Failure to place evidence at the centre of quality improvement remains a major barrier for advances in quality improvement

Mondoux and Shojania (M&S) issued a critique of our call to unify all disciplines of relevance for quality improvement (QI). They do not challenge the need for alignment of different fields that have played roles in the QI space. They selected to focus their critique on our views that ultimately the discipline of QI should be based on the principles of evidence‐based medicine (EBM) and decision sciences. In our response, we reaffirm our calls to help achieve needed alignment and integration of all disciplines of importance to QI through “a unifying framework for improving health care” with EBM and decision sciences at helm. Challenging the importance of placing QI on solid empirical basis is misguided: As QI is all about measuring and consequently improving clinical care, acting on reliable evidence must remain its “cornerstone”. Apparent differences in our views appears to be due to our focus on what care should be delivered, while M&S concentrate on how that care should be delivered. The former is the domain of a narrowly defined EBM, while the latter is the realm of improvement/implementation science—which, we argue, should also be evidence‐based. QI initiatives are fundamentally local activities, and regulators would be most helpful if they require each institution to provide an annual plan of its top QI activities not included in the existing mandated list of performance measures. Finally, we addressed a number of specific QI initiatives highlighted by M&S—use of opioids, handwashing, venous‐thromboembolism prophylaxis, hip replacement, and perioperative beta‐blockers—to show that they would have been carried differently if they were based on the principles of EBM. Thus, the failure to place evidence at the centre remains a major barrier for advances in QI.     

A unifying framework for improving health care

The quality health care around world is suboptimal. To improve the quality of contemporary health care delivery, advocates have proposed a number of scientific and technical initiatives. All these initiatives, however, have arisen and continue to operate in siloes, resulting in confusion and incommensurability among those concerned with health care improvement. Participants in the quality improvement (QI) space typically stress their own, often narrow, perspective, failing to place QI in context or to acknowledge other approaches. In order to improve delivery of health care, the following is required:

1. Provide a unifying framework for improving health care. We argue this is best done under a Health System Science (HSS) framework but with full understanding that the fundamental principles of HSS are rooted in evidence‐based medicine (EBM) and decision sciences.
2. Understand that QI initiatives are fundamentally local activities. Hence, incentivizing bottom‐up, local QI initiatives would improve health care delivery to a far greater extent than the current top‐down initiatives undertaken in a response to various regulatory mandates.
3. Akin to the “Choosing Wisely” initiative, which challenged professional societies, each institution should identify (a) the extent to which its practices are evidence‐based and (b) the top 5 health care practices or interventions that, at a given institution, represent overuse, underuse, or misuse/error or undermine clinicians' efforts to deliver kind and empathic care.

Providing a framework that can unify the current patchwork of the initiatives would help create a common basis to help align all the existing QI efforts. In addition, thinking small (at local level) may lead to health care quality improvements that national initiatives (thinking big), focused on regulation, competition, or legal requirements, have failed to achieve.     

Evaluating the implementation of confusion assessment method‐intensive care unit using a quality improvement approach

Quality improvement (QI) is a way through which health care delivery can be made safer and more effective. Various models of quality improvement methods exist in health care today. These models can help guide and manage the process of introducing changes into clinical practice. The aim of this project was to implement the use of a delirium assessment tool into three adult critical care units within the same hospital using a QI approach. The objective was to improve the identification and management of delirium. Using the Model for Improvement framework, a multidisciplinary working group was established. A delirium assessment tool was introduced via a series of educational initiatives. New local guidelines regarding the use of delirium assessment and management for the multidisciplinary team were also produced. Audit data were collected at 6 weeks and 5 months post‐implementation to evaluate compliance with the use of the tool across three critical care units within a single hospital in London. At 6 weeks, in 134 assessment points out of a possible 202, the tool was deemed to be used appropriately, meaning that 60% of patients received timely assessment; 18% of patients were identified as delirious in audit one. Five months later, only 95 assessment points out of a possible 199 were being appropriately assessed (47%); however, a greater number (32%) were identified as delirious. This project emphasizes the complexity of changing practice in a large busy critical care centre. Despite an initial increase in delirium assessment, this was not sustained over time. The use of a QI model highlights the continuous process of embedding changes into clinical practice and the need to use a QI method that can address the challenging nature of modern health care. QI models guide changes in practice. Consideration should be given to the type of QI model used.     

Challenging the epistemological foundations of EBM: what kind of knowledge does clinical practice require?

This paper raises questions about the epistemological foundations of evidence‐based medicine (EBM). We argue that EBM is based upon reliabilist epistemological assumptions, and that this is appropriate – we should focus on identifying the most reliable processes for generating and collecting medical knowledge. However, we note that this should not be reduced to narrow questions about which research methodologies are the best for gathering evidence. Reliable processes for generating medical evidence might lie outside of formal research methods. We also question the notion of the knower that is assumed by EBM. We argue that EBM assumes an enlightenment conception of knowers as autonomous, substitutable individuals. This conception is troubled by the way that clinicians learn the role of anecdote in health care and the role of patient choice, all of which bring into play features of clinicians and patients as situated individuals with particular backgrounds and experiences. EBM's enlightenment conception of the knower is also troubled by aspects of the way evidence is produced. Given these limitations, we argue that EBM should retain its reliabilist bent, but should look beyond formal research methodologies in identifying processes that yield reliable evidence for clinical practice. We suggest looking to feminist epistemology, with its focus on the standpoints of individual situated knowers, and the role of social context in determining what counts as knowledge.     

Clinical audit and quality improvement – time for a rethink?

Rationale and aim Evidence of the benefits of clinical audit to patient care is limited, despite its longevity. Additionally, numerous attitudinal, professional and organizational barriers impede its effectiveness. Yet, audit remains a favoured quality improvement (QI) policy lever. Growing interest in QI techniques suggest it is timely to re‐examine audit. Clinical audit advisors assist health care teams, so hold unique cross‐cutting perspectives on the strategic and practical application of audit in NHS organizations. We aimed to explore their views and experiences of their role in supporting health care teams in the audit process. Method Qualitative study using semi‐structured and focus group interviews. Participants were purposively sampled (n = 21) across health sectors in two large Scottish NHS Boards. Interviews were audio‐taped, transcribed and a thematic analysis performed. Results Work pressure and lack of protected time were cited as audit barriers, but these hide other reasons for non‐engagement. Different professions experience varying opportunities to participate. Doctors have more opportunities and may dominate or frustrate the process. Audit is perceived as a time‐consuming, additional chore and a managerially driven exercise with no associated professional rewards. Management failure to support and resource changes fuels low motivation and disillusionment. Audit is regarded as a ‘political’ tool stifled by inter‐professional differences and contextual constraints. Conclusions The findings echo previous studies. We found limited evidence that audit as presently defined and used is meeting policy makers' aspirations. The quality and safety improvement focus is shifting towards ‘alternative’ systems‐based QI methods, but research to suggest that these will be any more impactful is also lacking. Additionally, identified professional, educational and organizational barriers still need to be overcome. A debate on how best to overcome the limitations of audit and its place alongside other approaches to QI is necessary.     

Particularism in health care: challenging the authority of the aggregate

In health care, particularism asserts the primacy of the individual case. Moral particularists, such as Jonsen and Toulmin, reject deduction from universal moral principles and instead seek warrants for action from the multiple sources unique to a given patient. Another kind of health care particularism, here referred to as the knowledge of particulars, is offered as a corrective to evidence‐based medicine (EBM), its influence on health care practice and policy, and specifically to EBM's reliance on the aggregate. This paper describes the knowledge of particulars and identifies strategies for its legitimation in health care policy and practice. First, the paper documents the ascendancy of the aggregate through EBM's definition of ‘what works’ in health care. Second, it delineates the limits of health care knowledge based on the analysis of aggregates, not only for the care of individual patients but for the formulation of policies about patient care. Third, the paper analyses prominent rejections of the particular in contemporary health policy discourse and relates them to larger political purposes. Finally, it depicts the knowledge of particulars as the basis for clinical prudence and offers three potential strategies for promoting particularism as essential to high‐quality care.     

‘One mission accomplished,more important ones remain’: commentary on Every‐Palmer,S., Howick,J. (2014) How evidence‐based medicine is failing due to biased trials and selective publication. Journal of Evaluation in Clinical Practice, 20 (6), 908–914

Every‐Palmer and Howick suggest that evidence‐based medicine (EBM) is failing in its mission because of contamination of research by manufacturer and researcher‐motivated bias and self‐interest. They fail to define that mission and to distinguish between the EBM movement and the research enterprise it was developed to critique. An educational movement, EBM accomplished its mission to simplify and package clinical epidemiological concepts in a form accessible to clinical learners. Its wide adoption within educational circles fostered critical literacy among several generations of practitioners. Illumination of bias, subterfuge and incomplete reporting of research has been a strength of EBM. Increased uptake and use of clinical research within the health care system properly defines the failing mission that eludes Every‐Palmer and Howick. Responsibility for failure to make progress towards its achievement is shared by virtually all relevant streams within the system, including policy, clinical guideline development, educational movements and the development of approaches to evidence synthesis. Discordance between the epistemological premises pervading today's research and health care community and the complex social processes that ultimately determine research use constitutes an important factor that must be addressed as part of a remedy. Enhanced emphasis on and demonstration of alternative approaches to research such as realism and realist synthesis and the momentum towards development of a learning health care system hold promise as guideposts for the rapidly evolving health care environment.     

The clinical nurse leader: a catalyst for improving quality and patient safety

Aim  The clinical nurse leader (CNL^®) is a new nursing role introduced by the American Association of Colleges of Nursing (AACN). This paper describes its potential impact in practice.
Background  Significant pressures are being placed on health care delivery systems to improve patient care outcomes and lower costs in an environment of diminishing resources.
Method  A naturalistic approach is used to evaluate the impact the CNL has had on outcomes of care. Case studies describe the CNL implementation experiences at three different practice settings within the same geographic region.
Results  Cost savings, including improvement on Centers for Medicare and Medicaid Services (CMS) core measures, are realized quickly in settings where the CNL role has been integrated into the care delivery model.
Conclusions  With the growing calls for improved outcomes and more cost-effective care, the CNL role provides an opportunity for nursing to lead innovation by maximizing health care quality while minimizing costs.
Implications for nursing management  Nursing is in a unique position to address problems that plague the nation's health system. The CNL represents an exciting and promising opportunity for nursing to take a leadership role, in collaboration with multiple practice partners, and implement quality improvement and patient safety initiatives across all health care settings.     

Trends in the perceived complexity of primary health care: a secondary analysis

Rationale If the complexity of the patient's medical problems increases or the complexity of the interactions between the doctor and the patient, the staff or the health care system increase, then complexity of patient care will increase. This study examined trends in patient complexity, and identified doctor, practice and improvement strategy characteristics associated with perceived complexity. Methods This secondary analysis used data from three Community Tracking Surveys with 22 134 primary care doctors completing surveys about themselves, their practice setting, practice improvement strategies and complexity of care in three consecutive 2‐year time periods (1996–1997, 1998–1999, 2000–2001). Data were analysed using hierarchical logistic regression. Results The proportion of primary care doctors who perceived that complexity of care had increased over the past 2 years rose from 31.5% to 35.9%. Perceived complexity of patient care was consistently related to being in solo practice and the belief that they could not frequently obtain high‐quality services and referrals for patients. As availability of services increased, complexity decreased whereas as use of practice improvement strategies increased, complexity also increased. Conclusions Understanding that we cannot determine whether respondents understood care as ‘complicated’ or ‘complex’, potential consequences of this increase in complexity include an increase in medical errors and referral rates along with decreased quality of patient care and career satisfaction.     

The Emerging Imperative for Health Care Quality Improvement

There are widespread and growing concerns about the variable and too often inadequate quality of health care in the United States. As a result, health care quality is being questioned and subjected to scrutiny as never before. Awareness of the quality deficits, combined with rising health care expenditures and changing attitudes of payers and consumers, has given rise to a nascent but growing quality improvement movement. Multiple barriers must be surmounted by this movement, but substantive work is under way on all fronts. Emergency medicine will definitely be affected by the quality improvement movement and should quickly move forward to define and establish performance measures for high-quality emergency care in an era when chronic disease dominates the agenda. Emergency medicine should also aggressively work to operationalize a culture of quality to minimize medical errors, to practice evidence-based medicine, to translate research results into clinical practice in a timely manner, and to establish accountability mechanisms for quality improvement and clinical excellence.     

依法规范行医,循证保护自己

近20年来,我国医疗纠纷的发生率和严重程度均呈上升趋势,对患者、医院和医生都造成不良影响.尤其值得注意的是:频发医疗纠纷中80%缘于医护人员的服务态度、语言沟通和医德医风问题.如何在"以人为本"的21世纪建立我国新型医患关系,如何在未来竞争更加激烈的医疗市场上占有一席之地,我国的医务工作者应该有一个更清醒的认识.循证医学的产生和发展为医学科学和临床实践搭起了一座桥梁,是广大医务工作者转变观念、更新知识、不断完善自身的有力武器.中国医师协会将携手中国循证医学中心积极开展多方面合作,帮助我国医师依法规范行医,循证保护自己.     

Creating a culture of caring: A collaborative academic‐practice approach to clinical education

Strong academic and practice partnerships are needed in the ever‐changing health care environment. Sometimes an invisible barrier exists between clinical practice and academia; academic‐practice partnerships are a way to bridge this barrier. Since 2008a team‐based model of clinical education known as the Culture of Caring (COC) has brought together three academic institutions with a large hospital system to develop a unified clinical experience and curriculum that improves the student, provider, and patient experience. In the COC model the team consists of academic‐practice leaders, clinical instructors, staff nurses, and students. Together they engage in a structured curriculum that is integrated into both the clinical environment and the academic setting. Each week of clinical the students focus on a topic that is paired with journal articles and learning activities that allow the team to engage in learning that is applicable to the clinical practice environment. The learning activities allow students to engage in learning about evidence‐based practice and quality improvement initiatives that are taking place on the unit. The implementation of this collaborative approach to a clinical nursing education model has had a positive impact on the working relationships between the academic partners and clinical practice leaders.     

循证医学与临床实践

目前循证医学方法学已广泛应用于临床医疗实践,指导、制定临床各科疾病的治疗方案,评价药物、治疗方案的有效性、适用性,以及为政府部门制定卫生政策、新药的研究、开发评价提供证据,并已形成了许多相关学科。介绍循证医学对临床医疗、中医药发展和药学研究的影响及其临床指导作用,提倡在临床医疗实践中,充分应用循证医学的原则与方法,为临床、科研、卫生决策、医学教育提供最佳证据,并应用最佳证据指导临床决策。     

An epistemological shift: from evidence‐based medicine to epistemological responsibility

In decision making concerning the diagnosis and treatment of patients, doctors have a responsibility to do this to the best of their abilities. Yet we argue that the current paradigm for best medical practice – evidence‐based medicine (EBM) – does not always support this responsibility. EBM was developed to promote a more scientific approach to the practice of medicine. This includes the use of randomized controlled trials in the testing of new treatments and prophylactics and rule‐based reasoning in clinical decision making. But critics of EBM claim that such a scientific approach does not always work in the clinic. In this article, we build on this critique and argue that rule‐based reasoning and the use of general guidelines as promoted by EBM does not accommodate the complex reasoning of doctors in clinical decision making. Instead, we propose that a new medical epistemology is needed that accounts for complex reasoning styles in medical practice and at the same time maintains the quality usually associated with ‘scientific’. The medical epistemology we propose conforms to the epistemological responsibility of doctors, which involves a specific professional attitude and epistemological skills. Instead of deferring part of the professional responsibility to strict clinical guidelines, as EBM allows for, our alternative epistemology holds doctors accountable for epistemic considerations in clinical decision making towards the diagnosis and treatment plan of individual patients. One of the key intellectual challenges of doctors is the ability to bring together heterogeneous pieces of information to construct a coherent ‘picture’ of a specific patient. In the proposed epistemology, we consider this ‘picture’ as an epistemological tool that may then be employed in the diagnosis and treatment of a specific patient.     

‘All the King's horses …’: the problematical fate of born‐again evidence‐based medicine: commentary on Greenhalgh,T., Snow,R., Ryan,S., Rees,S., and Salisbury,H. (2015) six ‘biases’ against patients and carers in evidence‐based medicine. BioMed Central Medicine, 13:200

The phrase ‘evidence‐based medicine (EBM)' is being used by both EBM advocates and adversaries to broadly denote the production and use of clinical research throughout the healthcare system. Recently, this trend was joined by a call for a general expansion and rebirth of EBM to encompass a diverse range of healthcare activities otherwise corresponding to person‐centred care. The call asserts that EBM is to blame for anti‐patient biases within clinical practice and in policy and public health domains. Effective critique of either EBM or of the healthcare system requires that EBM itself be properly identified as a research literacy movement that grew out of clinical epidemiology of the 1970's and 1980's. We demonstrate the ineffectiveness of inappropriately targeted critiques of healthcare under the banner of born‐again EBM. We identify the strengths and weaknesses of EBM as an educational movement drawing on the concept of literacy associated with the Brazilian educator Paolo Freire. We consider the relationship of EBM to clinical epidemiology and conclude that it cannot fruitfully divorce itself from the latter. We briefly consider existing precedents for philosophically sound conceptual platforms for advocacy of person‐centred healthcare and broad based critique of the healthcare system including relationship‐centred care. We conclude that traditional EBM, as a framework for research literacy training of both clinicians and policy makers, must continue to play a subsidiary role within an expanding patient‐centred healthcare system and that advocacy efforts on behalf of patient voice and engagement are best pursued unencumbered by subsidiary agendas.     

循证医学实践与干部医疗保健工作

循证医学实践在临床工作中已取得一定经验，采用循证医学的原理和方法指导干部和老年人群的医疗保健工作是一项全新的课题。不仅对临床医生认识疾病诊治和判断疗效及预后，建立客观合理的健康保健计划具有指导意义。对保健对象获取科学先进的预防保健知识，认知疾病治疗目标和预后，避免不合理和不必要的医疗负荷具有重要意义。同时对卫生行政部门的医疗保健决策也有一定的参考意义。     

Needs assessment survey for simulation‐based training for gastrointestinal endoscopy nurses

The optimal performance of gastrointestinal (GI) endoscopy nurses is required for patient safety and quality improvement. The aim of the present study was to assess the educational needs for simulation‐based training for Korean GI endoscopy nurses using importance‐performance analysis. A cross‐sectional survey was conducted with 238 Korean nurses from 25 endoscopy units. The educational needs of these nurses were identified using the 35 item clinical competence importance–performance scale. Exploratory factor analysis of the scale identified the following eight factors: emergency care, patient monitoring, evidence‐based practice, documentation and referral, patient safety, nursing process, patient assessment, and infection control. A significant overall mean difference was identified between importance and performance for all eight factors, with emergency care showing the largest difference. It was also ranked the highest priority for continuing education in the importance–performance analysis matrix. Therefore, simulation‐based training should focus on enhancing emergency care competence for GI endoscopy nurses to improve patient safety and quality of care.