions’ impact on patient outcomes, motivating staff to want to continue doing the intervention, and increasing the likelihood of its sustainability.ConclusionsThis research contributes to the field of implementation science, providing evidence on key strategies for sustainability and the underlying causal mechanisms of these strategies that increases the likelihood of sustainability. Identifying causal mechanisms provides evidence on the processes by which implementation strategies operate and lead to sustainability. Future work is needed to evaluate the impact of informal leadership, learning collaboratives, audit-feedback, and patient stories as strategies for sustainability, to generate better guidance on planning sustainable improvements with long term impact.

The Seniors Quality Leap Initiative (SQLI): An International Collaborative to Improve Quality in Long-Term Care

ObjectivesTo describe an innovative Canadian and US community of practice that employs empirical evidence based on risk-adjusted indicators to guide collaborative initiatives to improve the quality of care in nursing homes. DesignOngoing study of quality of care related to pain management in nursing home residents using clinical assessment records. Settingand Participants: Nursing home residents in 14 organizations in Canada and the United States between 2014 and 2017. The most recent analytic samples for quality indicator calculation involve 11,123 unique residents in 68 homes associated with 12 different long-term care organizations. MeasuresAssessment data on pain and associated risk adjusters were obtained from the RAI/MDS 2.0 and MDS 3.0 assessments in Canadian and US nursing homes, respectively. ResultsThe Seniors Quality Leap Initiative has been functioning as an active community of practice for almost a decade with the aim of demonstrating leadership in the use of collaborative approaches to drive evidence-informed improvements in the quality of long-term care. Initiatives with a specific emphasis on improving care related to pain resulted in notable improvements in quality of clinical care in specific homes as well as within the network as a whole. Conclusions and ImplicationsThe Seniors Quality Leap Initiative demonstrates that a partnership between organizations in 2 countries can foment quality transitions through a shared commitment to identifying needs; employing flexible, but practical initiatives; and evaluating the impact of those initiatives through a transparent reporting mechanism.

Beyond Performance Indicators: Reforming Higher Education Evaluation Systems to Promote Improvement

As higher education attainment has become increasingly essential for both individual socioeconomic outcomes and the economic competitiveness of nation-states, and as the cost of financing the higher education enterprise continues to rise, university quality has become an urgent concern for students, families, and policy makers around the globe. The widespread interest in assessing university quality manifests itself in the rise of global rankings (Hazelkorn, 2015) and the increasing use of so-called performance indicators by government agencies. This paper focuses on the latter phenomenon. The first part of the paper examines the benefits and limitations of higher education performance indicators as conventionally implemented, and the second part advances a set of suggestions to address these shortcomings by adapting performance systems to represent and incentivize evidence-informed improvement efforts.

"Part of the Team": Mapping the outcomes of training patients for new roles in health research and planning.

BackgroundA patient research internship (Patient and Community Engagement Research program—PaCER) was created to support a provincial commitment by Alberta Health Services’ Strategic Clinical Networks™ to find new ways to engage patients in a new interdisciplinary organization to support evidence‐informed improvements in clinical outcomes across the health system.ObjectiveImplement and test a new research method and training curriculum to build patient capacity for engagement in health through peer‐to‐peer research.DesignProgramme evaluation using Outcome Mapping and the grounded theory method.Setting and ParticipantsTwenty‐one patients with various chronic conditions completed one year of training in adapted qualitative research methods, including an internship where they designed and conducted five peer‐to‐peer inquiries into a range of health experiences.Main Outcome MeasuresOutcomes were continually monitored and evaluated using an Outcome Mapping framework, in combination with grounded theory analysis, based on data from focus groups, observation, documentation review and semi‐structured interviews (21 patient researchers, 15 professional collaborators).ResultsKey stakeholders indicated the increased capacity of patients to engage in health‐care research and planning, and the introduction and acceptance of new, collaborative roles for patients in health research. The uptake of new patient roles in health‐care planning began to impact attitudes and practices.ConclusionsPatient researchers become “part of the team” through cultural and relationship changes that occur in two convergent directions: (i) building the capacity of patients to engage confidently in a dialogue with clinicians and decision makers, and (ii) increasing the readiness for patient engagement uptake within targeted organizations.

Evidence-informed innovation in schools: aligning collaborative research and development with high quality professional learning for teachers

Innovation efforts in schools commonly wrestle with two challenges: how to secure ownership of change among teachers and how to ensure that improvements are based on evidence. This paper draws on findings from a two-year collaborative research and development (R&D) project in England which involved 66 school clusters (teaching school alliances (TSAs)) in implementing and evaluating school-based innovations and a separate umbrella review of evidence on effective continuous professional development and learning (CPDL) for teachers. We find that collaborative R&D can enhance the ownership of change among participating teachers and ensure that innovations are based on evidence. We define a framework for integrating R&D and CPDL which could enable evidence-informed improvement to be scaled up, impacting on all staff. Drawing on Winch et al.'s (2015) model of teachers' professional knowledge we argue that the proposed framework could enhance the potential for teaching to be accepted as an "evidence-informed professional endeavour".

Developing an Organizational Model for Improvement: From Translation to Practice.

This department column highlights translation of research into healthcare quality practice. Achieving the highest quality in healthcare is a goal that requires focused attention and accountability. Standardization in practice through translation and application of evidence-informed practice promotes excellence in outcomes. To meet the goal of achieving the highest quality of care through evidence-informed translation and application in practice, organizations should outline a plan for developing, organizing, implementing, and evaluating evidence-informed improvement interventions. The purpose of this article is to provide an example for developing an organizational model for improvement from concept to application.

The need for operational research and capacity-building in support of the Global Technical Strategy for Malaria 2016-2030.

The need for operational research and capacity-building in support of the Global Technical Strategy for Malaria 2016-2030.

A Model of Successful School Leadership from the International Successful School Principalship Project

The International Successful School Principalship Project (ISSPP) has been actively conducting research about the work of successful principals since 2001. Findings from four project books and eight models derived from this project are synthesised into a model of successful school leadership. Building on Gurr, Drysdale and Mulford’s earlier model, the work of school leaders is described as engaging within the school context to influence student and school outcomes through interventions in teaching and learning, school capacity building, and the wider context. The qualities a leader brings to their role, a portfolio approach to using leadership ideas, constructing networks, collaborations and partnerships, and utilising accountability and evaluation for evidence-informed improvement, are important additional elements. The model is applicable to all in leadership roles in schools.

Combined Clinical and Home Rehabilitation: Case Report of an Integrated Knowledge-to-Action Study in a Dutch Rehabilitation Stroke Unit

There is growing awareness that the poor uptake of evidence in health care is not a knowledge-transfer problem but rather one of knowledge production. This issue calls for re-examination of the evidence produced and assumptions that underpin existing knowledge-to-action (KTA) activities. Accordingly, it has been advocated that KTA studies should treat research knowledge and local practical knowledge with analytical impartiality. The purpose of this case report is to illustrate the complexities in an evidence-informed improvement process of organized stroke care in a local rehabilitation setting. A participatory action approach was used to co-create knowledge and engage local therapists in a 2-way knowledge translation and multidirectional learning process. Evidence regarding rehabilitation stroke units was applied in a straightforward manner, as the setting met the criteria articulated in stroke unit reviews. Evidence on early supported discharge (ESD) could not be directly applied because of differences in target group and implementation environment between the local and reviewed settings. Early supported discharge was tailored to the needs of patients severely affected by stroke admitted to the local rehabilitation stroke unit by combining clinical and home rehabilitation (CCHR). Local therapists welcomed CCHR because it helped them make their task-specific training truly context specific. Key barriers to implementation were travel time, logistical problems, partitioning walls between financing streams, and legislative procedures. Improving local settings with available evidence is not a straightforward application process but rather a matter of searching, logical reasoning, and creatively working with heterogeneous knowledge sources in partnership with different stakeholders. Multiple organizational levels need to be addressed rather than focusing on therapists as sole site of change.

Incorporating self-management in prosthetic rehabilitation: case report of an integrated knowledge-to-action process.

In improvement of clinical practice, unidirectional approaches of translating evidence into clinical practice have been pinpointed as main obstacles. The concept of engaged scholarship has been introduced to guide knowledge-to-action (KTA) processes, in which research knowledge and practical knowledge derived from therapists, patients, and organizational structures mutually inform each other. Accordingly, KTA experts should engage end-users earlier in knowledge translation and work in concert with them on both knowledge creation and knowledge implementation. The purposes of this case report are: (1) to provide an illustrative example of an evidence-informed improvement process in prosthetic rehabilitation in a local setting and (2) to articulate the bidirectional translation work incorporated into an integrated KTA process. A KTA expert translated research knowledge on self-management and task- and context-specific training into a functional prosthetic training program for patients with a lower limb amputation. Therapists contributed as co-creators to the translation process with practical knowledge of the specificities of the target group and local organizational context. The KTA expert moved the co-created knowledge into action in iterative and interactive steps with local therapists, patients, and managers. This bidirectional KTA translation process led to shared ownership of the functional prosthetic training program, in which self-management and task- and context-specific training principles and practices were integrated. Bidirectional knowledge translation builds on explicating and integrating the different knowledge practices of researchers, therapists, and their patients. Knowledge-to-action experts and end-users have their own roles and activities in such knowledge translation processes. Appreciating these different roles in genuine partnerships and acknowledging the distinct but equally valued knowledge practices can help in effectively translating evidence into action.

Engaging nurses to strengthen medication safety: Fostering and capturing change with restorative photographic research methods.

We used participatory photographic research methods adapted from the field of ecological restoration to engage Brazilian intensive care unit nurses in a critical review of medication safety in their work environment. Using focus groups, practitioner-led photo walkabouts with photo narration, and photo elicitation focus groups in iterative phases of data collection and analysis, nurses developed and implemented several practical and cultural improvements for their unit. Participants focussed on organizing the medication room for efficient workflow and accessible supplies, improving reporting practices, and reconsidering how they could manage safety issues in their unit and in the hospital as a whole. Our results demonstrated that restorative photographic research methods enabled participants to (re)think and redesign their work environment in keeping with several recommended practices for improving medication management. It also validated the need for continuous evidence-informed improvements if nurses hope to optimize medication safety in the complex systems of intensive care.

Bridging the ivory towers and the swampy lowlands; increasing the impact of health services research on quality improvement

Decisions about how to organize and deliver health services are often more complex and seemingly less rational than decisions about what clinical care to provide. The concept of 'Evidence-Based Management', or what might more appropriately be termed 'Evidence-Informed Improvement', does not seem to have captured the hearts and minds of the people responsible for managing health-care provision. Organizational decision-making is more likely to be influenced by political, ideological and pragmatic factors, and by the personal experience of the decision-makers, than by science. Whilst some people would regard the messiness of management decision-making as inevitable, most would accept that decisions could be improved by making greater use of the established health service research evidence, and through a stronger commitment to developing new evidence. Over the last two or more decades the evidence base created by Health Service Researchers has grown in quantity and in quality and yet much of it remains invisible to the people who most need to use it. This paper explores how the disconnect between the traditional 'producers' of research evidence in academia, and the managerial and clinical 'consumers' of that evidence, has contributed to the challenge of embedding an evidence-informed approach to service improvement. The advantages of a closer working relationship between academia and health services are outlined and three approaches to evidence creation and utilization are described which attempt to maximize the influence of scientific evidence on managerial practice.

Advancing Coordinated Care in Four Provincial Healthcare Systems: Evaluating a Knowledge-Exchange Intervention

This research project created and evaluated a knowledge-exchange intervention designed to facilitate an increase in organizational readiness for implementing coordinated stroke care in four primarily rural provincial healthcare systems. Knowledge brokers were linked to networks within, across and outside the provinces to support, inform and disseminate best practice recommendations for coordinated stroke care within the provincial healthcare systems. The intervention increased awareness and dissemination of recommendations, which stimulated the implementation of coordinated stroke care. Similar knowledge-exchange interventions might work in other healthcare jurisdictions with similar demographics, to promote evidence-informed improvements in healthcare.

Improving rehabilitation treatment in a local setting: a case study of prosthetic rehabilitation

Objective: To contribute to the discussion on the research—practice gap by illustrating obstacles and opportunities that arise in an evidence-informed improvement process of prosthetic rehabilitation in a local setting. Setting: Dutch rehabilitation centre. Presupposition: The improvement process was considered as a two-way translation process rather than a unidirectional process of knowledge transfer between science and practice. Method: Case study and participatory research methods comprising documentary analysis, treatment observations, individual and focus groups interviews, and literature studies. A qualitative software program (Atlas-ti) was used to triangulate the collected data. Results: The main concern of local practitioners was identified to be the post-discharge decline in functional capacity in elderly amputees. This was related to a predominantly biomedical and biomechanical approach, and accompanying traditional therapist—patient interactions. The content and underpinnings of prosthetic treatments were scarcely specified in either the scientific literature or the local setting. Generic principles and practices from other fields were useful for treatment innovation for post-discharge problems, such as task- and context-specific training and self-management education. A circuit training focused on motor learning and a problem-solving training focused on social learning were developed by integrating amputation-specific knowledge. Conclusion: Improving rehabilitation practice with the use of available evidence is a heterogeneous and multifaceted scientific enterprise. Such an enterprise requires as much self-reflexivity from researchers as from practitioners.

Promoting change through research and evidence-informed practice: a Knowledge Transfer Partnership project between a university and a local authority

This article reports on a Knowledge Transfer Partnership project between a local authority and a university, the aim of which is to encourage a culture of evidence-informed practice and continual improvement across the local authority’s Family Services Directorate as part of its performance management framework and to ensure that the Research Governance Framework for Health and Social Care (DH, 2001) is fully implemented. The article describes the successful completion of some of the key stages of the project, including developing and implementing an improvement strategy aimed at increasing levels of engagement with research and evidence-informed approaches to practice.