Implementing and Evaluating

Evidence Based Practice

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EBP steps

• Formulate a clinically relevant and

“answerable” question
• Find the best evidence
• Evaluate the evidence
• Integrate with clinical expertise and patient
values and apply to your patient
• Evaluate your performance

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This presentation will cover:

• What do we mean by change?

• Models of change
• Change and the individual
• Responses to change
• Tools and techniques to help the change
process
• Measuring and evaluating change

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What do we mean by Change?

• Planned
– Deliberated, based on conscious reasoning
or actions
• Emergent
– Spontaneous and unplanned
– Resulting from decisions unrelated to
change but based on assumptions
– Influenced by internal and external factors
• Reactive or proactive (Iles & Sutherland,
2001)

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What do we mean by Change?

• Episodic
– radical
– Infrequent, discontinuous and intentional
– Replacing one programme with another
• Continuous
– Incremental
– Ongoing, evolving and cumulative
– Constantly adapting to ideas
(Weick & Quinn, 1999)

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Types of Change

• Developmental
– Enhances or corrects existing aspects of an
organisation
• Transitional
– Seeks to achieve a known desired state that
is different from existing one
• Transformational
– Radical e.g. change in structure, processes,
culture and strategy of an organisation
(Ackerman, 1997)

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Models of Change

• Learning Theory
• Social Cognition Models
• Lewin’s Model of Change
• Beckhard and Harris’ Model of Change

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Learning Theory

• Positive consequences increases likelihood of

behaviour
• Negative consequences decreases likelihood
• Desirability of factors is important

(Skinner, 1953)

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Social Cognition Models
• Beliefs, attitudes and intentions are
central in shaping behaviour
• 3 sets of belief are important:
– perceived benefits weighed against
perceived barriers (Is it worth it?)
– perceptions about the attitudes of others to
the behaviour (What do others think?)
– self-efficacy - the belief in one’s ability to
perform a particular behaviour (Can I do
it?)
(Conner & Norman, 1996)
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Lewin’s Model of Change

3 Stages:
• Unfreezing - a need to unfreeze current
attitudes and behaviours
• Changing - includes exploration of new ways
of working
• Refreezing - establishment of a new stable
equilibrium
(Lewin, 1958)

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Beckhard & Harris’ Change Model
5 Stages:
• Looking at the need for change
• Defining the future state
• Undertaking present state analysis
• Devising an implementation plan
• Undertaking the implementation
(Beckhard & Harris, 1987)

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Change and Individuals

Binney and Williams (1997) defined

different individual responses to
change:
• ‘missionaries’
• ‘believers’
• people who pay ‘lip service’
• ‘hiders’ and ‘refugees’
• members of the ‘underground’ resistance
• ‘honest opponents’
• ‘emigrants’
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 Early majority Late majority
(deliberate) (sceptical)
Early adapters
(respectful) Laggards
(traditional)

Innovators
(venturesome)
The adopter curve

2% 13% 34% 34% 16%

Rogers, E.M. (1962) Diffusion of innovations. New York : Free Press.

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School of Health Sciences and Social Work
Tools and techniques to help the
change process

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Clarifying what you want
to change

Your aim may be to:

• make a specific change to one
procedure in the light of the best
evidence
• make your own department more
evidence-driven
• seek to change practice across a range
of departments or organisations

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Clarifying what you want
to change
• Analyse the current situation
• Build a clear picture of where you are starting
from and where you are trying to get to
• Develop a clear vision of what you are wanting
to achieve

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Clarifying what you want
to change

• Why do you wish to change?

– What are the benefits and costs for patients
and clients, quality of service, and working
relationships?
• What needs to be changed?
– What problems are associated with current
arrangements?
• What will the new arrangements look
like?
– What will it mean in practice?
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Identifying Stakeholders

These may include:

• colleagues who will be directly affected
by the change
• other colleagues less directly affected
• patients and clients
• service user groups
• people in other health care
organisations
• others who may be affected e.g. carers
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Identifying Stakeholders

• will depend on your own circumstances

• will be different in different settings
• identify all stakeholders involved
• different views within any one group of
stakeholders.

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Stakeholder Analysis

Decide whether each stakeholder is

currently:
• opposing change
• allowing change to take place without
actually supporting it
• actively helping change happen
• making change happen

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Patient and Client Views

• essential to obtain user views of the area

under review
• may provide a very different perspective from
that of health professionals
• may look for different outcomes
• make use of patient participation groups and
self-help groups

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Barriers and Enabling Factors

• interests and attitudes of stakeholders

• culture of yours and other parts of the
organisation
• national, regional and local policy
• resource availability
• wider economic, social and political factors

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Barriers to Change

Funk et al (1991) describe 4 categories:

• characteristics of the adopter
– values, skills and awareness of the practitioner using
the research
• characteristics of the organisation
– opportunities, barriers and limitations found in the
setting
• characteristics of the innovation
– the quality of the research itself
• characteristics of the communication
– the presentation and accessibility of the results

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Barriers to Change
PACE projects (Dunning et al, 1998) identified:
• lack of perception of relevance
• lack of resources
• short-term outlook
• conflicting priorities
• difficulty in measuring outcomes
• lack of necessary skills
• no history of multidisciplinary working
• restricted effectiveness owing to limitations of
the evidence
• intensity of contribution required

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Enabling Factors

• relevance and quality of the research evidence

• professional and organisational standards of
care
• a research-focused organisational culture
• pressure from patients and clients
• support from policy initiatives
• support from your colleagues
• support from the wider health service

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Force-field Analysis

• A technique for analysing forces for and

against change
• Identify all the driving and restraining forces
for change
• Decide which forces are important
• Note how you could make the most of each
driving force and reduce the impact of each
restraining force

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Force-field Analysis

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SWOT Analysis
• Strengths
– what are you currently doing well
• Weaknesses
– areas where you could improve on current
performance
• Opportunities
– changes in the wider context which may
support your change
• Threats
– changes in the wider context that may have
a negative impact

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Group Work (a)

• Who are the stakeholders?

– Who will support changes and why?
– Who won’t support changes and why?
– How can you best approach each stakeholder
• What are the barriers?
• What are the enabling factors?
• How can you overcome the barriers?

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Setting Objectives

SMART:
• Specific
• Measurable
• Appropriate
• Relevant
• Time-bound

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Building Alliances

• change in one area may have repercussions

for other areas
• take time to get to know other stakeholders
• create partnerships
• aim to create a ‘win-win’ solution

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Change Agents

Within your list of stakeholders:

• who can play a key role in implementing
change
• who can actively support you to gain the
support of your peers

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Patients/Clients as Change Agents
• Improving the relevance and quality of patient
information
• improving the relevance of health promotion
information
• increasing access to treatment
• assessing changes in quality of life after
treatment
• supporting cancer campaigns

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Disseminating Information

• Printed materials
• face-to-face briefings
• mass media
• leaflets targeted at service users and
professionals
• dissemination of guidelines for professionals

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Education and Training

• Will need more than information alone

• interactive approaches are likely to be
successful
• outreach visits may be helpful (O'Brien et al,
2008)
• education combined with other interventions
are most likely to be effective (Forsetlund et
al, 2009)

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An Overview of Systematic Reviews
• Passive dissemination approaches
generally ineffective
• Most other interventions are effective
under some circumstances, none under
all
• Educational outreach and reminders are
generally effective
• Multifaceted interventions more
effective than single interventions.
(Grimshaw et al, 2002)
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Supporting Mechanisms

• Restructuring medical records

• creating care pathways
• patient-specific reminders
• ‘stamps’ or ‘stickers’ on notes
• computer based aids
• informing support staff
• devising new forms or notes
• destroying mechanisms for old systems

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Implementing Change

PACE projects (Dunning et al, 1998) main

learning points, need to:
• Have a realistic timetable
• co-ordinate the work
• Acquire new skills
• keep in touch with those affected
• Have a balanced approach
• not be too ambitious
• expect the unexpected
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Principles for Successful
Implementation
• Change incrementally and use local
opinion leaders
• introduce the change flexibly
• market the change
• individuals need to be ready to change
• individuals need to have the skills to
change
• do not start too ambitiously
(Bury, 2003)
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Measuring and Evaluating Change
• Evaluate the process itself and how people
have responded to it
• Evaluate the immediate impact of the change
• Evaluate the longer-term outcomes

– Including Patient and Client involvement

– Clinical Audit

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Evaluating the process
Evaluate during the process and see how people
have responded to it:
• Through questionnaires completed by
patients, clients or professionals
• helps you identify problems as they happen

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Evaluating the immediate
impact of the change:
• assess whether and to what extent the
intended change has taken place
• e.g. change in prescribing behaviour or
referral rates

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Evaluating the longer-term
outcomes:
• Use formal research to find out long-term
outcomes
• is change actually leading to benefits among
patients and clients?

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Developing an action plan
for change
• What is current practice in the area?
• What outcomes are you trying to achieve?
• What are the benefits for staff and service users?
• Who are the key stakeholders?
• Who will and will not support the proposals and why?
• What are the barriers?
• What strategies can you use to overcome these
barriers?
• What are the enabling factors?
• How will you implement the change?
• How will you sell the change?
• Who can help you?
• How will you measure the success of the project?

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References
• Insightful references concerning Managing
Change in the NHS are available online
from the Health Service and Delivery
Research Programme and Organisation at

http://www.netscc.ac.uk/hsdr/managingchan
ge.html

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