The use of external change agents to promote quality improvement and organizational change in healthcare organizations: a systematic review

Abstract

BackgroundExternal change agents can play an essential role in healthcare organizational change efforts. This systematic review examines the role that external change agents have played within the context of multifaceted interventions designed to promote organizational change in healthcare—specifically, in primary care settings.MethodsWe searched PubMed, CINAHL, Cochrane, Web of Science, and Academic Search Premier Databases in July 2016 for randomized trials published (in English) between January 1, 2005 and June 30, 2016 in which external agents were part of multifaceted organizational change strategies. The review was conducted according to PRISMA guidelines. A total of 477 abstracts were identified and screened by 2 authors. Full text articles of 113 studies were reviewed. Twenty-one of these studies were selected for inclusion.ResultsAcademic detailing (AD) is the most prevalently used organizational change strategy employed as part of multi-component implementation strategies. Out of 21 studies, nearly all studies integrate some form of audit and feedback into their interventions. Eleven studies that included practice facilitation into their intervention reported significant effects in one or more primary outcomes.ConclusionsOur results demonstrate that practice facilitation with regular, tailored follow up is a powerful component of a successful organizational change strategy. Academic detailing alone or combined with audit and feedback alone is ineffective without intensive follow up. Provision of educational materials and use of audit and feedback are often integral components of multifaceted implementation strategies. However, we didn’t find examples where those relatively limited strategies were effective as standalone interventions. System-level support through technology (such as automated reminders or alerts) is potentially helpful, but must be carefully tailored to clinic needs.

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“…The value of this particular strategy of audit and feedback with individualized close follow up has been demonstrated elsewhere. 24 While health centers that received facilitation utilized the tool more on average across the study period, the fact that health centers without facilitation utilized the tool at a similar rate by the end of the study period suggests that basic educational materials might be sufficient for successful Barriers to tool uptake were also evident, particularly in Heath Centers D and E that chose not to engage with the tool. In health center D, dramatic staff turnover in leadership left minimal awareness of the tool's presence.…”

Lifetime risk assessment in cholesterol management among hypertensive patients: observational cross-sectional study based on electronic health record data

“…We argue, however, that lack of sufficient, individual physician feed-back and robust leadership engagement to overcome clinical inertia are also major, but modifiable reasons for this failure. Computerized decision support systems could offer one way to drive change for the better, but feedback alone is not sufficient for system-wide change [26,27].…”

The Balanced Opioid Initiative: protocol for a clustered, sequential, multiple-assignment randomized trial to construct an adaptive implementation strategy to improve guideline-concordant opioid prescribing in primary care

“…Practice facilitation (PF) is a clinic-level strategy that targets clinic processes and workflows. In general, practice facilitation focuses on local customization and has a stronger evidence base than educational/engagement meetings and audit and feedback reports, which are usually not tailored to specific clinics [31]. Practice facilitation is also more labor intensive than educational/engagement meetings and audit and feedback reports.…”