Assessing organisational readiness for change prior to the introduction of clinical guidelines in multidisciplinary stroke care

Dr Sharon Hamilton              	Professor S McLaren

Reader in Nursing		Professor of Nursing

University of Teesside		South Bank University

Middlesbrough			London

England			England

All health professionals and managers want to provide high quality clinical care that produces the best outcomes for patients

Assumption underpinning this study....

But results from national audits and other studies of outcome following stroke in the UK showed that....Stroke care in the UK was suboptimal

For example;Not all hospitals in the UK had a stroke unitAssessment was fragmentedOnly half of patients had a swallow screening on admissionMultidisciplinary working was poorNeeds of carers not assessed in over 3⁄4 of patients 

There was a need to influence clinicians to implement best practice 

Early multi-disciplinary assessment is crucial for diagnosis and treatment but was not reflected in practice

Key points

However
        - Implementing research evidence into clinical practice is challenging
        - A range of change management strategies are available but need to be adapted to address local barriers
        - Diagnostic analysis is recommended for this purpose
        - There is a paucity of recommended study designs

The main study
        - This presentation describes the first part of a larger study to evaluate the use of a multifaceted strategy for implement best evidence in stroke assessment
        - Main study design: realistic evaluation framework incorporating a quasi-experimental design and elements of action research

		Stage 1: Diagnostic analysis

		Stage 2: Pre-intervention data collection 

		Stage 3: Implementation of intervention (guidelines for stroke assessment)

		Stage 4: Post-intervention data collection

		Stage 5: Diagnostic evaluation

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Diagnostic analysis is recommended as a precursor to change 

What is a diagnostic analysis?
        - Information gathering designed to identify complexities (barriers and facilitators) which can frustrate change – at the organisational and individual level
        - Useful for engaging clinicians in change process
        - This study tested the usefulness of a multi-method approach, informed by previous studies

Diagnostic analysis: theoretical underpinnings
        - Stage models of change, eg forcefield analysis (Lewin 1951)
        - Social marketing (Kotler 2006)
        - Precede/proceed model (Green et al 1980)

Assumption that change is linear and can be planned

Contextualist models challenge this assumption (Pettigrew et al 1992)

Diagnostic analysis: study design
        - South Thames Evidence into Practice (STEP)
        - Promoting Action on Clinical Effectiveness (PACE)  
        - Assisting Clinical Effectiveness (ACE)

None had used a diagnostic analysis for stroke care

Mixed method approach
        - Analysis of hospital public documents n=6
        - Interviews n=20 senior staff: n=6 patients
        - Focus groups n=5 nurses: 3= doctors
        - Team Climate Inventory questionnaire n=206 

Setting

			600 bed district general hospital 

No stroke unit

7 general medical wards

Organisational instability due to merger

Results: documents n=6

The public face of the organisation: 

Five themes identified:
        - Evidence-based practice
        - Management approaches/decision making
        - Staff training
        - Multidisciplinary working
        - Support for the study 

Patient interviews n=6
        - All patients were satisfied with their overall care at the hospital
        - Food was poor
        - Physiotherapy was a positive experience
        - No occupational therapy in hospital
        - Discharge home information poor

Results: Team Climate Inventoryn=148/206 (72%)
        - 7 nursing teams
        - 1 medical team
        - 1 therapy team
        - Variability in team-working
        - Team-working in 2 nursing teams and the medical team gave cause for concern

Results: staff interviews n=28

Four themes identified:
        - Stroke assessment lacked structure
        - Stroke services were generally poor
        - The hospital as an organisation was medically dominated
        - Past history of change in the hospital

		Barriers to change
        - No clinical leadership for stroke care
        - Low levels of multidisciplinary working
        - Low levels of team-working in 3 teams
        - Stroke assessment fragmented
        - Organisational instability due to merger
        - Severe shortage of permanent staff
        - No stroke unit –  7 wards

		Facilitators for change 
        - Positive working environment
        - Positive support to improve stroke care
        - Support from medical and nursing directors to change stroke care
        - Positive past experiences of change
        - Staff highly committed to hospital

Change strategy: targeting barriers
        - Opinion-leadership
        - Identify influential clinical leaders
        - Multidisciplinary professional advisory group 
        - Staff training sessions
        - Variety of times and dates
        - Provided in the classroom & on the wards
        - Individual & group sessions
        - Additional support for teams where team working shown to be low

Conclusion
        - The combination of qualitative and quantitative data captured multiple perspectives on the barriers and facilitators to change in this organisation
        - The information gathered influenced the tailoring of the change management strategy to the needs of the specific hospital

        - Dunning, M., Abi-Aad, G., Gilbert, D., Hutton, H., Brown, C. (1999) Experience, Evidence and Everyday Practice. London: Kings Fund Publishing.
        - Humphris, P. (1999) The Assisting Clinical Effectiveness (ACE) Programme. In Humphris, D., Littlejohns, P. (1999) Implementing Clinical Guidelines. Oxford: Radcliffe Medical Press Ltd.
        - Iles, V., Sutherland, K. (2001) Managing Change in the NHS. Organisational Change. A Review for Health Care Managers, Professionals and Researchers. London School of Hygiene and Tropical Medicine: National Co-ordinating Centre for NHS Service Delivery and Organisation Research and Development. 
        - NHS Centre for Reviews and Dissemination. (1999) Effective Health Care. 5(1): Great Britain: University of York. 
        - Ross, F., McLaren, S. (2000) The South Thames Evidence Based Practice (STEP) Project. Kingston University, St. George’s Hospital Medical School, Faculty of Health Care Sciences. 

Sharon.Hamilton@tees.ac.uk

        - http://www.implementationscience.com/content/2/1/21