Volume 180 · Issue 6 · Supplement

Patient care and outcomes could be significantly improved if the knowledge gained from health research was better translated into practice. This is the message from studies suggesting that 30%–40% of patients do not receive treatments of proven effectiveness and that 20%–25% have treatments that are unnecessary or potentially harmful.1,2 Three years ago, the Australian Government established the National Institute of Clinical Studies (NICS)3 to improve healthcare by helping to close important gaps between the best available evidence and current clinical practice. The NICS aims to do this by working with clinicians to support evidence uptake, helping to increase knowledge about the science of evidence uptake in clinical care, building national capacity for evidence uptake, and advocating for systemic change that will improve the use of evidence in clinical practice. The Institute was initially chaired, before his untimely death, by Chris Silagy, a world leader in promoting better use of evidence in healthcare. In its first years it has worked with a range of partners to identify important gaps between evidence and practice and to develop and test approaches for assisting clinicians to improve evidence uptake in these areas. Priority areas for initial work were chosen to reflect a range of disciplines, issues and settings, and to develop methods and tools that could be used in other clinical areas or settings with similar barriers to evidence uptake. Current projects focus on improving emergency care, heart failure management, pain management in cancer care, and prevention of deep vein thrombosis. In 2002, the NICS funded a targeted grants program for investigators seeking to improve appropriate use of interventions over a broader range of areas. Since then, the Institute has invested in a longer-term capacity-building program by developing evidence implementation fellowships. The NICS has also been identifying which measures are known to improve evidence uptake and which are seemingly ineffective, and is seeking advice on ways this knowledge might be best applied in Australia. In November 2003, the Institute held a meeting in Hobart at which a wide range of healthcare professionals, social scientists, policymakers and consumers met to discuss possible approaches to improving evidence uptake across the Australian healthcare system. Two working groups convened by the NICS, one chaired by Jeffrey Robinson and one by Chris del Mar, developed initial proposals for the meeting participants to discuss. The meeting was addressed by two overseas experts in knowledge translation approaches — Martin Eccles, from the United Kingdom, and Jeremy Grimshaw, from Canada. These acknowledged experts are the first visitors brought to Australia by the Institute to help inform its work program. This Supplement presents a report of this meeting.4 It also draws together a number of articles on ways to promote clinical change from people who contributed to the strategies discussed at the meeting and from other experts who will be visiting and providing advice to the NICS in the coming year. Many of these articles highlight the limitations of current studies and emphasise the need to learn more about the ways to promote and sustain behavioural, organisational and system change in healthcare. Research that builds understanding about diffusion of innovation and factors influencing knowledge uptake comes from a broad range of disciplines, many of which lie outside the traditional areas of focus for healthcare research. Grol and Wensing (page S57) outline theories and models of change and emphasise the need to address barriers at different levels when complex changes are required to improve care.5 They illustrate their argument with an analysis of the lessons for improving diabetes care, but the same principles could be applied in other areas. The article by Eccles and Grimshaw6 (page S52) focuses on the quality of guidelines and on features that might enhance their use. The article by Davis and colleagues (page S68) on the work of the Ontario Guidelines Advisory Committee7 shows the way one group supports clinicians by finding and appraising the quality of available guidelines and by developing practical implementation strategies. Factors influencing the adoption of innovations, and the difficulties and potential facilitators of sustainable change, are discussed in contributions from Australian experts in the field of behavioural change (see pages S55, S66).8,9 Other issues relevant to achieving successful change are discussed in articles by the Chairs of the working groups that developed strategies for the workshop participants to consider (see pages S63, S61).10,11 Grol and Grimshaw have commented elsewhere that, while sometimes the step from best evidence to best practice is simple, most of the time it is not12 — research so far shows that none of the many different approaches to changing practice is superior for all changes in all situations. The potential strategies for evidence implementation suggested at the Hobart meeting incorporate a variety of features and approaches. The “bare bones” of these strategies will be developed for consideration by the NICS Board. Further discussion with stakeholders will examine the feasibility of various approaches, leading to a decision about which strategies might be developed further, tested, and taken forward in 2004.

Heather Buchan MB ChB, MSc, FAFPHM · Jillian R Sewell MB BS, FRACP · Melissa Sweet BA, MA

Your brief is to develop innovative strategies which will encourage the widespread, sustainable and systemic adoption of evidence-based practice, with the goal of improving patient care. These strategies must be capable of being tested in different healthcare settings and of involving both private practitioners, including general practitioners, and the public sector. You should also suggest plans for their evaluation, including impact on patient outcomes, cost-effectiveness, and contribution to the knowledge base about change implementation in healthcare. This was the set of challenges given by the National Institute of Clinical Studies (NICS) to a multidisciplinary group of more than 70 strategic thinkers who attended a 2-day workshop in Hobart in November 2003. Workshop participants were not there to represent their organisations, but to lend to the task their individual expertise, creativity, and pragmatic knowledge of Australian healthcare systems. Summary of draft strategies developed by the two working groups to encourage the adoption of best evidence into practice in Australia General practice/community focus 1. Finding and plugging evidence gaps for common problems in general practice. Clinical data on the most common clinical reasons for encounter would be collected from general practitioners who had been recruited through Divisions of General Practice. This information would identify areas in which best evidence could be applied and would form the basis of an intervention to be tested through a randomised controlled trial, with Divisions as the unit of analysis. 2. An “evidence SWAT team”. The team would raise “evidence literacy” and counter the impact of unreliable information by strategic entry into health debates through the media, general practices and pharmacies. The team would act as a media “watchdog” and produce media releases, a website, briefing notes for GPs and pharmacists, and patient information. 3. A national network of dedicated evidence-based general practice sites for information transfer evaluation. Ten exemplary general practice sites would implement evidence-based practice. They would incubate and test new evidence-based tools and training. These sites would also have a teaching and training role and provide education for patients. Hospital focus 1. Creating and sustaining the evidence-based hospital. An evidence-based practice support unit would promote organisational change. The unit would regularly review the evidence for best practice, support guideline development and implementation, conduct audits and evaluation of practice, and develop close relationships with clinical units. 2. A stepwise approach to changing behaviour. Volunteer hospital units would be recruited to participate in a pilot study before a national implementation plan was rolled out. Units involved would identify what best evidence would be the focus of implementation and use interventions in stages of increasing cost and complexity to change practice. 3. Clinical research implementation networks. These teams would implement best clinical practice and evaluate its use. They would set clear objectives, form a central steering group, identify relevant evidence and priorities for implementation, and identify relevant process and outcome measures. SWAT = special weapons and tactics. Forward planningIn preparing for the workshop, the NICS convened two working groups — one to focus on general practice/community care and another on hospital care — to develop potential strategies to encourage adoption of best evidence, which could then be considered and further developed by the workshop participants. The two working groups were asked to develop generic change strategies to encourage implementation of evidence. It was specified that the strategies should: be appropriate to the Australian environment; produce positive outcomes for the greatest possible number of Australians; include ways of identifying and incorporating new evidence over time; be feasible and implementable by the NICS and partners from 2004; and be affordable. The detailed draft strategies developed by the two working groups are briefly summarised in the Box. The processWorkshop participants were given an overview of current knowledge by two international authorities in the area of evidence uptake: Professor Jeremy Grimshaw, Director of Clinical Epidemiology at the University of Ottawa, and Professor Martin Eccles, Professor of Clinical Effectiveness at the University of Newcastle upon Tyne. Professor Grimshaw said there was increasing interest in knowledge translation activities to promote evidence-based practice. However, there were many barriers to this occurring. The evaluation of guideline dissemination and implementation strategies had been flawed, with the result that there was an imperfect evidence base to guide decision-makers. They would have to exercise considerable judgement about how best to use limited resources for implementation. Professor Eccles said guideline developers traditionally have not taken the crucial extra step of spelling out the implications of the guidelines for practice. He described an intervention that successfully reduced ordering of lumbar spinal x-rays in the routine investigation of back pain in primary care in England and Scotland. It involved identification of local influential people, dissemination of guidelines, education of key stakeholders (including radiologists), and audit and feedback. A key component was instructing radiologists to attach a reminder note about the appropriate ordering of lumbar spinal x-rays when reporting back to GPs. However, it could not be assumed that such an intervention would be effective in other settings — for example, in Australia, the fee-for-service environment might be a barrier. Workshop participants then considered the strengths and weaknesses of the six draft strategies (Box) and further developed the proposals. Some participants also wished to develop other, new approaches. Workshop outcomesDiscussions highlighted the complexities surrounding the design and evaluation of systems to promote evidence uptake. They also reflected the challenges posed by this novel strategy-development process in engaging the expertise and perspectives of a variety of disciplines and stakeholders. In the end, it was not possible within the format of the workshop to address all of the challenges posed to participants at the outset. It is noteworthy that participants strongly valued the process of the workshop as well as its outcomes, judging by the post-workshop evaluation survey completed by participants. Group work and discussions led to some of the original proposals being built on, modified, rejected and/or amalgamated. The overall approaches that participants worked on included: establishment of clinical networks, using a variety of approaches and in a variety of settings; establishment of a media “watchdog”; and development and implementation of point-of-care interventions to promote evidence uptake. The common thread to these approaches was the notion that strategies may be more effective at encouraging evidence uptake if they target communities rather than individuals. The following is a brief summary of the workshop outcomes. 1. Establishing clinical evidence uptake networks, using a variety of approaches◆ Defining a networkA network has been described as a linked group of professionals and organisations from primary, secondary and tertiary care, working in a coordinated way that is not constrained by existing organisational or professional boundaries to ensure equitable provision of high quality, clinically effective care. The emphasis . . . shifts from buildings and organisations towards services and patients. Another view was that a network is “a group of people with a common interest”, existing because of the need to accomplish a real practical purpose. Networks could be pre-existing or new, national or local, and could extend beyond the hospital setting into primary care. Existing networks would need to identify evidence uptake as an additional core goal. The workshop group thought networks would work in most situations and settings, except where there was no evidence available or no organisational willingness to be involved, or where there were other constraints such as geographical limitations. Generally, networks would be patient-, discipline- or problem-based, rather than organisationally based. Examples of services and clinical areas in which evidence uptake could be a key feature of a network include pregnancy and newborn services; a diabetes network; a network forming around acute stroke management; maternity services; and intensive-care units. In other words, they must have strong service structures with multidisciplinary care and multiple interfaces. Desirable features of networks would include commitment to implementing evidence-based practice and sharing lessons with the NICS and other bodies; capacity to measure practice and change in practice; strong clinical leadership and sustainable infrastructure, such as colleges/hospitals — ie, a strategy for continuation once NICS support is no longer available; intention to include consumers and other professionals working in the same field; capacity to engage a majority of healthcare providers; capacity to be applied across settings; coverage of an area that is important and has national relevance (eg, chronic disease such as heart failure); willingness to develop a strategy for national adoption — one that goes beyond the pilot project and beyond the NICS’ specific support; capacity to access evidence of effective care — there must be evidence available of a gap, of a useful intervention, and of a significant, measurable, modifiable problem; a supportive body or partnership; effective governance and project management; expertise in the behavioural sciences. ◆ Views on how networks might operateIdentifying and supporting potential networks. The NICS could publish its criteria for an evidence-based clinical network and call for expressions of interest from networks to undertake a clinical-change program in areas identified as having gaps between best available evidence and current practice. The networks would source reliable evidence, have explicit criteria for selecting priority areas for action, develop an understanding of the situation and the relevant behaviours (including barriers and incentives to change), develop strategies for change, negotiate issues related to the interface between hospitals and other care environments, have a risk-management process, and measure clinical behaviours. The Institute could provide funding and support and could have a strong role in ensuring there was independent evaluation of the process. The Institute could also develop and provide tools for defining problems, identifying and reducing barriers, measuring, changing management, redesign, organisational development, quality improvement and team building. Plugging the gaps in primary care. This approach would focus not on individual GPs, but on Divisions of General Practice and other primary-care providers. The community would be involved in identifying areas of action and developing intervention strategies. The NICS and other organisations could help the Divisions drive this forward. Developing a broad-based approach. The NICS could take a “macro” approach, linking in with existing general practice and primary-care groups and increasing the uptake of evidence-based practice in general practice through capacity building of the whole practice team. There would be focus on a protocol-driven approach in chronic-disease management. The use of pooled practice data and feedback after analysis, together with chronic-disease registers to capture data, would help drive evidence use. Developing a “home base” of expertise. The NICS could convene a taskforce to develop a discussion document outlining a “home base” model for promoting evidence uptake through Divisions of General Practice. The home base would provide expertise in change strategies, biostatistics, systematic reviews, communication and qualitative research. Clinical priorities would be established, evidence sourced, and change strategies developed. Using an integrated systems approach. The NICS would encourage an integrated general-practice systems approach focusing on both the practice team and patients, using a “plan–do–study–act” cyclical model. This approach might target areas such as cardiovascular disease, diabetes and “SNAP” (smoking, nutrition, alcohol, physical activity). Strategies for the practice team could include incentives, practice development workshops, skills-building and networks. The patient-based intervention would “skill up” patients so that they could stimulate GPs to better adopt evidence-based practice. The role of the NICS could be to act as a catalyst by providing GPs with evidence and guidelines and getting information to patients. 2. Establishment of a media “watchdog”A media “watchdog” initiative would aim to increase individuals’ awareness and ability to be critical about the validity of health-related claims by raising “evidence literacy” and countering the impact of unreliable information, through strategic entry into health debates via the media. The project would be providing information about evidence — not definitive health advice. It would aim to encourage people to be more questioning of health information, to make greater use of reliable information sources, and to reduce the use of non-evidence-based interventions by the public and clinicians. A further aim would be to improve the quality of media reporting. The brief of the media watchdog would be to respond to information in news media and other forms of media (including advertising, promotions and Internet campaigns), as well as breaking scientific news and information. It would also be proactive, through “horizon scanning”, being prepared, reviewing the past for recurring issues, and reinforcing positive messages. This initiative would require considerable strategic planning and risk management. As an initial step, the NICS could establish a pilot project. 3. Development and implementation of point-of-care interventions to promote evidence uptakeEvidence provided at point of care can influence practice, and there is a need to tailor evidence for local practices. Different types of clinical environments require different types of point-of-care information. To inform decision-making, evidence must be limited to the essential. The NICS could support development of a kit that helps identify need, practice/evidence gaps, evidence, barriers and opportunities, appropriate strategies, information needs of decision-makers at point of care, strategies to ensure that information is used (such as checklists), feedback mechanisms for users, and evaluation. This approach would work well with existing and future clinical networks for specific issues and problems. Risks include overlap/duplication with other information systems, a perceived threat to professional autonomy, and obsolescence. As an initial step, the NICS could undertake a systematic review of point-of-care interventions and a stocktake of current developments in this area and identify a few priority areas in which lack of immediate information is the cause of the practice/evidence gap. Where to next?The suggested strategies will be further explored by the NICS Board with the aim of developing suitable ideas for implementation in 2004.

Melissa Sweet BA, MA

Overseas studies that aim to quantify the evidence base of conventional medical care give varying estimates, but many of these studies have potential for bias. We do not know how much of the total healthcare Australians receive is based on the best available evidence; studies of a number of specific conditions show that there are gaps between what is known and what happens in practice. The National Institute of Clinical Studies aims to identify and test systemic approaches to embed ongoing review and uptake of evidence into routine clinical care.

Heather Buchan MB ChB, MSc, FAFPHM

Traditional approaches to disseminating research findings have failed to achieve optimal healthcare. In a systematic review of 235 studies of guideline dissemination and implementation strategies, we observed the following: there was a median 10% improvement across studies, suggesting that it is possible to change healthcare provider behaviour and improve quality of care; most dissemination and implementation strategies resulted in small to moderate improvements in care; multifaceted interventions did not appear more effective than single interventions. The interpretation of our systematic review is hindered by the lack of a robust theoretical base for understanding healthcare provider and organisational behaviour. Future research is required to develop a better theoretical base and to evaluate further guideline dissemination and implementation strategies.

Jeremy M Grimshaw PhD, MBChB, FRCGP · Martin P Eccles MD, FMedSci, FRCGP

There are internationally agreed optimal methods for developing clinical practice guidelines. The quality of published guidelines varies. A validated assessment instrument should be used to identify well developed guidelines that can be used with confidence. There are multiple ways of presenting guidelines, including computerised systems. Computerisation of guidelines can cover a range of formats, from brief prompts through to complex decision-support systems. Integrating guidelines into computerised reminder systems has been shown to be effective in improving patient care, but there is less evidence to support the effectiveness of guidelines integrated into computerised decision-support systems.

Martin P Eccles MD, FMedSci, FRCGP · Jeremy M Grimshaw MB ChB, PhD

Maximising the adoption of evidence-based practice has been argued to be a major factor in determining healthcare outcomes. However, there are gaps between evidence-based recommendations and current care. Bridging the evidence gap will not be achieved simply by informing clinicians about the evidence. One theoretical approach to understanding how change may be achieved is Rogers’ diffusion model. He argues that certain characteristics of the innovation itself may facilitate its adoption. Other factors infuencing acceptance include promotion by influential role models, the degree of complexity of the change, compatibility with existing values and needs, and the ability to test and modify the new procedure before adopting it. The diffusion model may provide valuable insights into why some practices change and others do not, as well as guiding those who try to effect adoption of best-evidence practice.

Robert W Sanson-Fisher PhD

To bridge the gap between scientific evidence and patient care we need an in-depth understanding of the barriers and incentives to achieving change in practice. Various theories and models for change point to a multitude of factors that may affect the successful implementation of evidence. However, the evidence for their value in the field is still limited. When planning complex changes in practice, potential barriers at various levels need to be addressed. Planning needs to take into account the nature of the innovation; characteristics of the professionals and patients involved; and the social, organisational, economic and political context.

Richard Grol PhD · Michel Wensing PhD

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.

Jeffrey S Robinson FRANZCOG · Deborah A Turnbull MPsych(Clin), PhD

Concern about risks associated with medical care has led to increasing interest in quality improvement processes. Most quality initiatives derive from manufacturing, where they have worked well in improving quality by small, steady increments. Adaptations of quality processes to the healthcare environment have included variations emphasising teamwork; large, ambitious increments in targets; and unorthodox approaches. Feedback of clinical information to clinicians is a central process in many quality improvement activities. It is important to choose feedback data that support the objectives for quality improvement — and not just what is expedient. Clinicians need to be better educated about the quality improvement process to maintain the quality of their care.

Chris B Del Mar MD, FRACGP · Geoffrey K Mitchell MB BS, FRACGP

Few studies have monitored change in professional practice over time to determine the sustainability of change. Research from other behavioural change literature shows that initial change is difficult to maintain, with reported relapse rates as high as 80%. Interventions most likely to succeed are based on a clear understanding of target behaviours and the environmental context. Facilitators and barriers are usually multifaceted and occur at a number of interrelated levels. The issue targeted for intervention must be clearly defined at the outset, so that antecedents, determinants and supporting mechanisms can be defined, suggesting points for intervention and strategies for initial and sustainable change. The target population’s readiness to change is an important factor at both an individual and organisational level. In most cases, a combination of different interventions will be needed to achieve lasting change.

Jill Cockburn MSc, PhD

Doctors are inundated with medical information, some inadequately evidence-based, much of it captured in clinical practice guidelines (CPGs). The Ontario Guidelines Advisory Committee (GAC) selects topic areas, searches for all CPGs on the topic, and reviews them using the AGREE Instrument. Based in large part on the AGREE score, the GAC summarises one guideline in each topic area and mounts it on its website, with links to other information (eg, clinical algorithms) where possible. Two topic areas have been selected for implementation — the reduction of unnecessary preoperative testing and the rational management of acute low back pain. Implementation strategies include performance feedback, training of opinion leaders, development of algorithms and reminders, and communication through journals and continuing medical education activities.

on behalf of the Ontario Guidelines Advisory Committee*

Workshop participants Dr Edi Albert, Department of Rural Health, University of Tasmania Professor Sanchia Aranda, Peter MacCallum Cancer Centre Professor Chris Baggoley, Board Director, National Institute of Clinical Studies; and Chair, workshop participant group Ms Hilda Bastian, Informed Health Online; and Member, General Practice Working Group Ms Kylie Bierman, National Institute of Clinical Studies Professor Judith Black, Research Committee, National Health and Medical Research Council Associate Professor Ian Blue, Department of Rural Health, University of Tasmania Dr David Boadle, Department of Health and Human Services, Tasmania Ms Robina Bradley, National Institute of Clinical Studies Associate Professor Jeffrey Braithwaite, Centre for Clinical Governance Research, University of New South Wales Dr Anne B Brand, Australian Council for Safety and Quality in Health Care, Hospital and Ambulance Services Tasmania Dr James Brodribb, Royal Australian and New Zealand College of Obstetricians and Gynaecologists Dr Heather Buchan, National Institute of Clinical Studies Ms Genevieve Cantwell, Board Director, National Institute of Clinical Studies; and Chair, workshop participant group Ms Karen Carey-Hazell, Consumers' Health Forum of Australia Dr Karda Cavanagh, Board Director, National Institute of Clinical Studies Dr Peter Charlton, Health Insurance Commission Professor Jill Cockburn, Discipline of Health Behaviour Sciences, University of Newcastle Dr Ruth Cornish, National Institute of Clinical Studies Associate Professor Caroline Crowther, Department of Obstetrics and Gynaecology, University of Adelaide; and Member, Hospital Working Group Professor Trish Davidson, Royal Australasian College of Surgeons Dr Jan Davies, National Institute of Clinical Studies Professor Chris Del Mar, Centre for General Practice, University of Queensland; and Chair, General Practice Working Group Ms Christine Dennis, Australasian Association for Quality in Health Care Dr Peter Didsbury, New Zealand Guidelines Group Ms Noreen Dowd, Metropolitan Health and Aged Care Services, Department of Human Services, Victoria Mr Geraint Duggan, National Institute of Clinical Studies Professor James Dunbar, Greater Green Triangle University Department of Rural Health, Flinders and Deakin Universities Ms Julie Finucane, College of Emergency Nursing Australasia Professor David R Fletcher, Board Director, National Institute of Clinical Studies Dr Martin Gallagher, The Canberra Hospital Professor Nicholas Glasgow, Australian Primary Health Care Research Institute, Australian National University Professor Adele Green, Health Advisory Committee, National Health and Medical Research Council Associate Professor Sally Green, Australasian Cochrane Centre Dr Robert Grenfell, West Victoria Division of General Practice Ms Sally Hall, South East NSW Division of General Practice Ms Marnie Hannagan, National Institute of Clinical Studies Professor David John Henderson-Smart, Centre for Perinatal Health Services Research, University of Sydney; and Member, Hospital Working Group Professor Ian Hickie, beyondblue: the national depression initiative; and Chair, workshop participant group Professor David Hill, The Cancer Council Victoria Ms Sue Huckson, National Institute of Clinical Studies Dr Paul Ireland, National Institute of Clinical Studies Professor Linda Johnston, Victorian Centre for Nursing Practice Research, University of Melbourne Associate Professor Elizabeth Kalucy, Primary Health Care Research and Information Service Dr Shane Kelly, South Metropolitan Health Service, Western Australia; and Member, Hospital Working Group Associate Professor Marcus Kennedy, Australasian College for Emergency Medicine Ms Sandra King, Australian Government Department of Health and Ageing Dr Andrew Knight, Wentwest Education Ltd Dr John C B Litt, Royal Australian College of General Practitioners Dr Karen Luxford, National Breast Cancer Centre Ms Judith Mackson, National Prescribing Service Professor Guy Maddern, Australian Safety and Efficacy Register of New Interventional Procedures -- Surgical, Royal Australasian College of Surgeons Ms Heather McDonald, Australian Council on Healthcare Standards Dr Vin McLoughlin, Australian Council for Safety and Quality in Health Care; and Chair, workshop participant group Ms Beth Micklethwaite, Consumers' Health Forum of Australia Dr Sue Phillips, National Institute of Clinical Studies Professor Leon Piterman, Department of General Practice, Monash University Professor Sally Redman, Board Director, National Institute of Clinical Studies; and Chair, workshop participant group Professor Neil Rees, School of Law, University of Newcastle Emeritus Professor Tom Reeve, Australian Cancer Network Professor Jeffrey Robinson, Department of Obstetrics and Gynaecology, University of Adelaide; and Chair, Hospital Working Group Professor Ann Roche, National Centre for Education and Training on Addiction, Flinders University; and Chair, workshop participant group Professor Rob Sanson-Fisher, Advisor, National Institute of Clinical Studies; and Member, Hospital Working Group Professor Nicholas Saunders, Faculty of Medicine, Nursing and Health Sciences, Monash University; and Chair, workshop participant group Associate Professor Ian Scott, Internal Medicine Department and Clinical Services Evaluation Unit, Princess Alexandra Hospital Dr James Semmens, Centre for Health Services Research, University of Western Australia Dr Jill Sewell, Chair of Board, National Institute of Clinical Studies; and Chair, workshop participant group Associate Professor Michael Solomon, Surgical Outcomes Research Centre, Central Sydney Area Health Service and University of Sydney; and Member, Hospital Working Group Mr David Swan, Queen Elizabeth Hospital Dr Norman Swan, Australian Broadcasting Corporation Ms Melissa Sweet, Sweet Communication Associate Professor Noel Tait, Australian National University Medical School Ms Fiona Tito Wheatland, Enduring Solutions Pty Ltd Associate Professor Deborah Turnbull, Department of General Practice, University of Adelaide; and Member, Hospital Working Group Dr Martin Van Der Weyden, Medical Journal of Australia Dr Robert Walters, Australian Division of General Practice Professor Jeanette Ward, School of Public Health and Community Medicine, University of New South Wales; and Member, General Practice Working Group Ms Lisa Wardlaw-Kelly, Australian Government Department of Health And Ageing Dr Lynn Weekes, National Prescribing Service Ms Michaela Willet, National Institute of Clinical Studies Professor Andrew Wilson, School of Population Health, University of Queensland Associate Professor Patsy Yates, School of Nursing, Queensland University of Technology Dr Jane Young, Surgical Outcomes Research Centre, Central Sydney Area Health Service; and Member, Hospital Working Group In absentia Dr John Aloizos, Australian Pharmaceutical Advisory Council; and Member, General Practice Working Group Mr Paul McGlew, Australian Government Department of Health and Ageing; and Member, General Practice Working Group Professor Paddy Phillips, Flinders Medical Centre; and Member, Hospital Working Group