Explaining Outcomes in Major System Change: A qualitative study of - - PowerPoint PPT Presentation

Explaining Outcomes in Major System Change:

A qualitative study of implementing centralised acute stroke services in two large metropolitan regions in England Naomi Fulop Professor of Health Care Organisation and Management, University College London

Academy Health Annual Research Meeting, 26th-28th June 2016, Boston USA

Naomi Fulop, Steve Morris, Angus Ramsay, Rachael Hunter, Simon Turner Tony Rudd, Charles Wolfe, Christopher McKevitt Pippa Tyrrell, Ruth Boaden, Catherine Perry Innovations in major system reconfiguration in England: a study of the effectiveness, acceptability and processes of implementation

• f two models of stroke care

Funded by the NIHR Health Services & Delivery Research programme (HS&DR) (Project number 10/1009/09). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HS&DR, NIHR, NHS or the Department of Health

Background

• Major system change: reorganisation of delivery system

to e.g. increase provision of evidence-based care and clinical outcomes (not just individual level)

• e.g. service centralisation – some evidence on outcomes,

but very little on how implemented

• To open up ‘black box’ need to:

(i) distinguish between implementation outcomes (e.g. adoption of, fidelity to the intervention) and intervention

• utcomes (Proctor et al, 2011)

(ii) study relationships factors that influence implementation (e.g. nature of intervention and approaches to implementation) and intervention outcomes

• i.e. combine ‘what works?’ with ‘how and why?’

Framework for major system change

Decision

• n which model

to implement Intervention development/ selection [PARIHS, CFIR, KTA] C2 Implementation approaches Context, approaches to facilitation [PARIHS, CFIR, KTA] C3 Implementation

• utcomes

Adoption, spread, fidelity [Proctor 2011, Mendel 2008] C4 Intervention outcomes Clinical

• utcomes

Patient experience Cost effectiveness Evidence based care Including care provision, health outcomes, patient and carer experience [KTA, Mendel 2008] C5 Decision to change Drivers for change, governance & leadership of decision-making [Best 2012; CFIR] C1

Fulop et al, 2016

Background to major system change in stroke

• Services not organised to enable

evidence-based clinical practices to be provided

• Greater Manchester and London led

way in reconfiguring services to address these concerns

National Stroke Strategy (2007) set

• ut case for change:
• 3rd biggest cause of death in UK
• Outcomes for stroke in UK

compared poorly with those internationally

Community rehabilitation services

3 HASUs

(1x24/7, 2 in-hours)

11 DSCs ≤4 hrs >4 hrs Suspected stroke

London

8 HASUs (all 24/7) 24 SUs Community rehabilitation services Suspected stroke

Greater Manchester ‘A’ Before

Stroke unit/ward Greater Manchester (x12) London (x30)

Community rehabilitation services Suspected stroke

After

The changes

What we know: why different models chosen?

• Both systems aimed to increase provision of evidence-

based clinical interventions; little evidence on which model best to achieve this

• Both systems originally proposed to implement the more

radical, 24 hour model

• More radical transformation in London was enabled by ‘top

down’ leaders’ political authority challenging the existing service delivery context and managing (some) stakeholders’ resistance to change

What we know: dealing with resistance

London: ‘holding the line’ “Stroke was their [clinician representatives’] life, and they wanted to get the best for stroke […] but actually what got it through was being straight with them, trying to explain it to them, but in the end holding the line.” (Commissioner and Project Board Member) Greater Manchester: ‘consensus’ “The minute it felt like unanimity was being compromised on that clinical discussion on the 24 versus the 4 hour pathway, I think we were always going to be minded then to tilt towards holding unanimity and taking what might be a small step, but still the right step.” (Commissioner)

What we know: provision of clinical interventions

• Looked at provision of evidence based clinical

interventions: access to stroke unit, scans, aspirin, assessments (physio, swallow, nutrition)

• HASUs significantly more likely to provide interventions
• But different proportions of pts treated in HASU

– 93% in London, 39% in Manchester

Ramsay et al, 2015 London: more likely than elsewhere to provide interventions Manchester: no different from elsewhere

BUT

Care got better in all areas over time…



WHY? Fidelity to the model

What we know: clinical outcomes

• Length of stay in hospital

reduced significantly more in Greater Manchester and London than in the rest of England (by 2 days in GM, 1.4 days in London)

• Mortality in London reduced

significantly more than in the rest of England (96 additional lives saved per year) – no equivalent effect in Greater Manchester

What we need to know

Intervention outcomes Evidence based care [Ramsay 2015] More likely than elsewhere No more likely than elsewhere C5 Implementation

• utcomes

[Ramsay 2015] C4 93% treated in HASU 39% treated in HASU HASUs provide evidence based care; DSCs vary HASUs provide evidence based care Clinical

• utcomes

[Morris 2014] LoS = ▼ Mortality = ▼ LoS= ▼ Mortality = NSD

London Greater Manchester

Fulop et al, 2016

Implementation approaches

C3 Facilitation? Management? Facilitation? Management? Influence of model selected? Influence of model selected? Decision

• n which model

to implement [Turner 2016] C2 1x 24/7 HASU; 2x IH HASUs;10x DSCs 4h window for HASU 8x 24/7 HASUs; 24x SUs All eligible for HASU Led by regional authority: ‘Holding the line’ Network-led: ‘Consensus’ Decision to change [Turner 2016] C1 Both regions: National Stroke Strategy (2007); Variation in provision of evidence based care

Methods

• Qualitative fieldwork at 2 levels: governance & service
• Analysis of 653 documents
• 125 semi-structured interviews
• 4 stages of analysis:

(i) narrative summaries & timelines of changes (Turner et al,

2016)

(ii) service-level narrative summaries using constant comparative method (iii) Used i) and ii) to identify implementation tasks and how undertaken (iv) Applied our framework to cross-case analysis

Fulop et al, 2016

Findings: service model selected Greater Manchester

‘I don’t understand who’s supposed to be going here and who’s supposed to be going there, and if I don’t, I bet other people don’t know’

(GM stroke physician)

Complex Selective ‘We need to have a definite time of onset […] and if that time exceeds the four hours then we won't be taking them to the Hyper Acute Stroke Unit’

(GM ambulance representative)

London

‘we cannot give crews fragmented messages, you can’t say that you can get this type of care between 8 and 5 Monday to Friday but not on the second Wednesday of the month because there’s a meeting, crews don’t work that way’

(London ambulance representative)

Simple ‘it’s not about “can you do it right?” its about, “how consistently can you do it, and will everybody get that care?”’

(London regional health authority representative)

Inclusive Fulop et al, 2016

Decision on which model to implement

Findings: implementation approaches Greater Manchester

‘it probably wasn’t a written principle but actually what we do is hold consensus and try and deliver this through unanimity’ (GM

commissioner representative)

No accreditation

• r financial

levers ‘If you phase it, it does create a degree of confusion […] you change it, and then you change it, and then you may change it again’(GM ambulance representative) Pilot, then phased Platform to share learning ‘so much learning came out of it through this […] informing how the model should look […] it was all very emergent’ (GM

network representative)

London

‘Having to meet all these standards […] has provided a stick for hospital management to invest in stroke services’ (London stroke

physician)

Accreditation & financial levers ‘the one thing that we really did push for was a “go live” date, not a “go live” date in one area and another in other areas’ (London ambulance

representative)

‘Big bang’ ‘We were there to remind them of what they had signed up to […] of the quality standards that they needed to meet, but always in a supportive manner’

(London network representative)

Hands-on facilitation

Implementation approaches

Fulop et al, 2016

Intervention outcomes Evidence based care [Ramsay 2015] More likely than elsewhere No more likely than elsewhere C5

The whole picture

Clinical

• utcomes

[Morris 2014] LoS = ▼ Mortality = ▼ LoS= ▼ Mortality = NSD 93% treated in HASU HASUs provide evidence based care; DSCs vary 39% treated in HASU HASUs provide evidence based care Implementation

• utcomes

[Ramsay 2015] C4

London Greater Manchester

Implementation approaches [Fulop 2016] ‘Big bang’ Accreditation & financial levers Hands-on facilitation Pilot, then phased No accreditation or financial levers Platform to share learning C3 Decision

• n which model

to implement [Turner 2016] C2 More complex, selective model Simple, inclusive model Led by regional authority: ‘Holding the line’ Network-led: ‘Consensus’ Decision to change [Turner 2016] C1 Both regions: National Stroke Strategy (2007); Variation in provision of evidence based care

Conclusions

• Interaction between models selected and

implementation approaches influenced implementation

• utcomes esp fidelity to the model
• Key implementation approaches: ‘big bang’ launch,

service standards tied to financial incentives, ‘hands on’ facilitation

• Different implementation outcomes likely to have

affected differences in provision of evidence-based care and patient mortality

• Our framework may support planning of and evaluation
• f major system change - needs to be tested in different

healthcare contexts

Fulop NJ, Ramsay AIG, Perry C, Boaden RJ, McKevitt C, Rudd AG, Turner SJ, Tyrrell PJ, Wolfe CDA, Morris S. Explaining

• utcomes in major system change: a qualitative study of implementing centralised acute stroke services in two large

metropolitan regions in England. Implementation Science 2016; 11:80. DOI: 10.1186/s13012-016-0445-z. Fulop N, Boaden R, Hunter R, McKevitt C, Morris S, Pursani N, Ramsay AIG, Rudd A, Tyrrell P, Wolfe C. Innovations in major system reconfiguration in England: a study of the effectiveness, acceptability and processes of implementation of two models of stroke care. Implementation Science 2013, 8:5 doi:10.1186/1748-5908-8-5. Lamont T, Barber N, de Pury J, Fulop N, Garfield-Birkbeck S, Lilford R, Mear L, Raine R, Fitzpatrick R. Beyond the ivory tower: New approaches to evaluating complex health and care systems. BMJ 2016; 352:i154. Morris S, Hunter RM, Ramsay AIG, Boaden R, McKevitt C, Perry C, Pursani N, Rudd AG, Schwamm LH, Turner SJ, Tyrrell PJ, Wolfe CDA, Fulop NJ. Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis. BMJ 2014;349:g4757. Ramsay AIG, Morris S, Hoffman A, Hunter R, Boaden R, McKevitt C, Perry C, Pursani N, Rudd A, Turner S, Tyrrell P, Wolfe C, Fulop NJ. Effects of centralizing acute stroke services on stroke care provision in two large metropolitan areas in England. Stroke 2015; doi: 10.1161/STROKEAHA.115.009723. Turner S, Ramsay AIG, Perry C, Boaden R, Morris S, Pursani N, Rudd A, Tyrrell P, Wolfe C, Fulop NJ. Lessons for major system change: centralisation of stroke services in two metropolitan areas of England. J Health Services Research & Policy 2016; OnlineFirst, doi:10.1177/1355819615626189.

For more information: n.f n.fulo lop@ucl. l.ac.uk

Selected references