Encouraging Best Practice in Residential Aged Care Program: Final Evaluation Report

3.3 - Model of change/implementation

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3.3.1 Model of change

Having a model of change is sometimes referred to in the literature as having a planned approach to change or designing specific interventions based on some form of needs assessment or diagnosis. The importance of considering change at various levels (the individual, the team, the organisation, the broader context) is well-recognised (Ferlie and Shortell 2001; Grol and Wensing 2004), with a multi-level approach implying the need for some degree of organisation and planning. A recent large-scale empirical study of organisational change in health care has identified ‘a coherent change strategy’ as playing a key role in progressing service improvement (Fitzgerald, Ferlie et al. 2007).

The implementation strategies used in the EBPRAC program to change practices are summarised in Table 6, based on a well-recognised taxonomy (Elkhuizen, Limburg et al. 2006; Cochrane Effective Practice and Organisation of Care Review Group (EPOC) 2007).

The range of implementation strategies in Round 1 and Round 2 were similar except for a greater emphasis in Round 2 on changes to improve continuity of care, primarily in the three palliative care projects, and education of general practitioners, in part due to greater involvement of divisions of general practice in Round 2.

All projects included a financial incentive for facilities to participate, usually to cover the costs of staff training. Twelve projects relied heavily on structured education of one form or another to change practice, either educational meetings or educational outreach visits. The mix of implementation strategies summarised in Table 6 is generally consistent with the range of strategies identified in a recent systematic review of dissemination and implementation strategies used by teams working in healthcare (Medves, Godfrey et al. 2010).

For two projects action research was the primary driver of change. Other projects which used action research did so more as a form of evaluation, with less focus on influencing what was implemented in individual facilities. There is variation in how the term is used in the literature but typically action research involves the simultaneous use of data gathering, feedback and action ‘which offers a method of research and intervention and also a process for change’ (Bate 2000, p 491). Action research is commonly used in nursing but a recent review of the literature on using action research to implement evidence-based practice in nursing could only conclude that it was a ‘promising approach’ (Munten, van den Bogaard et al. 2010).

Table 6 Summary of implementation strategies

Category of intervention	No. of projects	Examples
Institutional incentive	13	Back-fill costs for staff training Purchase of equipment
Educational meetings	11	Workshops for ‘champions’ or facility staff
Local opinion leaders (including 'champions' or 'link nurses')	10	Pain champions Falls resource nurses
Distribution of educational materials	10	Development and distribution of flow charts and brochures
Audit and feedback (any summary of performance on providing care)	9	Dementia care mapping Rates of infection
Resident mediated interventions (new clinical information, not previously available, collected from residents and given to the facility)	7	Pain assessments Oral health assessments
Cooperation with external services or communication and case discussion with off site health professionals	6	Nutrition support person External mentor
Changes to improve continuity of care	5	Oral health care plans End-of-life care pathways
Environmental audits	4	Environmental Audit Tool
Changes in physical structure, facilities and equipment	4	Environmental modifications Purchase of beds and hip protectors
Local consensus processes	3	Action research Plan-Do-Study-Act cycles
Clinical multidisciplinary teams (new team or additional members of an existing team)	3	Pain management team Wound care network
Educational outreach visits (also known as academic detailing)	2	1:1 education as part of the prn medications project
Reminders (resident or encounter-specific information intended to prompt someone to recall information)	1	Reminder system for skin tear prevention

Top of page One project used the Collaborative Methodology which is one of the most widely recognised quality improvement methodologies. The evidence base for the methodology is not strong, although positive (Schouten, Hulscher et al. 2008), but this should not be taken as an argument not to use the methodology – it simply reflects current knowledge and is consistent with what is known about quality improvement in general. As far as can be ascertained, the Collaborative Methodology has not been used previously in residential aged care.

The rationale for selection of the various implementation strategies was underpinned by a mix of evidence (e.g. use of education), previous experience (e.g. use of action research) and available expertise. One project did a search of the literature to identify change management strategies that the project could employ.

Elements of planning and diagnosis occurred in both rounds of EBPRAC projects. Diagnosis typically occurred in the form of a baseline audit which then informed what was implemented. Eleven projects implemented changes across all facilities at approximately the same time, whereas two projects took a staggered approach to implementation.

In summary, projects used appropriate interventions to implement evidence-based practice. Many different approaches were taken but with several common elements – a strong focus on education (primarily 1:1 or small-group and interactive), use of local facilitators, feedback of data to staff and provision of resources. All projects used multiple interventions to bring about change, averaging seven per project, which is recognised as more effective than reliance on single strategies.

The mixed results for the impact of the program (see Chapter 4) indicate that there are no ‘magic bullets’ for successful implementation of evidence-based practice in residential aged care, which is consistent with current knowledge in the literature. The various strategies such as education or audit and feedback are not ends in themselves but means for increasing staff skills, gaining insight into why change is necessary or understanding the benefits of change. Education is necessary, but not sufficient, for change to occur (see Section 4.4). More definitive evidence of ‘what works’ in what circumstances requires further research.

3.3.2 Activities of project staff

Another indication of the approach taken by each lead organisation can be seen in an analysis of how staff employed on projects spent their time. Table 7 summarises the activity of project staff according to four main categories – project governance, project establishment, project implementation and project evaluation – for each project, based on data provided by projects in the economic evaluation spreadsheet. Averaged across all projects, approximately one quarter of project staff time was spent on project governance and establishment, one quarter on evaluation, with half the time spent on implementation.

Table 7 Percentage of project staff time by purpose and activity

Project activity	Project													Av.
	1	2	3	4	5	6	7	8	9	10	11	12	13
Governance	22	13	8	23	25	23	3	27	15	14	23	18	6	17%
Establishment	3	2	3	4	2	5	7	4	15	6	8	3	7	6%
Implementation	59	33	77	59	30	64	53	53	50	63	30	63	68	51%
Evaluation	15	51	12	14	43	8	37	16	20	17	39	16	19	27%
Total	Each column totals 100%

The data should be treated with some caution as the percentages are estimates only. For example, it is very difficult in some cases to separate out time spent on implementation from time spent on evaluation when a particular activity (e.g. baseline auditing) may have been used both for evaluation and implementation (by feeding the results back to facility staff to inform goal setting and action plans).

Of the time spent by project staff on implementation Table 8 summarises how that time was spent on project implementation activities, averaged across all projects.

Table 8 Percentage of project staff time spent on implementation activities, across all projects

Implementation activities	Percentage
Preparing and running education of one form or another (workshops, academic detailing, on-the-job training).	12.9%
Development and dissemination of policies, protocols, procedures and educational materials.	8.8%
Working with facilities to identify priorities for implementing evidence based practice/quality improvement.	7.3%
Assessment of residents.	5.6%
Identifying, working with and supporting a facility based ‘champion’ who takes the lead in implementation within the facility.	5.4%
Assessment/audit of facility performance or adequacy.	5.3%
Feedback and discussion of results of assessments/audit with facilities. This includes assisting facilities to develop a response to the results of an assessment/audit.	4.2%
Other activities	1.4%
Total	50.9%

Despite the different approaches used by each project there was a strong concentration of effort on a small number of activities – organising and supporting education, undertaking assessments of one form or another, supporting facility-based champions and working with facility staff to understand audit results and identify priorities for action.
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3.3.3 Local facilitators

Facilitation is used frequently to implement evidence-based practice, often in the form of facilitation by individuals. Facilitation is the process of enabling (or making easier) the implementation of evidence into practice (Harvey, Loftus-Hills et al. 2002). Despite the large body of literature ‘there are few explicit descriptions or rigorous evaluations of the concept’ (Harvey, Loftus-Hills et al. 2002, p 585). Eleven projects used some form of local facilitator, variously described as a ‘champion’, ‘link’ or ‘resource’ person, in some cases backed up by an external facilitator such as a ‘best practice manager’ or ‘nutrition support’ person. In some projects specific training for the role was provided. In one of the behaviour management projects (Hammond Care) there was no internal facilitator but an external mentor instead. The local facilitators had quite different roles, ranging from relatively passive ‘contacts’ for the transmission of information between project staff and facility staff to more active change agents. In total, 177 facility-based champions were trained as part of the EBPRAC program.

The diverse range of roles amongst facilitators in the EBPRAC program is reflected in the literature where the concepts of opinion leaders, facilitators, champions, linking agents and change agents are not clearly defined and are used inconsistently, making it difficult to compare results across studies that have investigated these roles (Thompson, Estabrooks et al. 2006). There is little empirical evidence on how best to identify organisational champions and harness their enthusiasm (Greenhalgh, Robert et al. 2004).

The particular role adopted by facilitators will determine the personal attributes required to be effective in that role. Given the range of roles across such diverse projects it is not possible to be definitive about what makes a ‘good’ facilitator. Facilitators, irrespective of their name and role, cannot be considered in isolation from other factors such as the resources available to undertake their role (some projects paid for facilitators to be released from their normal duties), the support they receive from their managers and the support they receive externally. It has been argued that ‘no amount of empirical research will provide a simple recipe for how champions should behave that is independent of the nature of the innovation, the organizational setting, the socio-political context and so on’ (Greenhalgh, Robert et al. 2004, p 615).

However, based on the experience in the EBPRAC program, it is apparent that facilitators should be respected members of staff, who are enthusiastic about the role, have good knowledge of the staff and the facility they work in, and have good communication skills:
In order for these sorts of projects to work well, we need to have the champions to be passionate people. There’s no point putting someone into a champion role who is a bit lukewarm. You need to have someone who’s excited, keen to be driving the project. You need to have someone who’s got some intelligence. You need to have someone who’s got some good facility knowledge and knows the staff they’re working with and knows the things that will work and the things that won’t. They need to be someone who’s accountable to deadlines and timeframes. (F)
Where they’ve made a good choice and they’ve empowered them, its’ worked really well … I think the bottom line is it needs to be somebody who is respected in the organisation … who their peers will listen to and who has a good communication skill so they can talk to management about what they require and be an advocate for what’s going on, but also not be afraid of taking on staff in the sense of the way in which they can alter the way they provide support to different people. (P)
This person was highly motivated, highly engaging, well liked, respected … she spent a lot of time helping out other staff do other things, which really helped build a collegial relationship which meant that people would try to travel further for her, in whatever she was asking to do. (P)
It is important that facilitators are not working without support. As indicated in Section 3.5.1 they should be supported by their managers. Support can also come from elsewhere:
A lone champion is not an effective way to facilitate change in practice. It is essential that there is a team approach either with a champion supporting other staff structures to facilitate change or a small group of key staff to drive change at different levels/points in the process. (T4).
Facilitators in the EBPRAC program received considerable support from project teams, support that would not be available to them in day-to-day practice. There is a need to be cautious about drawing conclusions about the facilitator role based on experience in the EBPRAC program. Only two of the projects identified the champion role as an ‘essential ingredient for success’ (the wording used in one of the questions in the six-monthly project progress reports):
The funded best practice champion position is essential not only in terms of their role within the organisation and the consortium activities, but also as a demonstration to the organisation that having such a role, even with a minimal .2 EFT can be effective in implementing change. (T2)
Having an enthusiastic and dedicated resource nurse appears to be critical. (T3)
The lead organisations tended to identify (in project progress reports) the ‘essential ingredients for success’ in broader terms than just the local facilitator role, referring to:
engagement of interested people
trust and good communication between the key staff
a committed and enthusiastic senior member of the aged care staff to facilitate uptake of the learning initiatives amongst all staff
recruit a supportive team with leadership and change management skills
the project must be supported by credible, known local leaders
It may be that the more useful way of considering this issue is that when there is a need for change to be ‘facilitated’ that this work can come from a formally appointed ‘champion’ but it can also come from other people in leadership positions e.g. people in management positions, clinical leaders (typically registered nurses) or informal leaders.

In summary, a large number of local facilitators were trained by the projects but there was no consistent evidence about the effectiveness of the role. In part, this may be due to the differing roles and responsibilities of the facilitators.

It is apparent that the concept of ‘champions’ is well established across the sector and given the resources devoted to the role it would be useful to know more about whether it is effective. Consideration should be given to undertaking further research to identify how best to select champions, how best to train champions, how best to support champions or even whether the champion model is effective at all.
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