The fourth panel evaluated the challenges in translating and implementing research into practice, as well as strategies for overcoming these challenges. Christine G. Williams, M.Ed., Director of the Office of Communications and Knowledge Transfer at AHRQ, who served as facilitator for the session, noted that research must not only be incorporated into medical practice, but also translated into Federal, State, and local policies, since these policies can function as important intermediaries between research findings and practice change.
Paul Conlon, Pharm.D., J.D., vice president of clinical quality and patient safety at Trinity Health, offered the health system and hospital perspective on the challenges.
Dr. Conlon highlighted several critical challenges facing hospitals and health systems as they attempt to translate research into practice.
Dr. Conlon believes that the key to overcoming these challenges is to treat physicians as partners. The best way to establish this partnership is to make sure that any patient safety program or other initiative truly adds value to physician practices. Value enhancement can come in a variety of forms, including higher quality of care, more efficient care systems (especially in the hospitals in which physicians work), and a respectful work environment for both physicians and nurses. Hospitals should also seek physician input into the design of care. In short, the hospital goal should be to become the partner of choice for physicians.
Health care systems can play many other roles in promoting the use of research findings:
Karen Wolk Feinstein, Ph.D., president of the Jewish Healthcare Foundation, offered the perspective of both a family member of a victim of an error and the head of a major foundation with funds to invest in patient safety.
A number of years ago Dr. Feinstein's active 93-year old father-in-law entered a well-known, highly respected hospital for a procedure, only to leave the facility disoriented and unable to manage his life. A rapid downward spiral after the hospitalization ultimately led to his death. This experience convinced her to fund a foundation-led study to investigate comorbidities that arise in elderly patients from hospital stays. The study uncovered a number of low-cost techniques for improving the situation. The hospital that cared for her father-in-law agreed to make these changes, and Dr. Feinstein felt very good about the study.
But when Dr. Feinstein's mother entered the same hospital none of these procedures had been put in place. What was most irritating to Dr. Feinstein was that her elderly mother was constantly woken at 3 a.m. to have her vital signs (e.g., blood pressure) checked, despite the fact that one of the study's recommendations was not to wake elderly patients who are sleeping unless absolutely necessary. Evidently, the nurses and other caregivers on this unit were too busy to figure out how to implement this change. In addition, no one at the hospital had ever considered the full costs of waking elderly patients in the middle of the night. Rather than consider the costs of having elderly patients become sleep deprived, disoriented, and potentially depressed upon leaving the hospital, hospitals were evidently too focused on the potential legal ramifications if something had happened to her mother between 2 a.m. and 4 a.m.
Dr. Feinstein concluded from this experience that reform efforts that rely on the application of research in the real-world setting are very difficult. Simply informing caregivers of findings certainly does not work. For change to occur, there has to be some "pull" or demand from health care organizations themselves. In other words, these organizations have to want to change and to be capable of change. The culture must support such change.
Unfortunately, most hospital units do not exhibit this desire to change. On most units it is not clear who the customer is or who is in charge. The financial incentives for change are also unclear, as most purchasing organizations do not encourage health systems to adopt best practices. While there are a few places where caregivers are demanding change by welcoming data collection, error investigation, and problem solving (Dr. Feinstein highlighted the Mayo Clinic's efforts to put the patient first and to promote teamwork, evidence-based medicine and on-the-spot problem solving), such situations are clearly the exception rather than the rule.
To create a demand for patient safety within health care organizations, Dr. Feinstein called on purchasers and insurers to begin to share some of the savings from doing things right, and to be willing to pay more for higher quality and improved safety. Clinicians and hospitals that do things right today are rewarded for their efforts with declining revenues and falling profits. She also called on hospital board members and other leaders to step up to the plate and provide the type of visionary leadership necessary to change a culture and promote reform.
Richard Lilford, Ph.D., FRCOG, FRCP, MFPHM, professor of clinical epidemiology in the Department of Public Health and Epidemiology at the University of Birmingham in the United Kingdom, noted that the message being delivered may be very important in determining the rate at which the research is put into practice. In fact, the failure to incorporate research findings into practice is not primarily due to a lack of effort to make these findings known.
Dr. Lilford noted that there is an important distinction between the way that knowledge is transferred (the messenger) and the content of that knowledge (the message). He believes that focusing exclusively on the messenger without considering the message may be short-sighted. To illustrate his point, Dr. Lilford highlighted the wide variations in the rate at which different innovations diffuse. For example, X-rays diffused rapidly while regular washing of hands by caregivers has diffused slowly. In his view, two factors drove this difference. First, the evidence on the benefits of X-rays was very clear to anyone who examined it. But many practitioners were initially skeptical that hand washing truly mattered, even in the face of evidence to the contrary. (Dr. Lilford noted that caregivers' prior beliefs influence their willingness to act on evidence; many clinicians implicitly assumed that it did not matter if they washed their hands.) Second, X-rays were a new, add-on, revenue-producing procedure that could easily be adopted, while hand washing required a time-consuming change in practice that brought no new revenues.
Unfortunately, organizational research often does not produce clear-cut, yes-no results. Those relatively few findings that are clear are often adopted quickly on a national level. But the adoption of less clear-cut findings will depend upon organization-specific issues. Different organizations will absorb it in different ways. As a result, it is critical to build closer ties between the research and the organizations using it, to make sure that knowledge is "socially absorbed" into the culture of the institutions that deliver patient care.
Paul Schyve, M.D., senior vice president of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), believes that the key to ensuring that research findings are translated into practice is for the "mavens" (the experts who develop the findings) to link with "connectors" (who spread the word on the findings) and "salesmen" (who take the ideas and get organizations to try them). This model is borrowed from a paper written by Molly Joel Coye of the Health Technology Center (presented at a January 2003 conference sponsored by AHRQ and the National Institute for Healthcare Management Foundation) that is based on the principles in Malcolm Gladwell's The Tipping Point.
Researchers are the mavens when it comes to identifying strategies for improving patient safety. The connectors include a whole host of organizations, including accrediting bodies like JCAHO, associations, large health care systems, purchasing coalitions, professional societies, and government agencies and regulators. The salesmen include the leaders within organizations, including CEOs, senior managers, boards of trustees, and physician leaders.
Dr. Schyve believes that the salesmen are the critical players in getting research translated into practice. As a result, the key issue revolves around giving the salespeople what they need to be effective salesmen. This is a two-step process, involving making the salesmen themselves believers and giving them the tools to sell these beliefs to others. Dr. Schyve laid out five critical questions that the mavens and connectors must answer to give the salesmen within institutions what they need to effectively promote change:
Dr. Graham reviewed AHRQ's role in promoting the translation of research findings into the everyday practice of medicine. He began by sharing a question asked by Congressmen John Porter during a 1998 subcommittee meeting, directed to the late John Eisenberg, M.D. (AHRQ director at the time). The "Porter Question" (see box below) emphasized the importance of ensuring that agency findings are used to benefit patients. It has become an important benchmark by which AHRQ has measured its work since that time.
| The Porter Question "What we really want to get at is not how many reports have been done, but how many people's lives are being bettered by what has been accomplished. In other words, is it being used, is it being followed, is it actually being given to patients?... [W]hat effect is it having on people?"— Congressman John Porter, 1998, Chairman, House Appropriations Subcommittee on Labor, HHS, and Education. |
Dr. Graham highlighted a variety of ways in which AHRQ helps to bridge the chasm between research findings and the everyday practice of medicine. Through research grants and the development of important data, AHRQ engages in the following:
AHRQ prioritizes its efforts by considering the impact that research could have. There is a hierarchy of potential impact. At the lowest level of this hierarchy, research may help to improve other research (e.g., how other researchers conduct their investigations). At the second level, research improves policies and processes. At the third level, research can improve daily practice by changing behavior. And at the top level, research can lead to improvements in outcomes, access, and efficiency, which represents the ultimate goal and gets to the heart of the Porter Question. AHRQ uses this hierarchy to deliberately and systematically track the impact of AHRQ-funded research.
AHRQ serves a variety of customers in its efforts to reach this ambitious goal, including clinical decisionmakers, health system decisionmakers (purchasers, health plans, and provider organizations), and public policy decisionmakers. While the information provided to each customer type differs according to the roles they play, the primary objectives in serving each customer are the same—to improve outcomes, access, and quality, to encourage appropriate resource use, and to enhance cost-effectiveness.
The AHRQ research and knowledge transfer process focuses on first building the knowledge base by figuring out what works at a clinical and organizational level and then figuring out how to get people, systems, and policymakers to use or do what works. The next step is to support the widespread implementation of what works, and then to sustain the use of the evidence-based practice over time. Specific AHRQ strategies for transferring knowledge include the following:
AHRQ is moving away from its "push" approach to transferring knowledge in which both research findings and the decision to use them are viewed as discrete events to a "push, pull, and partner" approach in which both steps are viewed as a process to be conducted in partnership with the users of research.
Dr. Graham concluded his remarks by urging researchers to work to ensure that their research makes its way to the top of the research hierarchy pyramid. To maximize success in this effort, he outlined seven roles for researchers in translating their work into practice:
Following the presentations, attendees engaged in a general discussion of the issues surrounding translating research into practice. Key insights from this discussion are provided below:
With Dr. Stryer as moderator, the final session focused on the future, offering both "blue-sky" and practical strategies and suggestions for how to improve patient safety through research.
Mark E. Bruley, B.Sc., vice president of accident and forensic investigation at ECRI, focused on the need for the development of engineering controls within medical devices and information technology to promote patient safety.
A nonprofit health services research agency, ECRI has extensive experience in the patient safety arena. ECRI performs accident investigations at hospitals and facilities around the world, and its medical device safety reports provide a critical link between the research community and the manufacturers of medical devices and technologies. Approximately 15 percent of products reviewed by ECRI have been modified after the evaluation. In some cases, problems that could have caused great harm were addressed before the product's release.
Engineering controls provide barriers and forcing functions that prevent humans from making errors. A common example can be found in automobiles, where engineers have put in place controls that prevent cars from being started when not in the appropriate gear (i.e., in the "drive" position rather than "park"). Engineering controls can include physical barriers, software features, and human factors (e.g., controls, displays, alarms, connectors). Designing these controls requires an understanding of human factors and the clinical realities of the settings in which health care practitioners operate. Examples of engineering controls in health care include the following:
Mr. Bruley believes that current researchers are not focused enough on investigating the potential of engineering controls to enhance patient safety. He sees an opportunity for researchers to promote safety by working more closely with the medical device community.
Mr. Bruley shared four recommendations that collectively will enhance the ability to identify, research, and put into place engineering controls that can prevent errors in health care.
Lucian L. Leape, M.D., adjunct professor of public health at the Harvard School of Public Health, focused on the next steps for researchers and AHRQ in the area of patient safety. Thanks to a flurry of activities, Dr. Leape believes there has been some progress in the area of patient safety over the last several years. But progress has been slower than many would like, and much more needs to be done to improve patient safety in the future.
To facilitate progress, Dr. Leape called on the research community to finish their projects, which will help to answer key questions and identify new research questions to be answered. Often the best research questions arise as a result of initial work in an area. Researchers should also share their results (both successes and failures) broadly. For its part, AHRQ should not focus its limited resources on basic knowledge about patient safety; enough is already known about how and why people make mistakes. He also believes that the existing list of effective practices for improving safety is long enough (at least for now). While some work should continue to establish the evidence base related to effective practices (i.e., proving that they work), the industry can not wait for definitive evidence before taking action. To that end, Dr. Leape called for AHRQ to focus its attention on implementation—that is, understanding how to make the adoption of effective safety practices happen within institutions. One critical issue is how to motivate institutional leaders to push for change.
Unlike in other countries, the U.S. health care system is attempting to achieve needed levels of safety voluntarily. Calling this approach a great social experiment, Dr. Leape noted that no safe industry has ever become safe in this manner. Industries such as airlines are highly regulated and exert strong administrative controls over personnel. Health care has neither of these characteristics. Dr. Leape is cautiously optimistic that this "bottom-up" approach can work. A growing cadre of people "get it" when it comes to patient safety. He is hopeful that this mass of people will soon become a "critical mass" that can eventually change the culture of medicine.
David P. Stevens, M.D., vice president of the Association of American Medical Colleges (AAMC), discussed the next steps in patient safety in the field of medical education.
He reviewed what history teaches about change in health care, using three issues as illustrations:
Dr. Stevens believes that individuals who go into health care learn in much the same manner that pilots learn to fly. Citing a stages of development model (The Dreyfus Model, developed in the 1970s and adapted to health care by Paul Batalden and David Leach), he noted that health care practitioners and students go through six stages of learning—the novice stage (characterized by memorization of rules), advanced beginner and competent stages (where rules are adapted to standard and then more complex situations), proficient and expert stages (where expertise is gained slowly over time), and finally the master stage (when a skill is completely mastered). Individuals follow the expected path with respect to learning the practice of medicine, with medical students being novices and practicing physicians and faculty being experts.
But not all aspects of learning in health care follow this particular path. For example, within the area of genomics and proteomics, faculty and practicing physicians may well be novices, having never received training in this relatively new field. And in the area of information science, medical students may well be the experts, with residents being only competent and practicing physicians being novices.
But within the area of patient safety, everyone is learning from each other. It is not clear who are the teachers and who are the learners. The traditional knowledge and authority gradient has been replaced by a knowledge and authority "equilibrium" where all parties learn from each other.
Dr. Stevens described an AAMC project (funded by The Robert Wood Johnson Foundation) to develop a framework of explicit rules and principles that will support the redesign of patient care and resident and student learning within teaching settings. The project involves the bringing together of various groups, including physicians, nurses, pharmacists, and others to take a "30,000-foot view" of how work can be redesigned to improve both patient care and learning (the presumption is that these two functions should not be separated). Key goals include the following: enhancing patient safety; improving patient and learner satisfaction; preserving key relationships, including doctor-patient and teacher-learner; removing re-work; creating time for care and learning; and creating greater joy in work.
The project is not just a "pie-in-the-sky" evaluation. It includes practical on-the-ground components that focus on use of simulations and rehearsals, eliminating unnecessary redundancies while creating redundancies for safety, using IT systems to support care and learning, improving scheduling systems as well as communication during handoffs, and developing high-performance microsystems (e.g., in the doctor's office).
Dr. Stevens highlighted some immediate steps that teaching institutions can take to enhance patient care and learning through the creation of a safety culture that emphasizes new strategies and new partners. His suggestions for creating a culture of safety include the following:
To cultivate new partners, Dr. Stevens called for the following:
Dr. Graham concluded the panel presentations by emphasizing the next steps for the health care system as a whole. Basic organizational theory suggests that for the system to change, it must acknowledge the need to change. Within the Nation's medical care system, there is at least an acknowledgment today of the need to improve safety and quality. Yet because humans regard change (e.g., adopting new systems and values) as loss, resistance still exists. Changes that are additive and require less loss will be more readily adopted than those requiring fundamental modification of systems or individual behaviors. These changes will meet with fierce resistance, which must be understood if it is to be overcome. On a tactical level, Dr. Graham called on researchers to find ways to link, transfer, integrate, and migrate knowledge into those settings that can bring about the changes in behavior that will in turn lead to improved safety and outcomes. Researchers must identify points of leverage (e.g., change agents and salespeople) that can serve to maximize the impact of research findings.
Following the presentations, attendees asked the panelists questions and engaged in a general discussion of the next steps in patient safety research. Key insights are provided below:
Dr. Graham concluded the meeting by agreeing with Dr. Clancy's view that the health care system today is probably not significantly safer than it was several years ago. But that fact does not mean that progress has not been made. The "mindset" of the health care system has changed; most acknowledge that patient safety is a huge problem and that the system must change to address it. While enthusiasm and the pace of change varies significantly across institutions, acknowledgment of the need for change does exist broadly.
Dr. Stryer built upon Dr. Graham's remarks by noting that the best gauge of the conference's success is what happens when everyone goes home. He urged attendees to work with their peers to promote change by shifting the conversation about patient safety to a new level and by cultivating leaders throughout the organization to act as catalysts for change. For its part, AHRQ will continue to play a leadership role in this effort, both through new programs such as the Patient Safety Improvement Corps and through efforts to work with the mavens and the connectors to identify and share evidence and stories that are so critical to achieving change.
Current as of September 2003
Internet Citation:
Making the Health Care System Safer: Second Annual Patient Safety Research Conference. September 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/ptsfconf.htm
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