Bringing Research and QI together

 21st February 2017

   

Prof Frank Röhricht                                    Dr Amar Shah

We have a unique richness of research and improvement expertise now at ELFT, spread across all parts of the organisation. This puts us in a great position to be able to bring the best of both these fields together, in our ambition to improve the health of the population we serve.

Whilst we have been developing skills in improvement across the organisation at pace and scale over the last three years, many have questioned how this new way of making changes to services sits alongside the use of research and evidence.

The Trust aspires to provide the highest quality of care and is committed to continuous improvement and learning. The Trust aims to be a centre of excellence for healthcare research in the areas where it provides services. Research activities are not an appendix to service delivery, but a core part of the Trust’s work. ELFT is now engaging in a process that will align research, innovation, improvement and operations in a more seamless and cost-effective way.

There are many similarities between research and QI:

• Both generate new knowledge. Research is testing innovations and helps us understand what works (efficacy), often by comparing an intervention against a control or placebo, and it aims to clarify whether knowledge is generalisable. Improvement helps us test this in the real-world setting, making adaptations if necessary, and understand how to best implement interventions with known efficacy (effectiveness).
• Both methods are grounded in the basic scientific method of starting with a hypothesis, designing an experiment to test this, and then collecting data to see whether our hypothesis held true. In QI, a properly designed PDSA cycle will go through the exact same steps. Clinical research on efficacy is often conducted in a very rigorous manner where we try to control for confounding factors and bias, and can therefore gather evidence about cause and effect. Research is driven by specific and independent concepts whereas QI often refers to clinical experience as a main source for improvement work. Improvement is ‘applied science’ where we acknowledge that improving services in the real-world is complex, with multiple variables involved, so whilst we can show a relationship in time between an intervention and an outcome, we cannot demonstrate a causal link.
• Both rely on data to guide practice. Research helps us demonstrate which interventions have evidence to justify their use for a particular condition in a given setting. Improvement helps us demonstrate which changes lead to improvement in a given setting, using data and testing to build our degree of belief that an idea has merit.

So, how can we use research and QI together?

Given the similarities and differences, research and QI can complement each other to allow research findings to be utilised in QI, and vice versa the testing of innovative ideas through QI can lead to significant questions (efficacy, generalisability, processes) that are addressed in research.

1. A well designed quality improvement project should bring together knowledge – from within the team (of what ideas might make a difference based on their experience of working within the system), from outside the team (from other places that may have tackled a similar problem) and from the evidence-base (where it has been shown in pure science that a particular intervention has efficacy). All of this knowledge should be brought together in a single theory of change, illustrated in the driver diagram.

Here’s a couple of examples to illustrate:

• We currently have many teams working to reduce non-attendance at appointments. These teams are testing a number of ideas, developed by staff and service users in the services. They are also testing SMS messaging, based on research evidence which has shown efficacy. The teams are also using the knowledge from research about what form of wording has the greatest impact on behaviour, to inform the tests being run in these services.
  https://www.gov.uk/government/publications/reducing-missed-hospital-appointments-using-text-messages/a-zero-cost-way-to-reduce-missed-hospital-appointments
• Many of our inpatient wards have been working on violence reduction. At the very start of this work, we looked to the evidence base to identify interventions that had been shown to reduce inpatient violence on mental health wards. We presented these to the project teams, who utilised these in building their theory of change.
  https://qi.elft.nhs.uk/collection/published-projects/

In order to support this type of link between research findings and quality improvement, a group of clinicians has been formed as a “Horizon Scanning Expert Advisory” panel. The group meets monthly and works otherwise via email correspondence. Its main aim is to scan available information from a range of different sources to gather ideas for testing in QI projects according to specific themes priorities defined by the localities. Recently, the group was asked to identify ideas from research and innovation literature on the themes of reducing bed occupancy and improving recovery care focus. The horizon-scanning team identified an intervention called “Patient Controlled Admissions” for frequently admitted patients who often pose challenging or violent behaviour on admission. This intervention has been evaluated in research in Scandinavia and is now being tested in a couple of QI projects at ELFT.

 

2. Research methods can help us identify areas of opportunity, for us to target improvement work. Thematic analysis of complaints, serious incidents or service user feedback can help us identify the biggest areas of concern. This should feed into the way that we prioritise what to tackle through quality improvement work. For example, an analysis of the feedback captured on a year of Executive WalkRounds identified two big areas of opportunity: the IT helpdesk and estates repairs, which have now led to the design of two corporate QI projects on these topics.
3. The sequential testing and scale-up of ideas through quality improvement can build increasing degree of belief that a change can lead to improvement in multiple contexts. Sometimes quality improvement projects can improve practice even though it is not fully understood which components or interventions are most effective or relevant. This could then lead into systematic and controlled research studies, using more rigorous study design to examine the efficacy of the intervention once all other known confounders have been controlled.

 

A prime example for the interface between quality improvement, service development and research is the current deployment of a new CPA process. The new approach incorporates the findings from locally conducted research, i.e. the structured DIALOG+ therapeutic engagement and intervention tool. The Trust-wide scale-up of the new recovery care focused CPA process integrates local service needs, quality improvement methods and the locally derived evidence base from research trials across the entire organisation.