Making changes to improve care

Once you have identified the best available evidence that is relevant to the problem or issue of your patient or population your thoughts might turn to how to implement the change.

Adoption of changes will require support from the patient or population and relevant members of your organisation.

Here you will learn to:

  • About approaches to applying evidence in practice
  • Shared decision-making and communicating risk/benefit
  • Barriers to the uptake of evidence

Getting started

Your search for evidence began with an issue or problem in relation to a patient. After identifying and appraising relevant evidence you will need to summarise your findings and consider whether change is warranted. The best evidence may confirm your practice is appropriate. The evidence may show you something new to implement or show something new that would not be appropriate to implement in your care context. That is the decision to make.

Summarise the evidence

Where there is only one review to consider then your appraisal checklist might serve as your summary. If you have multiple reviews to consider then an overall summary reflecting all of the findings will be needed. Consider: Does the evidence answer your question? Is the evidence of good quality and is it relevant to your patient? If so, what changes are proposed to address the original issue or problem?

Plan to introduce the change

Consider how you will introduce this change. Evidence-based care requires integration of evidence within the local context of care as well as with patient preferences and values, their health condition and context, and your professional expertise. Bringing about change can be challenging when attempting to combine each of these elements.

Before implementing changes, a plan can be helpful. There is no prescribed plan for EBP application. Use the steps outlined below to develop your own plan tailored to your needs and context.

The evidence-to-practice pipeline describes steps for EBP implementation. [1] In summary the steps correspond to activities to:

  • raise awareness of the proposed change,
  • gain acceptance of its worth, and then
  • support patients and health professionals with what is needed to take this up into practice and to sustain the change.

Taking it further

If you then want to introduce changes more widely such as across a department then Wensing and Grol [2] tell us that a systematic approach is essential, and this requires preparation and planning. Their implementation of change model provides more detail on what is required across the following steps:

  1. Develop a proposal for change that clearly communicates attributes such as advantages (and how they outweigh any disadvantages), alignment with current values and standards, and feasibility.
  2. Analyse the actual performance before change and highlight any deviations from desired care, identify problem areas including barriers, but also useful facilitators for change.
  3. Develop a strategy for change including how you plan to work with health professionals and patients to raise awareness and gain acceptance (this requires you to understand your target group including their relationships within the group and their motivation for change), and how you will measure the impact of changes.
  4. Integrate changes into care and support conditions required to sustain change.
  5. Ongoing evaluation of outcomes and revision of plans where needed.

Having found relevant evidence that offers an option for addressing a patient issue or problem you may want to share this information with them so that a decision can be reached in collaboration. In palliative care shared decision-making is likely to involve both the patient and family as well as members of the health care team. It can be a way for patients to exert some control over their situation in challenging circumstances.  Whether and how much patients want to be involved will vary across a continuum and over time. [3]

Shared decision-making might be viewed as 'a mechanism for applying evidence with an individual patient through personalising the clinical decision.' [4] It is not simply informing the person. To be a part of decision-making the patient needs to understand the potential risks and benefits of any change. How they understand the information provided will be affected by their emotions and personal values. Hoffman suggests five simple questions that can be used by clinicians to guide the process: [4]

  • What will happen if the patient waits and watches?
  • What are the test or treatment options?
  • What are the benefits and harms of each option?
  • How do the benefits and harms weigh up for the patient?
  • Does the patient have enough information to make a choice?

Working with patients to understand risks and benefits

Decision-aids are one way of helping patients to understand risks and benefits, For patients you will need to consider proposed changes in line with their circumstances and how their values might affect the balance of risks and benefits of any proposed care options. [5]

Understanding the risk versus benefit for any proposed changes in care can help patients to make decisions about whether it is acceptable to them. This will also help you to know and discuss your patient’s values and preferences and any concerns or questions they may have. The Australian Commission on Safety and Quality in Health Care have eLearning and decision support tools to help with this.

Implementing change requires a range of strategies to assist all stakeholders to understand and support the proposal. Consideration of the likely facilitators and barriers to change will help you to design a strategy that is more likely to be accepted.

Common barriers to implementing change include: 

  • Social factors in relation to patients. [2] This might relate to their knowledge, attitude (personal and within their social network), or opinions of respected others.
  • Professional (e.g. knowledge, attitudes and skills, habits of practice) [6]
  • Professional-patient interaction barriers (e.g. communication and information processing issues) [6]
  • Structural barriers (e.g. financial disincentives) [6]
  • Organizational barriers (e.g. inappropriate skill mix, lack of facilities or equipment, financial barriers) [6]
  • Peer group barriers (e.g. local standards of care not in line with desired practice) [6]

  1. Glasziou P, Haynes B. The paths from research to improved health outcomes. BMJ Evid Based Med. 2005 Feb;10(1):4-7.
  2. Wensing M, Grol R, Grimshaw J. editors. Improving Patient Care: The Implementation of Change in Health Care. 3rd ed. Wiley-Blackwell. 2020 Feb. Web.
  3. Kuosmanen L, Hupli M, Ahtiluoto S, Haavisto E. Patient participation in shared decision-making in palliative care - an integrative review. J Clin Nurs. 2021 Dec;30(23-24):3415-3428. doi: 10.1111/jocn.15866.
  4. Hoffmann TC, Légaré F, Simmons MB, McNamara K, McCaffery K, Trevena LJ et al. Shared decision making: what do clinicians need to know and why should they bother? Med J Aust. 2014 Jul 7;201(1):35-9. doi: 10.5694/mja14.00002.
  5. Guyatt GH, Haynes RB, Jaeschke RZ, Cook DJ, Green L, Naylor CD et al. Users' Guides to the Medical Literature: XXV. Evidence-based medicine: principles for applying the Users' Guides to patient care. Evidence-Based Medicine Working Group. JAMA. 2000 Sep 13;284(10):1290-6. doi: 10.1001/jama.284.10.1290.
  6. Grimshaw JM, Eccles MP, Lavis JN, Hill SJ, Squires JE. Knowledge translation of research findings. Implement Sci. 2012 May 31;7:50. doi: 10.1186/1748-5908-7-50.

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