Lessons from the Clinical Support Systems Program: facilitating better practice through leadership and team building

The rapidly increasing array of strategies and models for improving clinical practice and patient outcomes may be confusing for clinicians. However, the CSS model, in demystifying design and implementation of evidence-based practice improvement projects,7 has proven effective in local environments.

The model is effective because of its simplicity and scope. Instead of being tightly prescriptive, it provides a broad framework in which the specifications are sufficiently minimalist to enable application to a wide range of clinical settings and diseases. This has enabled clinicians to design their own systems of care that cut across prevailing fragmented organisational settings to implement evidence-based care within new systems.

Implementation of simple rules is increasingly recognised as an effective strategy for change in complex care systems.8 These rules do not impose solutions on clinicians. Rather, they help clinicians to find creative solutions that have local ownership and are locally relevant.

Clinical leaders are widely acknowledged as important facilitators of change,9 but their high profile is often derived from involvement in multiple activities. They thus tend to be exceedingly busy and often absent from the clinical setting in which change is being implemented.

The CSSP experience has illustrated that good leadership is essential to improve clinical practice (Box 1). But, instead of being vested in a single individual, leadership should be a joint responsibility. Different members of the clinical team need to take on various components of the leadership role, according to skills, experience and the tasks required. That the doctor may not always be the appropriate team leader is an important realisation that may be difficult to rectify.

Multiple strategies to maintain the interest and commitment of team members are also necessary (Box 1). This can be particularly difficult in workplaces with high staff turnover. The role of long-term team members in orienting new staff is critical in sustaining the practice improvement initiative.

The principle underpinning the CSS model was the integration of evidence-based medicine (EBM) and clinical practice improvement (CPI).2 This integration proved to be challenging for multidisciplinary teams. As EBM and CPI are constructs that derive from different paradigms, their language and tools differ. Clinicians participating in the CSSP needed to grapple with what it actually meant for their practice to bring these two constructs together. Some clinicians were clearly more comfortable with one paradigm than the other, so negotiating for shared meaning took time.

EBM is the accepted approach in medicine for systematically defining and applying the best available evidence. The strongest level of evidence is regarded as that generated through systematic reviews of multiple randomised controlled trials. However, randomised controlled trials are more suitable for assessing some aspects of medical practice (eg, prescribing) than others (eg, effective communication with the patient). Moreover, randomised controlled trials have been applied with different levels of intensity across medical specialties. At the same time, the evidence base for clinical practice in other professional disciplines, such as nursing and allied health, does not always fit easily into the EBM paradigm. Multidisciplinary teams need to agree on the evidence base they will use to initiate better practice. There is little incentive for clinicians from a particular discipline to participate in improvement programs if their contribution to patient care is excluded from the evidence focus (Box 2).

Strategies to support local practice improvement are likely to include aspects of education or training. For example, there is usually a need to disseminate the evidence for practice changes in the form of guidelines or to train staff in interventions such as the use of a decision-support tool. While education and training are not the sole remedy for changing entrenched structures, cultures and work practices, they are important components of the change process. Multifaceted approaches are needed for complex care systems.10 Individual clinicians learn in different ways and also differ in the way they are linked into organisational structures.

Strategies are also likely to include some form of measurement and review of practice according to the agreed evidence base. The CSSP experience showed that clinicians are keen for meaningful feedback about the care they provide. Indeed, having access to such information can provide a strong motivation for clinicians to engage in a practice improvement project. However, there is a tendency to compensate for a lack of relevant clinical information in some areas by accumulating large amounts of data that are cumbersome to evaluate. This can hamper implementation of new projects. Practice improvement initiatives are best supported by a minimum evidence-based dataset that can be added to as needed.11

The dependence of evidence-based practice on effective partnerships between clinicians and consumers is increasingly recognised. Evidence moves from theory into practice when consumers encounter clinicians.7 Both make decisions contributing to health outcomes, so both need access to the best available evidence to make informed decisions. The quality of this encounter influences the information exchanged. This, in turn, influences decisions made by both parties and the resultant uptake of evidence.

Some clinicians participating in the CSSP were initially unconvinced about the requirement to involve consumers. They tended to have limited experience in working with consumers. Over time, scepticism was replaced by an appreciation of the valuable contribution consumers can make to practice improvement projects (Box 3).

Consumers were willing to assist clinicians in their efforts to improve the healthcare system. Clinicians have a responsibility to keep consumers informed about the influence of their involvement, particularly the changes that result from feedback they have provided.

The direct involvement of the RACP in the CSSP has made an important contribution to increased interest in better practice initiatives by doctors.7 At the same time, this involvement has been a new experience for the RACP, which has learned much about the practical role it can play in supporting its Fellows and trainees in developing their own CPI programs.

Clinicians are enthusiastic about improving the quality of clinical practice, but obtaining information to help develop a local project can be time-consuming. Even identifying where to begin the search for information can be difficult. The RACP is supporting busy clinicians through its “Achieving better practice” website (www.racp.edu.au/bp), which provides a wide range of information, practical advice and resources in one easy-to-find location. A major feature of the website is the “Initiating better practice” manual (www.improveyourpractice.com.au). The manual offers a simple, effective guide for clinicians seeking to improve the quality of their patient care. It provides a practical introduction to the CSS model and draws heavily on the experiences of clinicians involved in the CSSP. A step-by-step structure guides users through the process of designing a project, forming a team, involving consumers, designing interventions, measuring and reviewing practice and sustaining better practice. Case studies and tips to assist users, as well as traps to avoid, are included.

However, it is clear that support needs to extend beyond these practical initiatives. All professional bodies interested in improving healthcare need to ensure that the education and training provided support better practice. The quality of supervision, the on-the-job professional socialisation, the relevance and breadth of knowledge and skills acquired, the congruence between formal curricula and practical exposure, as well as the workload, are all important components of the training process that influence the ability of trainees to provide quality care now and into the future. There is also the potential to explore opportunities for collaboration between organisations. Current training processes tend to foster individualism and isolationism that counteract the team-based systems approaches necessary to support practice improvement.

The development of team-based systems of care based on best evidence will also depend upon integration of these concepts into undergraduate, postgraduate and continuing education programs.

The RACP, in association with the Australian Government Department of Health and Ageing and several state health departments, has led the way in developing the CSS model. The model has been used successfully to put into practice collaborative, evidence-based systems of care for the several specific disease processes or presentations studied in the program. The challenge now is to translate the lessons learnt and processes developed to the care of patients with other diseases and to progressively extend the use of the CSS model to other healthcare institutions or systems. Models of care and collaboration will need to vary to some degree according to the disease process and the environment in which the disease is being managed. However, the basic tenets of the CSS model remain — that is, access to and use of the best available evidence, and collaboration between healthcare professionals.