Improving patient care Wensing
(3rd)
Chapter 1: implementation of change
A combination of structured guidance (top-down) and participation of target populations
and stakeholders (bottom-up) is often needed to achieve real and sustainable changes in
practice.
For example de-implementation, waiting time for diagnosis, variation in the provision of
care, patient-centered care.
,1.3 various approaches
Different innovations and proposals for change demand different implementation strategies.
- Marketing approach emphasizes the importance of developing an attractive
message.
- Cognitive approach regards profs and patients as individuals who make decisions
after considering and weighing. Most important: profide care providers with
balanced summaries of scientific literature and guidelines.
- Motivational approach; change is mainly created by individuals’ internal motivation
to achieve optimal competency and performance of care providers. Use of
experiences and problems.
- Reinforcement approach; behavioral theory, using prompts, rewards and sanctions.
Influence behavior by external forces (paying f.e.)
- Social interaction approach; assumption that change come by example, interaction
and influence of other indiviuals. Using opinion leaders, outreach visits, peer
assessment, adaptations in the patient care team and using patients to ask questions
and put pressure.
- Management approach; creating organizational conditions essential for change, such
a specific organizational culture or type of leadership. Assumption: system problem.
Examples: quality and safety management.
- Control approach, based on power to influence people’s performance, using
authority or sanctions.
1.4 what is implementation?
Definition: a planned process and systematic introduction of innovations and/ or changes of
proven value; the aim being that these are given a structural place in professional practice,
in the functioning of organizations or in the health care structure.
Two contrasting approaches to implementing can be distinguished:
An example of a method wich combines aspects of both: knowledge brokering (Lomas 2007):
activities to put decision makers in contact with researchers. There is a need for well-trained
, intermediaries between researchers and policy makers and people from the practice of
healthcare.
1.5 which recommended practices should be adopted?
Guidelines are successful, but can have a hard time to be implemented, support tools are
needed to transfer the key message into practice.
In many cases, the driving force behind the desired improvement is that existing practice
does not lead to the intended result, mistakes, patients are not satisfied, working methods
are inefficient or unsafe.
1.6 A systematic approach to sustainable change
A good diagnostic analysis of the tar- get group and the setting is needed, in turn directing a
well-structured implementation plan. In most cases, this means using a variety of
improvement strategies to be applied in a certain order. Throughout the process, continuous
evaluations check whether the change is under way and the target is reached.
Chapter 2: theories on implementation of change in
healthcare
Impact theories, ch 3 about process theories.
Determinants of implementation can be organized according to the following categories:
- The innovation itself:
- The target group of professionals; users of the innovation: Their knowledge, skills
opinions, attitudes, values, routines can facilitate or impede implementation
- The patients: Their attitudes etc.
- The social and practice setting: attitude of colleagues, culture,social network, view of
opinion leaders, style of leadership
- The organizational system, regulations, and economic structures:
- The strategies for dissemination and implementation used
Theories can be divided into impact theories (determinant framework) and process theories.
Impact theories describe hypotheses and assumptions about how a specific intervention will
facilitate a desired change, as well as the causes, effects, and factors determining success.
Process theories (theories of change) refer to implementation activities: how they are best
planned, organized, and scheduled in order to be effective and how the target group will
utilize and be influence by the activities.
2.2 theories on factors related to individual professionals
Cognitive theories
Rational decision making theories, pro’s and cons are crucial for performance change.
