As THIS Institute works to build an evidence base to support healthcare improvement, we sat down with one of the world leaders in improvement research: Dr Sanjay Saint, George Dock Professor of Medicine at the University of Michigan, Chief of Medicine at VA Ann Arbor Healthcare System and – we are very pleased to say – chair of our Scientific Advisory Board. Dr Saint is one of the authors of a book about translating research into practice, and was gracious enough to share his thoughts on how to ensure research has a meaningful impact on healthcare. Here are some snippets from that conversation...
Q. As improvement researchers, we all want our work to translate into practice change. How can we approach improvement studies to help achieve that goal?
I think fundamentally it comes down to the following things. The first is trying to identify what are the best practices that seem to work, that improve patient outcomes, and that improve their satisfaction. Are those studies based on rigorous designs? Second, once we figure out what works, we look to see: are we doing those things, and are we doing them across the health system? Or are there some gaps? The third step is identifying where those gaps are and trying to understand: why aren't we actually doing what we should be doing? And then finally, we try to overcome some of those obstacles.
Q. In your experience, why does some evidence not find its way through to practice?
There are a number of obstacles, including challenges with staff engagement, insufficient resources and lack of leadership. Improvement initiatives can go wrong if data isn’t collected effectively, if the reporting infrastructure isn’t appropriate or if there’s confusion about what the data suggest. There is also a hefty amount of tribalism in healthcare which can lead to a silo-based mindset. For example, in far too many hospitals, surgeons only listen to surgeons, nurses only listen to nurses, and so on. As researchers, we must come up with approaches to overcome some of these obstacles.
Q. So it isn’t enough just to generate evidence about best practices?
The evidence alone is insufficient – it’s not self-implementing. We also have to address socio-adaptive aspects like the culture of the health system, or the microculture of a hospital or even an individual unit. Does this best practice fit in to that culture?
Then, there is the issue of prioritisation. We ask healthcare professionals to do so many different things. How can they prioritise the practice your research suggests ahead of the dozens of other practices they've been told to prioritise?
It ultimately comes down to the people involved. Are they committed to the new evidence-based approach, or are they too overworked and overstressed to do the right thing each time? These problems are pervasive, so the solution must be holistic.
Q. Many healthcare professionals say they’ve heard all this talk about research before. How do you overcome this scepticism?
Unfortunately, those of us in healthcare sometimes get jaded. We’re told over and over that this initiative is going to be different. This time it’s going to make a sustained improvement.
Getting past this scepticism requires participation from people who are making these decisions – doctors, nurses, pharmacists, and others – and who are involved with clinical care. They give the research credibility with the frontline staff and – perhaps even more importantly – they will understand what the real issues are.
Q. How important is patient involvement?
Patients are incredibly important in this type of research. They are the ones who stand to benefit the most from healthcare improvement, and involving them will help researchers understand how they prioritise care.
When a patient comes to the hospital, what is most important to them? Maybe they’re most concerned with receiving the right medications. Maybe it’s important that their doctors dress in a professional manner. Or maybe they’re worried the hospital will lose their glasses or hearing aids.
Working together with patients and families to find possible improvements is critical, especially if things are not going well. I saw this in the US – and I suspect this happened in the UK as well – a few decades ago with the HIV epidemic. When I was in medical training in the 1990s, patients diagnosed with HIV and AIDS died at an unacceptably high rate. Today, it's a disease people can live with, and many of those improvements came about because of patients, families, and advocacy groups pushing for change.
Q. Are there other examples you can share, perhaps from your own work in the US, of research that supported change?
In the US, we’ve been doing a lot of work around indwelling urethral (“Foley”) catheters. The evidence shows they lead to both infectious and non-infectious harm, and patients don't like having them put in their bladders. Yet more than a third of Foley catherisations are unnecessary, and doctors are often not even aware a patient has a catheter.
To address these issues, we tested various approaches on a small scale in our hospital. Led by a physician and a nurse, the key intervention was having the bedside nurse identify who had a catheter and whether or not it met the criteria as an appropriate indication. If it didn't, it would be removed.
This intervention reduced inappropriate catheterisation rates from more than a third, down to less than five percent. We then scaled up to include six other US hospitals. Once we were convinced it also worked in those hospitals, we spread it to a thousand hospitals across the country. So far, the intervention has helped reduce catheter-associated urinary tract infections on medical surgical floors by about 30% in participating US hospitals, and we’re doing similar things in other countries.
Q. How will THIS Institute’s unique approach help it overcome some of the challenges of generating research that leads to practice change?
By fuelling its research projects with citizen science, THIS Institute has already shown its commitment to involving healthcare professionals, patients and the public. Engaging these voices early in the research process will go a long way toward influencing practice change down the road.
The way THIS Institute communicates research will also be critically important. The traditional approach has been to publish research findings in peer-reviewed journals, where they can be read by academics and – perhaps – by decision-makers. But as history has shown, that doesn’t always lead to change. In addition to publishing research, THIS Institute will be using other channels – including social networks, multimedia storytelling and interactive theatre – to help them reach broader audiences of healthcare professionals, decision-makers and members of the public.
I'm thrilled and honoured to be chair of THIS Institute’s Scientific Advisory Board, and we in the US will be paying close attention to what comes from THIS Institute in the future.