13 January 2012
The most recent MeReC Bulletin (December 2011) considers the problem of the implementation gap: the best evidence often does not get adopted quickly into practice. It highlights relevant evidence and ideas from educational theory, decision-making theory, information management and implementation science and brings them together in one place. It is intended to encourage a fresh approach to difficult challenges.
This MeReC Bulletin will be of interest to everyone whose job involves introducing evidence-based changes to practice. These changes may include health technologies such as medicines, but also treatment pathways, ways of working or similar, which are new or at least new to their potential users. The bulletin identifies seven key principles from the evidence base, and those charged with introducing evidence-based changes to practice should consider these carefully.
Complex versus complicated
It may be tempting to assume that implementing evidence into practice in healthcare is purely a complicated problem, like sending a rocket into space. Complicated problems can be broken down into discrete component parts. Processes are predictable and so proven methodologies can be used with reasonable expectation of success, including those developed in other locations or situations. Although there may be complicated aspects to it, implementing changes in healthcare is really a complex problem, other examples of which include raising children. Although there are identifiably different parts to the task, boundaries are blurred and activity in one part affects other parts in ways which are not always predictable and which are sometimes surprising. Although some approaches can be identified as better than others, past experience and advice from experts can serve only as guides. Applying simple formulae that worked previously may not lead to success and may even lead to problems.
Approaches that are solely mechanistic are appropriate for purely complicated problems. However, healthcare is provided for individual people (and their carers) and by a number of teams of individual people. All these people have the freedom to act in different ways that are not totally predictable, and whose actions are interconnected and affect those of others. In such a complex system, a decision to change is ultimately made by individuals. But people are not passive recipients of changes to practice; they interact with them purposefully and creatively, often through dialogue with other users. It is therefore just as important to consider what needs to be done from a ‘bottom up’ perspective, to support individuals in adopting evidence and changing their behaviour, as from a ‘top down’ perspective of making system or organisational changes.
Ideas about how people learn, how they make decisions and how they can better manage information can be helpful in developing strategies for implementing the adoption of evidence into practice, and reviewing why some strategies have been more or less successful than others. The bulletin discusses these and builds on MeReC Bulletin 2011;22 (1), which discussed how people make decisions and how decision-making might be done better.
Seven principles for more successful implementation of evidence into practice
Several principles can be identified from the evidence and models highlighted in the bulletin. These are summarised below:
- Aim for adoption of the change in practice, not its imposition. Sustained change is most likely if those affected come to value the change and ‘own it’ for themselves. Raising awareness and stimulating interest (addressing the ‘what’s in it for me?’ question) can lead to a decision to change and action to do so. Use a targeted, multifaceted approach to ‘help it happen’.
- Consider the concerns and questions of potential adopters. Potential adopters are likely to question the rationale behind the change in practice, especially if it appears to conflict with their previous assumptions and knowledge. Instead of attempting just to transmit information, aim to help people build new knowledge and understanding from and onto their prior knowledge. Recognise and address the need people have for a motivation which they value to learn more about the evidence and the proposed change in practice, and stimulate tension for change.
- Make it easier for people to do the right thing. Potential adopters are also likely to have questions and concerns about how they can put the proposed change to work in their particular situation. They need help and support to do this. Changing ways of doing things which have become habits is hard, even when one is strongly motivated to do so. Prompts, reminders, feedback, etc. are likely to be helpful but must be tailored to the problems adopters face.
- Support effective foraging, hunting and hot-synching. Practitioners face a daily flood of information. Supporting effective Information Mastery will help them manage this, and can also help them put the information with which they are presented into context, especially if this appears to challenge or undermine the proposed change in practice.
- Recognise and support the communities of practice in which potential adopters work. People acquire and make sense of new information, and form the mindlines which drive their practice, largely by brief reading and talking to other people. Getting the support of the community(ies) of practice is crucial for extensive adoption of evidence into practice, and ‘boundary spanners’ are likely to be particularly important in encouraging its diffusion.
- Allow potential adopters to experiment with and adapt the change in practice to their situation. The context in each setting is unique and so local adaptation of the change in practice and/or its implementation will usually be required. Successful adoption is more likely if adopters have the opportunity and autonomy to adapt and tailor it to their particular needs and circumstances. This needs to occur within clear ethical and governance arrangements.
- Plan carefully but be flexible and adaptable. Planning is indispensable, but plans must respond to changing circumstances and the needs and challenges of potential adopters. Set SMART (Specific, Measurable, Appropriate, Realistic and Time-bound) objectives, consider piloting changes, and include end-users in the planning to ensure that the change and its implementation are relevant to their needs.
These are explored in more detail in the bulletin.
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