Evidence on the shelf? Continuous improvement


In this issue of International Journal of Evidence-Based Healthcare, there is a relatively large number of ‘utilisation’ papers, compared with synthesis papers. I think that is a good thing; one of my former colleagues always used to say: ‘Let's stop collecting new evidence, and start using what we already know. We'll have a bigger impact on improving patient care’.

I am not sure that we need to stop research to enlarge our evidence base! However, I can see the logic in the statement: evidence that is sitting on the shelf, is not improving patient care!

Maybe this is the reason we read and hear so much about ‘Lean Health Care’. Although often seen as a method to reduce cost, Lean management (and its derivative Lean Healthcare) is in fact a method to improve value for our patients. In other words: improve quality, improve reliability and timeliness and reduce costs. The most important principle in Lean management is ‘continuous improvement’. This means introducing both new, evidence-based knowledge to our work processes, and the day-to-day improvement of our work processes by using the knowledge and experience of our workforce. In fact, this day-to-day improvement, sometimes referred to as ‘Kaizen’ or ‘using a Kaizen mind set’ is just as important as introducing ‘new’ knowledge. A key aspect of this approach is that frontline employees are not only involved, but are often the initiators of the improvement. This differs quite a lot from top-down implementation of, for example, new guidelines, usually based on the assumption that knowledge will automatically lead to changed behaviour. We know this is not true, for example, the pulmonologist who smokes, the marriage counsellor who has been divorced, etc.

Just having the evidence available is not enough. We need to put it to work and for that we are absolutely dependent of our workforce (to take ownership and responsibility). A study underlining this idea, is that by Abad-Corpa et al.[1] The authors argue that a lack of use of evidence in clinical practice is the main problem. The study identifies a number of contributing factors, giving some valuable insight into the process of change in the healthcare sector. During the study, a number of changes in clinical practice were agreed upon together with implementation or improvement strategies. This shows the importance of team or professional involvement in implementing evidence.

In this issue of the journal, there are some other examples of putting evidence to work. In three projects, audits are used as the tool to implement and sustain the use of evidence. First, Chong et al.[2] show us that a process of audit, feedback and re-audit stimulates the translation of evidence in the clinical setting, that is, improving the patency of central venous access devices. One of their findings is that the commitment and enthusiasm of team members and all the registered nurses in maintaining the patency of central venous access devices were the crucial factors for the success of this project. In another project, Poh et al.[3] use audit on a small number of key, evidence-based elements of nursing inter-shift handover to improve the handover process. They conclude that continuous evidence-based evaluation, identification and implementation of the nursing inter-shift handover process is essential to enhance patient safety.

Russell-Babin and Miley[4] show us that early delirium identification in elderly hip surgery patients can be improved by a multidisciplinary implementation project augmented by ongoing audit and feedback. One thing that is recognisable in these three projects is the ownership by the frontline workers and continuous improvement using an audit system.

The systematic review and meta-synthesis of qualitative evidence by Munn et al.[5] shows us that the inclusion of health assistants in models of care is complex and dependent on a variety of factors. The evidence suggests that there is a range of potential issues, such as concern amongst health staff regarding responsibilities and among health assistants regarding training and preparation.

In my opinion, these findings will help organisations and teams to make an informed decision on introducing health assistants and to help the team to experiment with different approaches, that is, trial and error learning. In other words: continuous improvement.

The other contributions are also focused on evidence utilisation and improving care processes and patient outcomes. Lee et al.[6] used multi-language posters at the foot of the cots in a paediatric ward as a reminder and communication method on fall prevention. The increased awareness resulted in a 50% decrease in fall incidence.

In Lean terminology, we would call this ‘visual management’, that is, a strong and visual cue of important risks.

In my daily practice as a consultant, helping organisations and teams to improve processes, I witness a vast number of failed ‘implementation’ projects. The most common failure occurs when there is a new idea or guideline, it is successfully piloted in one or two teams and then it is ‘rolled out’ in the rest of the organisation. I call this ‘Big Bang’ implementation. It often fails because in contrast to the teams that performed the pilot, the other teams have no control over the implementation. They cannot try it, play with it or adapt it and will not adopt it.

If you use small steps or continuous improvement, teams and professionals will have to be involved, improving the chances of a successful implementation and really getting the evidence off the shelf. Let us not forget that all healthcare professionals (and I include myself) have the obligation not only to perform our jobs to the best of our ability, but also to improve and to teach our (new) colleagues!