Changing healthcare organisations to change clinical performance

Jeffrey S Robinson and Deborah A Turnbull
Med J Aust 2004; 180 (6): S61. || doi: 10.5694/j.1326-5377.2004.tb05949.x
Published online: 15 March 2004


  • We propose the formation of evidence-based clinical practice support units in hospitals and clinical research implementation networks.

  • The purpose of these initiatives will be to increase the uptake of beneficial forms of care and remove harmful or ineffective practices. They will bring together clinicians and other professionals to improve clinical care across the healthcare system.

A fundamental question is currently being asked by many individuals and organisations: how can healthcare organisations or systems change to increase uptake of the beneficial forms of care identified as evidence-based practice and remove harmful or ineffective practices? There is a multiplicity of constraints, not least of which is the unique culture of each institution. It is critical for hospitals to adopt a professional culture conducive to evidence-based practice, a culture that will have implications for managerial hierarchies and human resource management.

In this article we highlight two approaches to encouraging change: evidence-based practice support units and clinical research implementation networks.

Many Australian authors have published systematic reviews of randomised controlled trials, a process that has been assisted by the Australasian Cochrane Centre. Recently, the Australian Government has funded access to the Cochrane Library for all Australians.1 So, the evidence for beneficial and harmful forms of care is readily available.

However, timely uptake of evidence requires translation of knowledge2 and promotion by hospital management and clinical leaders. This could be assisted by the formation of evidence-based practice support units within our hospitals and clinical research implementation networks for clinical services in a wider context.

Although undergraduate and postgraduate programs have included training in evidence-based practice, there have been few evaluations of the uptake of evidence by specialist units in hospitals. Early studies showed that inadequate dissemination of information was an obstacle,3 but ready access to the Internet has now largely overcome this problem. However, guidelines for best care do not yet exist in some areas,4 and acceptance or rejection of evidence is sometimes patchy.5

Evidence-based practice support units

Clinical care must be provided in a way that is equitable and effective. The development of evidence-based practice support units within organisations needs to be given serious consideration. The purpose of such units would be to help care providers review evidence to determine which practices need to change, to assist providers in preparing clinical protocols, and to provide audit and feedback. Part of this would be a review of clinicians’ behaviour — an essential prerequisite to implementing change. The unit would also need to help clinicians and patients to adjust to new forms of service delivery or treatment options, and continued support may require education programs, prompts and reminders for all. Changes to care provision should be based on a regular review of systematic reviews of randomised controlled trials and on audits to identify where gaps exist between current and best practice.

Where national guidelines are available, the costs of producing local protocols/guidelines can be minimised; however, local review and ownership of the protocols by a multidisciplinary group of care providers will be essential for successful implementation. Successful use of guidelines requires that they be available to clinicians when needed — current information and communication technologies make this feasible. Offering fellowships to clinicians within the units may provide incentives for them to improve their skills in translating evidence into practice and conducting health services research. Busy clinicians need time to work with and within the evidence-based practice support unit to determine their priorities for changing the way care is provided. This can not be accomplished by simply adding a line to their job description, but must include protected and funded time for this activity — it can not be left to be done in the hours after a busy night on call!

Many hospitals have excellent data collection systems for management and epidemiological purposes. Evidence-based practice support units will need to use these systems to compare current practice with evidence-based recommendations. The evidence-based hospital will also need to devise new ways of measuring the behaviour of clinicians to assess new outcomes. This process has already begun for maternity care in Victoria with the introduction of new performance indicators.6 All these functions could reside within an evidence-based practice support unit.

The hospital-based practice support unit should also conduct research to provide high quality evidence for changing clinicians’ behaviour within the hospital setting. This would encourage adoption of evidence and improve quality of care. Much of the research in this area has consisted of one-off before-and-after studies. The few studies using randomised controlled trials have been reviewed by the Cochrane Effective Practice and Organisation of Care Group,7 with the general conclusion that small gains can be achieved by a single intervention and larger gains by using a range of different strategies.8 It has been argued that evidence is “lacking”9 and that “those conducting evaluations should use the most robust design possible to minimise bias and maximise generalisability”.10

Clinical research implementation networks

To maintain equity of access and provide for different levels of service, clinical research implementation networks are being developed. It is logical that clinical units within an evidence-based hospital will be part of these clinical regional or national networks. In the wider healthcare system, clinical research implementation networks would also enhance the uptake of evidence in clinical networks across different levels of care.

Good examples of clinical networks that have successfully implemented evidence-based practice include neonatal networks in Australia11,12 and the United States.13 In addition to providing care within a region, networks will help individual units to make objective comparisons with similar units and counteract the tendency of some units to maintain a culture of isolation and self-belief in their own excellence.

Healthcare in Australia is changing very rapidly, and cost increases continue to outstrip the general inflation rate. Hospital managers have had to concentrate on restructuring service delivery in an attempt to restrain costs. Hospitals have fought for their right to retain their traditional roles and, at times, state/territory and federal governments have sought to load healthcare costs onto each other. Evidence-based practice support units and clinical research implementation networks will have to compete with other approaches to improving care, including risk management, but all can be seen as part of a continuing effort to improve the quality and safety of healthcare in Australia. The far-reaching benefits of a safer and more effective healthcare service will more than compensate for any extra costs incurred. The challenge remains to encourage hospitals and governments to adopt this long-term strategic plan.

  • Jeffrey S Robinson1
  • Deborah A Turnbull2

  • University of Adelaide, SA.


Competing interests:

None identified.

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  • 13. Horbar JD, Rogowski J, Plsek PE, et al. Collaborative quality improvement for neonatal intensive care. NIC/Q Project Investigators of the Vermont Oxford Network. Pediatrics 2001; 107: 14-22.


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