Award Title: Advancing clinical leadership in healthcare organisations to mobilise evidence into practice. A mixed methods study of clinical leadership in orthopaedic surgery
Funder: Department of Health and Social Care

Abstract: Question How can clinical leadership be improved to enhance the use of evidence in orthopaedic surgical practice? Background Variation from best practice in orthopaedic surgery causes inequity, inequality, harm for patients, and has negative consequences for healthcare. My research demonstrates that leadership is a key mechanism through which evidence-based practice(EBP) can be encouraged and knowledge spread across organisations. A knowledge gap exists in how to improve leadership to enhance EBP. This is a barrier to mobilisation of best practice recommendations in orthopaedics. This gap will be filled to understand the optimal methods, conditions and circumstances that influence leaders to enhance EBP. Aim To enhance clinical leadership for evidence-based orthopaedic practice, in order to improve quality of elective arthroplasty care, reduce unjustified variation and therefore save money for the NHS. Objectives	Perform realist synthesis to identify the variety of leadership models in surgery and to provide an explanatory analysis of the most effective leadership approaches in the context of practice 	Sample orthopaedic departments using a retrospective assessment of a range of arthroplasty and hospital performance outcomes to rank and categorise hospitals 	Undertake interviews with orthopaedic surgeons at various career stages and timepoints to explore relationships between performance, training, clinical leadership and EBP, and any potential improvements 	Integrate and triangulate data to develop interventions which enhance leadership strategies and training styles to encourage and enable clinicians to improve EBP 	Pilot empirically grounded leadership interventions to improve EBP of orthopaedic surgeons working in the NHS. Methods Year 1/WP1: Systematically search medical and business databases (Medline,ABI/INFORM,etc) to identify relevant primary research of all study designs. Use prespecified criteria to select and appraise studies using realist synthesis to define context, mechanisms and outcomes of effective leadership. Year 1-2/WP2: Conduct a database analysis of hip and knee arthroplasty 'provider quality indicators' data (risk-adjusted revision & 90-day mortality rates/ODEP implant ratings/quality of life). Clean data, then use STATA SE to conduct hierarchical (multilevel) regression models to explore relationships between outcome measures and overall hospital performance. Year 1-4/WP3: Use constructivist grounded theory to conduct semi-structured longitudinal interviews over 4-years with ~36 early career orthopaedic surgeons to explore context, beliefs and actions regarding leadership and EBP.Year 3/WP4: Conduct semi-structured cross-sectional interviews with ~5-10 national and ~18 hospital orthopaedic leaders. Analyse using constructivist grounded theory to identify similarities, differences and models of leadership practice.Year 4-5/WP5: Integrate data to construct a joint-display matrix of qualitative/quantitative/theoretical findings to inform intervention components. Follow the MRC Framework for Complex Interventions to develop interventions which enhance clinical leadership to improve EBP.Year 5/WP6: Conduct a series of communication and impact activities to share interventions through national workshops with surgeons, orthopaedic communities and hospitals to obtain feedback to co-produce outputs for wider dissemination.Impact The research will improve best practice to overcome the challenges affecting arthroplasty, including inequality in provision, increased demand for treatments, and variation in practice and spending. The fellowship will strive to improve health outcomes and enhance patient wellbeing via the provision of more standardised services across the country.

Lay Abstract: Aim To demonstrate how clinical leadership can be improved to enhance the use of evidence in orthopaedic practice. Background Evidence-based practice is the foundation of modern medicine, and clinical guidelines are produced to help clinicians use the best evidence when treating patients. However, across the NHS there are differences in how best practice is delivered. In planned NHS joint replacement surgery variation is clear. For example, in 2015, the number of primary hip replacement operations performed in England ranged from 55 to 208 operations per 100,000 people in the population. These differences can lead to unfairness and harm for patients. People suffer from a post code lottery in treatment, as patients in greater need access and receive treatment later than patients in other areas of the country. This project builds on previous research which examined the challenges of using evidence-based guidelines in orthopaedic surgery. The findings suggested that improving how evidence is used throughout the hospital was key to reduce variation. Clinical leadership was an important influencer of practice, and an area for improvement to encourage evidence-based practice in hospitals. This research aims to fill the gap in understanding about how best practice knowledge for joint replacement can be spread across hospitals by promoting and developing the leadership of evidence-based orthopaedic practice.Design and methods The following mixed methods research is planned: Literature review:To identify and understand the different types of clinical leadership which have been characterised in previous surgical research. Database study:To rank, categorise and explore the performance of hospitals according to a range of joint replacement statistics which are collected for all NHS hospitals. This will be used to select a group of nine hospitals to take part in the interview studies. Long term interview study:To interview groups of early career orthopaedic surgeons every nine months over four years to understand how they learn about leadership and the effect that their own leaders have on their evidence-based practice. Short term interview study:To interview clinical leaders in orthopaedic surgery to look for differences and areas of good leadership practice. Additional interviews will be conducted with national orthopaedic leaders to gather a wider NHS perspective on leadership and training. Data comparison and intervention development: To combine all data collected to compare hospital performance ratings with the interview findings in order to explore and explain similarities and differences in the data. Examples demonstrating the impact of leadership on practice variation will be identified. The results will be used to develop leadership interventions which aim to improve the use of evidence-based practice of orthopaedic surgeons working in the NHS. Communication plan:To work with surgeons who take part, and a wider network of clinicians, healthcare users, policymakers and project stakeholders to share and spread the research findings to a larger audience. This will include organisations responsible for medical education in orthopaedics and the training of NHS doctors. Patient and Public Involvement A community of public members who have had joint replacement surgery, arthritis or experience of orthopaedic healthcare services has contributed to planning this research and application. If awarded, its members will be invited to actively take part in the research by attending advisory group meetings, contributing to data analysis, and sharing early research findings across their public involvement networks.Dissemination In addition to the communication plan, a lay summary of the findings will be shared with participants and other NHS hospitals, charities such as Arthritis Research UK, and healthcare organisations responsible for delivering and managing NHS services and for training clinicians. Findings will also be shared through peer-reviewed publications, workshops, social media, national conferences and international collaborations.

Research Activity Codes: 7.3 MANAGEMENT AND DECISION MAKING
Health Categories: MUSCULOSKELETAL