Supporting health care systems to reduce variation and nurture a learning culture

As health care organisations transition to health care systems delivering services across a geographical footprint, there is a wealth of opportunities for library and knowledge services to support and enhance evidence-based care.

A 2017 study, despite being published a while back, demonstrates the enormity of the challenge facing the NHS of ensuring that all patients receive high quality, evidence based care. It’s a useful study for us as library and knowledge professionals to be aware of, highlighting as it does the level of variation and reasons why our expertise in mobilising knowledge is such an important contribution to the delivery of high quality health care.

Willis et al (2017) explored the variations in achievement of evidence-based, high-impact quality indicators in general practice. Seven high impact quality indicators were developed for primary care and the variation in achieving these indicators was measured across GP practices in West Yorkshire. Four indicators focused on processes of care (e.g. prescribing or testing) and three on clinical outcomes (blood pressure, cholesterol and glycaemic control).

Two key findings in the study are of particular interest.

1) The performance of GP practices in achieving quality indicators.

Achievement of the seven evidence based quality indicators across participating GP practices was as follows:

  1. Diabetes processes of care: 59.1%
  2. Risky prescribing: 8.7% (a low percentage indicates safer, more desirable practice)
  3. Anticoagulation in atrial fibrillation and risk of stroke: 63.0%
  4. Secondary prevention of myocardial infarction: 54.6%
  5. Diabetes control: 43.2%
  6. Blood pressure control in hypertension: 71.7%
  7. Blood pressure control in chronic kidney disease: 74.2%

These differences against quality indicators are perhaps expected, and demonstrate that some GP practices are struggling to achieve evidence-based practice in key areas of patient care.

2) A marked variation in performance between practices

The second key finding of interest to us is that the likelihood of receiving evidence-based treatment varied substantially as a consequence of the practice attended. Even accounting for contributing factors (such as the age profile of patients), the study found considerable variation in achievement of the seven quality indicators between GP practices.

What can we draw from this? It highlights that there are likely to be several contributing factors at play that prevent evidence-based recommendations from being implemented. According to the authors, this is likely to be due to differences in culture and behaviours:

“The odds of patients receiving recommended care or achieving recommended treatment targets varied between two- and over ten-fold by indicator according to the practice attended. These marked variations were partly explained by a range of routinely available practice and patient variables; it is likely that much variation is related to clinical and organisational behaviours.” (p11)

Library and Knowledge Services can play an active part in enhancing clinical and organisational information behaviours in health care systems. This may be through ensuring easy and timely access to the evidence base, equipping health care staff with skills in information searching and critical thinking, or embedding optimal knowledge management behaviours to encourage a learning culture. Accordingly, our contribution to organisational culture and behaviours can support health care systems to reduce unwarranted variation and improve the quality of care.

As knowledge specialists working in health, we are keenly aware that there is a gap between evidence and everyday practice, but perhaps most people attending an appointment at their local practice isn’t?

Reflecting on the findings of this study presents some interesting challenges to us as a profession. Firstly, as our perspective shifts towards supporting the knowledge requirements of health care systems, how can we work more effectively together to help the NHS tackle unwarranted variation in treatment? Secondly, knowledge management is more than simply disseminating evidence across our networks. How can we use our skills to influence behaviour, and how far should our role extend into embedding evidence into practice? Finally, library and Knowledge Services have a role in ensuring citizens are supported to self-manage their conditions effectively and are empowered them with knowledge. How can we do that most effectively?

Please share your thoughts on the issues discussed here, and if you have any interesting studies on this topic please share them too!

Victoria Treadway, Knowledge Management Facilitator, NHS RightCare Email: victoria.treadway@nhs.net Twitter: @librarianpocket

References

Willis, Thomas A, West, Robert, Rushforth, Bruno et al. (5 more authors) (2017) Variations in achievement of evidence-based, high-impact quality indicators in general practice : An observational study. PLoS ONE. e0177949. ISSN 1932-6203 https://doi.org/10.1371/journal.pone.0177949

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