Exploring the determinants of evidence use within clinical network - - PowerPoint PPT Presentation

Exploring the determinants of evidence use within clinical network stewardship models: A q methodology study

Jade Hart, The University of Melbourne Prof Margaret Kelaher, The University of Melbourne Prof Helen Dickinson, University of New South Wales

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Research questions

The overarching aim of this research is to understand how clinical network stewardship models influence the use of evidence in Australian State health system decision-making processes.

• 1. What are the clinical network stewardship models? How are they organised?

And what are the broader operating contexts that the clinical networks

• perate within?
• 2. How is evidence understood? What are the evidence needs by type and how is

evidence valued?

• 3. What are the features of clinical network stewardship models (and associated

decision-making processes) that influence overall evidence use?

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• 1. Background

and concepts

The Australian health system is complex

Lack of a single authority Continuous pursuits toward safety and quality Shift towards relational approaches to problem solving, but challenges with realising engagement in system decision-making Concerns over variable understanding and uptake of evidence – what works, where, and under what circumstances?

Evidence is ill-defined or multiply-defined

Focus on evidence use in system decision-making and policy Evidence - “anything that establishes a fact or gives reason for believing in something” (Lomas et al., 2005, p.3)

• Narrow definitions
• Broad definitions – i) research, ii) quantitative data, iii) reports/grey literature, iv)

colloquial evidence Evidence use (Weiss, 1979, Pelz, 1978)

• Direct use – evidence is instrumental
• Symbolic use – selective use of evidence
• Enlightenment as use – enhancing understanding

Evidence use as a process and/or outcome

Functions of health systems operationalised through stewards

1. Define the vision for health and strategies and policies to achieve better health 2. Make use of legal, regulatory and policy instruments to steer health system performance 3. Exert influence across all sectors and advocate for better health 4. Ensure the alignment of system design with health system goals 5. Ensure good governance supporting the achievement of health system goals 6. Compile, disseminate and apply appropriate health information and research evidence. (World Health Organization, 2000 and Veillard, 2012)

Australian Clinical Networks as stewards

“Voluntary clinician groupings that aim to improve clinical care and service delivery using a collegial approach to identify and implement a range of strategies.” (Haines et al., 2012, p.16).

Clinical Networks and membership

General Practitioners Neurosurgeons Pediatricians Midwives Consumers Peak associations Dietitians Physiotherapists Occupational Therapists Clinical Psychologists Pharmacists Physicians Registered nurses Managers Clinical Nurse Specialists Planners Nurse Practitioners Community Health Academia

Cancer Cardiac Emergency Maternity and newborn Renal Rural health Stroke Dementia

Australian Clinical Networks as evidence stewards

Key features of note

• Inclusive with participation being voluntary in nature
• Identify improvements in health service delivery and

patient outcomes

• Focused on embedding evidence
• Seek to facilitate clinicians to implement evidence-

informed practices. (McInnes 2012 and Cunningham et al., 2012)

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• 2. Exploration of

research questions using Q methodology

Exploration of the influence of clinical network stewardship models, evidence, and evidence use

Q methodology explores meaning and significance of subjective data Facilitates analysis in relative rather than absolute terms

Long list of the factors relating to how clinical network stewardship models can influence the use of evidence List of statements (concourse) Participant ranking of statements Systematic comparison of arrays – identifying emerging viewpoints Viewpoints examined to identify high and low scoring statements (Adapted from Meshaka et al., 2016, p.4)

Statements for participant ranking

4x domains

• 1. Network participation arrangements
• 2. The evidence base
• 3. Network management arrangements
• 4. Functional process to evaluate evidence

40x clustered statements

Constructs

Statements for participant ranking

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From my experience within a Clinical Network, my view of the factors influencing evidence use

Evidence base Network management Leadership The clinical network lead's/chair’s leadership style [Statement 1] Member relations Group culture of collective deliberation (e.g. culture of debate) [Statement 9] The quality of the evidence [Statement 19] Clinical network approaches that examine whole-of-health system design [Statement 29]

Exploration of the influence of clinical network stewardship models, evidence, and evidence use

Based on your own knowledge of and experience within a clinical network, sort the statements in order of those that you think have had more influence or lesser influence on evidence use by the clinical network. From my experience within a Clinical Network, my view of the factors influencing evidence use

More influence Lesser influence

• 4
• 3
• 2
• 1

+1 +2 +3 +4

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• 3. Findings and

implications for dissemination and implementation research

Participant profile

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Clinical network role n % total Clinical network member 17 65.4% Clinical network manager or project staff 6 23.1% Clinical network clinical lead/chair or equivalent 2 7.7% Other departmental staff 1 3.8% Total 26 100.0% Professional background n % total Clinician – nursing, allied health, health professional 12 46.2% Clinician – medical 7 26.9% Public servant (non-clinical) 3 11.5% Academic/researcher 2 7.7% Consumer/community member 2 7.7% Total 26 100.0%

Factor analysis

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Factor F1 F2 F3 F4

• No. of Defining Variables

9 5 7 4 Average Rel. Coef. 0.8 0.8 0.8 0.8 Composite Reliability 0.973 0.952 0.966 0.941 S.E. of Factor Z-Scores 0.164 0.218 0.186 0.243

Factor characteristics

Factor arrays

Factor arrays communicate the view points of the factor. These are expressed as a Q sort which shows how the concourse was reflective of the viewpoint.

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Factor One

• 4
• 3
• 2
• 1

+1 +2 +3 +4 2 8 3 6 1 17 19 7 38 4 16 12 11 5 20 28 27 39 32 18 14 9 21 30 40 35 15 10 22 33 37 24 13 25 34 36 23 26 29 31

More influence Less influence

Factor arrays

# Statement F1 F2 F3 F4 1 The clinical network lead's/chair’s leadership style 2 2 2 The clinical network manager's management style

• 4

4 1

• 3

3 Clinical network member trustworthiness derived from their professional reputation (e.g. effects of direct experience and/or those of others)

• 2

1 1

• 2

4 Clinical network member influence

• 4

3 3

• 3

5 Clinical network member knowledge 2 1 2 6 Achievement of appropriate clinical network representation through legitimate recruitment processes

• 1
• 2
• 2

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Factor one - Evidence stewardship as a form of good governance to realise health improvement

Viewpoint: Achieving improvements in the safety and quality of care is the agreed end goal. Realising this goal relies on good governance which is inclusive, evidence-based, and integrated within the broader policy, regulatory and legal framework. These are the features of effective health system stewards. Being evidence-based meets expectations for clinician and patient engagement, rational decision-making, and use of evidence that provides insight into “what works” in the local context for the betterment of patient outcomes.

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Factor two - Evidence as a means to influence the suite of disparate and influential leaders

Viewpoint: Health systems reflect disparate arrangements rather organisations working toward a shared vision. Individuals can serve as facilitators or barriers to system improvement at implementation. Clinical networks provide the clinical leadership and management supports to facilitate evidence use in ways that might not have been previously possible to address cross- boundary issues. Hence, the clinical networks membership and authorising environment provides the context for which evidence can shape the collective way forward.

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Factor three - Evidence use as a mechanism to implement the vision for health system reform

Viewpoint: Clinical networks are a health system stewardship model and use evidence to define the vision for how the health system should be configured to achieve best outcomes for patients. Providers and patients accessing the health system are ideally suited to provide insight into the priorities for change implementation consistent with the vision. Tailored solutions that are informed by diverse types of evidence are advantageous over universal approaches.

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Factor four – The generation and implementation of quality evidence must prevail

Viewpoint: Effective evidence-based decision-making relies on high-quality evidence, specialist expertise, and the application of robust evidence sourcing, evaluation and implementation processes. Given the focus on evidence quality, all forms of evidence are not considered equal, but exist in a hierarchy. While expert-led rational approaches are the benchmark, it is acknowledged that departmental, government and political priorities can have influence. The resources available to implement what’s required can enable or inhibit the capacity of the clinical network.

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Viewpoints and links to theory

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1. Implementation

• f evidence based

medicine among actors with positivist views

• 2. Knowledge

translation and evidence adoption along a process/pathway

• 3. Symbolic

evidence use among an actively engaged network to realize a shared vision

• 4. Knowledge-

driven problem solving using ‘best’ evidence via learning and action

Sackett & Rosenburg (1995) Lavis (2006) Van de Ven (1992) Bowen (2005) Weiss (1979) Pelz (1978) Weiss (1979) Dowding (1995) Weiss (1979) Refer 1 and 2

Conclusions and implications

• 1. Q methodology provides a novel realist approach to the exploration of questions

relating to evidence and evidence use; and responds to new calls for how we undertake evidence based policy research (Oliver 2014)

• 2. System level decision-making through networked structures is a composite of

participation, management, procedural features, and the manner with which existing evidence base interacts

• 3. Evidence use is influenced by and a product of how health system stewardship is

espoused and understood/enacted through various stewardship models

• 4. Next steps for the research program include extension to integrated theory building

and development of a conceptual framework.

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Thank you

Jade Hart , PhD Candidate Melbourne School of Population and Global Health The University of Melbourne j.hart1@student.unimelb.edu.au

Acknowledgements: 1. Australian Government Research Training Program Scholarship 2. State Government of Victoria – Department of Health and Human Services and Safer Care Victoria

References

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