Simple rules for evidence translation in complex systems: A qualitative study

Abstract

BackgroundEnsuring patients benefit from the latest medical and technical advances remains a major challenge, with rational-linear and reductionist approaches to translating evidence into practice proving inefficient and ineffective. Complexity thinking, which emphasises interconnectedness and unpredictability, offers insights to inform evidence translation theories and strategies. Drawing on detailed insights into complex micro-systems, this research aimed to advance empirical and theoretical understanding of the reality of making and sustaining improvements in complex healthcare systems.MethodsUsing analytical auto-ethnography, including documentary analysis and literature review, we assimilated learning from 5 years of observation of 22 evidence translation projects (UK). We used a grounded theory approach to develop substantive theory and a conceptual framework. Results were interpreted using complexity theory and ‘simple rules’ were identified reflecting the practical strategies that enhanced project progress.ResultsThe framework for Successful Healthcare Improvement From Translating Evidence in complex systems (SHIFT-Evidence) positions the challenge of evidence translation within the dynamic context of the health system. SHIFT-Evidence is summarised by three strategic principles, namely (1) ‘act scientifically and pragmatically’ – knowledge of existing evidence needs to be combined with knowledge of the unique initial conditions of a system, and interventions need to adapt as the complex system responds and learning emerges about unpredictable effects; (2) ‘embrace complexity’ – evidence-based interventions only work if related practices and processes of care within the complex system are functional, and evidence-translation efforts need to identify and address any problems with usual care, recognising that this typically includes a range of interdependent parts of the system; and (3) ‘engage and empower’ – evidence translation and system navigation requires commitment and insights from staff and patients with experience of the local system, and changes need to align with their motivations and concerns. Twelve associated ‘simple rules’ are presented to provide actionable guidance to support evidence translation and improvement in complex systems.ConclusionBy recognising how agency, interconnectedness and unpredictability influences evidence translation in complex systems, SHIFT-Evidence provides a tool to guide practice and research. The ‘simple rules’ have potential to provide a common platform for academics, practitioners, patients and policymakers to collaborate when intervening to achieve improvements in healthcare.Electronic supplementary materialThe online version of this article (10.1186/s12916-018-1076-9) contains supplementary material, which is available to authorized users.

A modified Delphi study to identify the features of high quality measurement plans for healthcare improvement projects

“…However, the long list of questions that emergedover 70offers insight into the complexity of measurement as an endeavour in QI work. Such complexity is a theme emerging in the study of QI more generally [53], but the number of questions may be a risk to feasibility for general use and, if unattainable, may risk alienating or demoralising teams. Face-to-face discussions in Stage 3 enabled decisions to be made where no consensus could be reached using the remote survey in stage 2, but may have been vulnerable to typical group norms and effects.…”

A mixed-methods study of challenges experienced by clinical teams in measuring improvement

“…As well as measurement-specific issues, broader characteristics of the organisational setting, well established in the literature as influencers of success in improvement, played a role in enabling or hindering the teams' ability to measure effectively. [21][22][23] This complexity means that narrow interventions are unlikely to be sufficient to improve the quality of measurement in quality improvement. Some relatively simple forms of support might, however, be helpful.…”

The experience of hospital staff in applying the Gentle Persuasive Approaches to dementia care

“…The team needs a safe space and protected time to share learning and build competence and confidence. Facilitation and leadership skills among mental health nurses can contribute to building capacities for improvement at individual, team and organizational levels (Reed, Howe, Doyle, & Bell, ). Internal facilitation and peer learning are vitally important (Jansson et al., ).…”