The management of change: an evaluation of the use of a multifaceted strategy to implement best practice in the multidisciplinary assessment of stroke patients

Hamilton, Sharon (2004) The management of change: an evaluation of the use of a multifaceted strategy to implement best practice in the multidisciplinary assessment of stroke patients. (PhD thesis), Kingston University, .


Background The drive to incorporate best evidence into clinical practice is supported by health policy. The implementation of best evidence requires professionals to change their practice. It is clear that in a health system where resources are finite, change should be prioritised towards an area of high burden on the NHS and where chnage would make a difference to patients. Stroke fulfils this criteria as it is a major cause of mortality and morbidity and therefore a major health issue. Furthermore, studies have shown that storke care is poor and assessment is often incomplete. Change is a complex process requiring a multifaceted implementation strategy as this is more likely to change practice, although specific combinations still need to be evaluated. Aim To evaluate the use of a combined strategy (an opinion-leader; guideline; a staff education programme; and a new recording system) for implementing multidisciplonary stroke assessment in an acute hospital setting. Methods A quasi-experimental study design with a pre-test / post-test group which incorporated an evaluation research approach and elements of action research was implemented. Conducted in five inter-related phases over 38 months this encompassed development, implementation and evaluation of the intervention. In Phase 1 (6 months) a diagnostic analysis was conducted using a multi-method approach to identify barriers and faciliatators to change. Phase 2 (9 months) comprised the development of evidence-based guidelines for the multidisciplinary assessment of stroke patients followed by a comparison of current recording practice with these guidelines. This phase also incorporated the collection of patient outcome data (length of stay, hospital mortality and satisfaction. Phase 3 (9 months) comprised the development and implementation of evidence-based guidelines for stroke assessment. Phase 4 repeated the measures of phase 2. Phase 5 comprised a diagnostic evaluation of the change management process and the modelling of 'context-mechanism-outcome' (CMO) configurations to bring together the resiluts of the phases of the study. Results The major findings were that the combined strategy had a variable impact on the practice of all the professions. The greatest impact was seen with the nursing profession. Pre-test compliance ranged between 0% and 95% (median 60%); post-test 39% and 72% (median 86%) demonstrating a 26% improvement in compliance. Fourteen of the 20 nursing profession specific guidelines reached statistical significance. Least compliance occurred in the medical profession whre compliance in the pre-test period ranged between 2% and 91% (median 45%); post-test 25% and 27% (median 27%). No measurable impact on patient satisfaction or patient outcomes was recorded. Conclusion The use of the multifaceted strategy had a variable affect on professional compliance with guidelines. Changing professional practice is a complex process requiring leadership with an opinion-leader and professional staff. Furthermore, a strong commitment is needed from professional staff to enable barriers such as professional power to be addressed. A diagnostic analysis is a useful tool for supporting the implementation of organisational change.

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