Taking action on overuse: Creating the culture for change

Parchman, Michael L.; Henrikson, Nora B.; Blasi, Paula R.; Buist, Diana S.M.; Penfold, Robert B.; Austin, Brian T.; Ganos, Emily H.

doi:10.1016/j.hjdsi.2016.10.005

Cited by 37 publications

(51 citation statements)

References 22 publications

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“…Niven and colleagues, as part of their literature synthesis on de‐implementation, propose adapting the Knowledge‐to‐Action model, which is a continuous cycle of knowledge inquiry, synthesis, and adaptation in the clinical setting, in which implementation strategies are selected and tailored on the basis of the barriers to knowledge use and informed by monitoring and evaluation. Parchman and colleagues have proposed a planned‐action model that articulates steps in engaging clinical practices in practice transformation to address overuse. The steps include creating conditions for change, engaging in sense‐making conversations with care teams and allowing them to take a sense of ownership of the issue to make their own decision about where the balance of benefit and harm lies.…”

Section: Discussionmentioning

confidence: 99%

How the dual process model of human cognition can inform efforts to de‐implement ineffective and harmful clinical practices: A preliminary model of unlearning and substitution

Helfrich

Rose

Hartmann

et al. 2018

Evaluation Clinical Practice

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Rationale and objectivesOne way to understand medical overuse at the clinician level is in terms of clinical decision‐making processes that are normally adaptive but become maladaptive. In psychology, dual process models of cognition propose 2 decision‐making processes. Reflective cognition is a conscious process of evaluating options based on some combination of utility, risk, capabilities, and/or social influences. Automatic cognition is a largely unconscious process occurring in response to environmental or emotive cues based on previously learned, ingrained heuristics. De‐implementation strategies directed at clinicians may be conceptualized as corresponding to cognition: (1) a process of unlearning based on reflective cognition and (2) a process of substitution based on automatic cognition.ResultsWe define unlearning as a process in which clinicians consciously change their knowledge, beliefs, and intentions about an ineffective practice and alter their behaviour accordingly. Unlearning has been described as “the questioning of established knowledge, habits, beliefs and assumptions as a prerequisite to identifying inappropriate or obsolete knowledge underpinning and/or embedded in existing practices and routines.” We hypothesize that as an unintended consequence of unlearning strategies clinicians may experience “reactance,” ie, feel their professional prerogative is being violated and, consequently, increase their commitment to the ineffective practice.We define substitution as replacing the ineffective practice with one or more alternatives. A substitute is a specific alternative action or decision that either precludes the ineffective practice or makes it less likely to occur.Both approaches may work independently, eg, a substitute could displace an ineffective practice without changing clinicians' knowledge, and unlearning could occur even if no alternative exists. For some clinical practice, unlearning and substitution strategies may be most effectively used together.ConclusionsBy taking into account the dual process model of cognition, we may be able to design de‐implementation strategies matched to clinicians' decision‐making processes and avoid unintended consequence.

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Section: Discussionmentioning

confidence: 99%

How the dual process model of human cognition can inform efforts to de‐implement ineffective and harmful clinical practices: A preliminary model of unlearning and substitution

Helfrich

Rose

Hartmann

et al. 2018

Evaluation Clinical Practice

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“…De-implementation is a complex process and may require complete termination of a practice, reduction in dose/frequency, or substitution of a practice Prasad & Ioannidis, 2014). Multiple EBP models guide implementation of new or revised practices based on the best available evidence (Melnyk et al, 2017;Rycroft-Malone et al, 2004;Stetler, 1994;Titler et al, 2001); however, we are aware of only three de-implementation models (Niven et al, 2015;Parchman et al, 2016;Phillips et al, 2015).…”

Section: Discussionmentioning

confidence: 99%

De‐implementation of tradition‐based practices in critical care: A qualitative study

Bourgault

Upvall

2019

Int J of Nursing Practice

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Aim To explore the process of tradition‐based practice (TBP) de‐implementation by critical care nurses. Background Ritualistic and routine practices have been described as sacred cows or TBPs. Many clinical practices have insufficient or no evidence and may lead to poor patient outcomes. De‐implementation (termination) of potentially harmful, ineffective, or non cost‐effective TBP is necessary to facilitate evidence‐based practice (EBP) in the clinical setting. Design Descriptive qualitative inquiry guided this study. Methods Twenty‐two critical care nurses from an acute care hospital in central Florida participated. Individual and focus group interviews were performed March to July 2016 and analysed using thematic analysis. Results Three themes were identified: (a) uncertainty, (b) desire to know, and (c) preparing for practice change. Nurses were uncertain about the scientific underpinnings of everyday clinical practices and had difficulty differentiating TBP from EBP. De‐implementation processes and strategies appeared to replicate implementation processes. Conclusion More research is needed to evaluate de‐implementation processes and strategies used for de‐implementation. An emphasis should be placed on ensuring that nurses are knowledgeable about fundamental EBP skills to encourage assessment of clinical practices for supporting research evidence. Awareness and understanding of TBPs will facilitate a more comprehensive approach towards achieving the gold standard of EBP.

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“…Even if numerous studies targeted to waste in healthcare have been published in recent years, interventions aiming at reducing variation in treatments and diagnostic procedures, are lacking …”

Section: Discussionmentioning

confidence: 99%

“…20 Even if numerous studies targeted to waste in healthcare have been published in recent years, [11][12][13] interventions aiming at reducing variation in treatments and diagnostic procedures, are lacking. 21 One of the reasons is that an intervention can be promoted at the service or hospital level following the temporal trend of the targeted prescription behaviour; while investigating the impact on variation implies to act at the network level analysing and benchmarking before and after data. Interventions at the network level can be performed collecting data manually or, if the network has a common IT platform like ours, directly extracting data.…”

Section: Discussionmentioning

confidence: 99%

Peer‐pressure and overuse: The effect of a multimodal approach on variation in benzodiazepine prescriptions in a network of public hospitals

et al. 2019

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Background The epidemic phenomenon leading to a progressive increase in benzodiazepine prescriptions represents a challenge for healthcare systems. In the hospital setting, indicators of prescription variation and potential of overuse are lacking and are rarely monitored. Inter‐hospital monitoring/benchmarking, via peer‐pressure, can foster the motivation to change. The aim of this investigation was to analyse whether, the reduction in new benzodiazepine prescriptions obtained thanks to a Choosing Wisely campaign, also contributed to reducing inter‐hospital variation. Methods Secondary analysis of a multicentre longitudinal intervention in a network of five teaching hospitals in Switzerland. We set out to explore the effect, on inter‐hospital benzodiazepine prescription variation, of a continuous monitoring/benchmarking strategy, which was proven effective in reducing the intra‐hospital prescription rate. The variance was used to assess inter‐hospital variation. To investigate the impact of the intervention a segmented regression analysis of interrupted time series was performed. Results A total of 36 299 admissions over 42 months were analysed (1 July 2014 to 31 December 2017). Before the intervention a significant constant upward trend in inter‐hospital variability was found (+0.901; SE 0.441; P < .05). After the intervention, the variance trend line significantly changed, decreasing by −0.257 (SE 0.005: P < .001) and producing by December 2017, a 27% absolute reduction. Conclusions Thanks to a multimodal approach based on monitoring‐benchmarking, a significant reduction in inter‐hospital benzodiazepine prescription variation was obtained. Aligning to peer strategy is a spontaneous consequence of open benchmarking that can be used to convert a variation‐based suspicion of overuse, into an occasion to actively review prescription habits.

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Taking action on overuse: Creating the culture for change

Abstract: Organizations can use this framework to enhance and strengthen provider engagement efforts to do less of what potentially harms and more of what truly helps patients.

Cited by 37 publications

References 22 publications

How the dual process model of human cognition can inform efforts to de‐implement ineffective and harmful clinical practices: A preliminary model of unlearning and substitution

How the dual process model of human cognition can inform efforts to de‐implement ineffective and harmful clinical practices: A preliminary model of unlearning and substitution

De‐implementation of tradition‐based practices in critical care: A qualitative study

Peer‐pressure and overuse: The effect of a multimodal approach on variation in benzodiazepine prescriptions in a network of public hospitals

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