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Study Title Study Lead Health & Social Care
Partner Organisations
Lay Summary
Managing Patient Safety Evidence in Birmingham Children’s Hospital (Service Theme 1) Dr Brian Litchfield-Cant,
Warwick Business School
Birmingham Children’s
Hospital NHS Foundation Trust
The ability to learn from evidence is critical to keeping patients safe. However, these evidences are highly complex, increasingly diverse, and frequently distributed across multiple systems. As a result, whilst healthcare organisations have access to a lot of evidence, this evidence does not always shape what they do. Birmingham Children’s Hospital is committed to manage evidence to ensure that patients are kept safe in a sector leading way. We have therefore established a group of research projects which support them achieve this ambition, and also helps other hospitals learns from them.
Because of the complexity and importance of this work, we are taking a multi-staged approach to investigate different dimensions of evidence management (acquisition, assimilation, transformation and exploitation). We are also researching different levels of this work i.e. evidence management across networks, teams and individuals. The first stage of research seeks to capture insights at the corporate management and governance level of risk evidence. We will conduct non-participatory observations of hospital risk committees and interviews with staff. Our findings will help shape strategic-level practice; they will also help identifying future stages of research.
The second stage of our research will develop insights about how evidence flows around an origination. The specific projects we research will depend on our first stage findings, but this will include researching things like the hospitals performance dashboard. We will look at how middle leave practices affect how these tools are used, for example the perceived tension in using a performance dashboard as management tool for control, and an early warning system for safety. We may also look at how patient experience evidence is captured and exploited across the hospital. The final stage of research focuses on the contextual challenges of learning from evidence at the front line of service provision. This stage of research includes a four-year Ph.D. project focusing on patient safety in day-to-night handover. Other project may including things like safety case methodology to proactively manage safety or the use of electronic prescribing.
Across these three phases, researchers will undertake qualitative research to capture rich contextual details which is often missing in this kind of research. We will interview staff and other stakeholders (e.g. regulators), whose behaviours affect the translation of evidence into clinical practice. We will observe forums through which evidence is processed, such as the various clinical governance committees. We will study documents for insights about Birmingham Children's hospital and also for wider contextual evidence.
Evidence into practice: applying absorptive capacity to the case of STARTBACK (Service Theme 4) Dr Helene Lambrix
Stoke-on-Trent Clinical Commissioning Group; North Staffordshire Clinical Commissioning Group STarT Back - stratified care for low back pain - includes a screening tool, which assesses and stratifies patients with back pain according to their individual risk of developing persistent, long-term back pain, with matched treatment pathways which target those risks, and to which patients may be fast-tracked. In the research trial, Keele University researchers showed that the use of the STarT Back approach could both improve patient outcomes and reduce costs. An implementation study also demonstrated similar clinical and cost effectiveness outcomes to the research trial, in particular:
• physiotherapy services could be geared to providing targeted treatments according to patients’ individual levels of risk.
• the use of the STarT Back screening tool was feasible in General Practice.
• STarT Back was effective in targeting medium and high risk patients with more effective treatments while reducing referral rates for low risk patients.
The research was well received in health care contexts and gained the attention of wider society through positive media reporting. Keele University were particularly motivated to ensure that STarT Back prove as effective in practice as the research promised and, through a dedicated implementation team, have been driving the implementation in selected locations.
Our study aims to review and in part follow the STarT Back implementation journey as it is adopted by practitioners, learning about the issues the implementation team and the practice locations face as they embed world class research into everyday practice. We follow a similar approach to our study of the implementation of the maternity triage by adopting a social science perspective of how knowledge and innovation can become embedded within organisations. The data analysis will be based on interviews, observations and documentation and guided by relevant theories enabling cross-case learning between studies.
BSOTS - Feasibility study for implementation in other maternity trusts of a maternity triage system developed during the CLAHRC pilot
(Service Theme 1)
Karl Prince,
Warwick Business School
Heart of England NHS Foundation Trust; University Hospital of North
Staffordshire NHS Trust
Case background
The Birmingham Symptom-specific Obstetric Triage System (BSOTS) was developed, in a collaboration between University of Birmingham researchers and Birmingham Women’s Hospital health care professionals, in response to an identified need for a standardised triage system to prioritise the clinical urgency of women during unscheduled pregnancy related attendances. The triage system, similar to those utilised in Accident and Emergency departments, involves a standardised initial assessment within 15 minutes of arrival to determine the level of clinical urgency and then provide the appropriate standardised care and investigations. An initial pilot of BSOTS has suggested that it offers a reliable method of triaging women, and that midwives feel the safety of woman and baby had been improved. This initial success has prompted researchers to begin a wider rollout to a few additional sites in order to demonstrate and understand how BSOTS performs in other contexts beyond the initial pilot site.
HECTOR – Heartlands Elderly Care, Trauma & Ongoing Recovery Project. A service-level evaluation of a pilot programme designed to improve outcomes for elderly patients sustaining trauma injuries (Service Theme 4) Dr Brian Litchfield-Cant,
Warwick Business School
Heart of England NHS Foundation Trust Hector stands for Heartlands Elderly Care, Trauma and Ongoing Recovery Project. The aim of this project is to improve outcomes for elderly patients who sustain trauma injuries. At the moment, the evidences which shape trauma care are rooted in the experiences of military and general civilian personal. As such care practices does not adequately account for age related evidence. To improve Trauma services HECTOR delivers a holistic care package shaped by new evidence about elderly patients. Birmingham University is evaluating the outcomes of HECTOR. Warwick Business School is focusing on how the scientific evidence which drove HECTOR is translated into healthcare practice. In particular, we are looking at the roles, strategies and properties that support or hinder effective translation of evidence into clinical practice. With these insights, we will be able to help support the faster, more complete and effective translation of research into practice. It is the hope of the Hector team (Birmingham University, Heart of England Foundation Trust and Warwick Business School) that these improvements will then be rolled out to other hospitals.
Integrating primary and secondary care mental health services: a new role for nurse practitioners in Birmingham and Solihull Mental Health Trust Dr Giovanni Radaelli,
Warwick Business School
Birmingham & Solihull
Mental Health Foundation Trust
This project investigates the development and implementation of a new organizational role, i.e. Advanced Nurse Practitioners, in the Birmingham and Solihull Mental Health NHS Foundation Trust (henceforth, BSMHFT). The introduction of Advanced Nurse Practitioners is part of a broader project of ‘workforce development’ that is aimed to improve the integration of primary and secondary care in mental health services. Advanced Nurse Practitioners are nurses with broadened responsibilities of clinical leadership and supervision, e.g. in terms of diagnosing medical problems, independently prescribing medications for symptoms, and performing advanced treatment procedures. The reorganization in BSMHFT requires these Advanced Nurse Practitioners to take on roles previously carried out by Community Psychiatrists in secondary care; i.e. to liaise with primary care practitioners (mainly GPs, but also other healthcare professionals in GP Practices) to triage patients presenting potential mental health conditions.
The objectives of this reorganizations are thus to encourage primary care practitioners to deal with routine or lower risk cases in primary care, rather than refer these onwards to secondary care and, consequently, have them to refer to secondary care only the more complex or high risk cases. The main prospective impacts of this reorganization are: (i) reducing the number of referrals to secondary care of low-risk patients, with consequent cost reduction and better caseload management for high-risk patients; (ii) developing competence for practitioners in primary care to improve the management of low-risk patients; (iii) developing the knowledge and competences of nursing professionals to support the clinical work multiprofessional and multidisciplinary teams.
This reorganization of primary and secondary care in mental health services is currently in the process of being rolled out into practice. The first phase of this rollout will involve the development of capability of Nurse Practitioners for their new, expanded, role; the development of criteria to triage patients with mental health problems with a particular need to identify those to be managed in primary care rather than secondary care. From the perspective of CLAHRC-WM Theme 5, this process provides an important opportunity to follow and acquire important insights on how an innovative role (such as the Advanced Nurse Practitioners, which are increasingly adopted in UK and US practice as a new standard of practice) are developed, adapted, and integrated in traditional practice.
Implementing ‘Patients Know Best’: Personal Health Records pilots in Sandwell and West Birmingham Hospitals NHS Trust Dr Giovanni Radaelli,
Warwick Business School
Sandwell and West
Birmingham Hospitals NHS Trust
This project investigates the implementation of Patients Knows Best (henceforth, PKB) technology in Sandwell and West Birmingham Hospitals NHS trust (henceforth, SWBH).
PKB represents an electronic personal health record which differs from traditional medical records as they (i) give control to patients over the access and use of clinical information and (ii) connect in an integrated system, health information that is currently fragmented and dispersed across different institutions. The effectiveness of personal health records is currently debated, since arguments for higher cost-effectiveness (especially ensued by the integration of data) and patient empowerment (especially ensued by increased patient control over their information) are balanced by professional concern related to loss of control and misuse of data and by several false starts in the past, such as the Google Health platform launched in 2008 and withdrawn in 2011. These failures have been attributed primarily to issues related to the implementation and acceptance of the new systems from providers and patients, rather than to technical limitations.
Drawing upon this, we look with specific interest to the local experience of SWBH, which has already piloted PKB in the Clinical Immunology service and is now extending first it to the National Behcets service based at the Birmingham and Midlands Eye Centre, and then to Diabetes and Rheumatology services based at Birmingham City Hospital. The PKB pilots in SWBH are currently pursuing multiple objectives, such as engage with established patient groups and clinicians in each of the above clinical areas to promote knowledge, engagement and uptake; facilitate e-communication with GP and other specialists through the PKB system; enable professional advice from e-access for patient in order to reduce inappropriate hospital follow up; define and assess the benefits of PKB uptake to scale-up its implementation to whole trust.
Implementation of the NHS Health Check Programme in Coventry and Warwickshire
(Service Theme 3)
Dr Brian Litchfield-Cant, John Leenen
Coventry County Council, Warwickshire County
This project investigates the implementation, uptake and effectiveness of the NHS Health Check programme across GPs and pharmacies in Coventry and Warwickshire.
The Health Check programme is a national programme of primary prevention launched in 2009 by the Department of Health. The programme, now a mandatory Local Health service, targets people aged 40-74 without a previous cardiovascular diagnosis, and assesses the top seven causes of preventable deaths, i.e. high blood pressure, smoking, high cholesterol, obesity, poor diet, physical inactivity and alcohol consumption. Through the early identification and management of these risk factors, the programme aims to prevent diabetes, chronic kidney disease, dementia and cardiovascular disease and thus reduce morbidity, mortality and health inequalities.
Currently, evidence on the effectiveness is still limited (one RCT and six cross-sectional or cohort studies) and provides contradictory results on increases in the detection of risk factors, in the prescription of statins and in the reduction of patients’ risk scores and risk factors. Furthermore, patients’ uptake of the programme is substantively lower than the expected 70% target. Qualitative studies have highlighted that one way to understand these contradictory results might be how the programme is implemented locally. These studies have in fact found important variations in multiple dimensions, such as the staff conducting health checks, training, risk score, communication of advices and access to internal and external services. Taken together, current evidence emphasizes the need for more research that could provide less contradictory evidence on the effectiveness of NHS Health Checks as well as diverse type of research that could link information about the local variations in the implementation of the programme with quantitative indicators of effectiveness and uptake.
Drawing upon this concern, our project adopts a mixed methods approach with pursues two main objectives: (i) describe and assess the heterogeneity of Health Check programmes implemented within Local Authority areas and (ii) produce evidence on the link between these different local programmes and indicators of uptake, process outcomes and (where data permit) health outcomes. First, we investigate how the legal framework provided the “Regulations 2013” (which posited a unique implementation model) has been translated locally in different solutions. We seek to: identify the different implementation model that coexist in Coventry and Warwickshire; cluster these according to the nature of invitation (e.g. rate and type of invitation) and management (e.g. tests included; key players); explain why and how GP practices have developed their version of the programme (e.g. contingencies that motivated specific adaptations to the national model). Second, we develop statistical models to explain the predictors of uptake and process outcomes. The models will include predictors at multiple levels of analysis, such as properties of the eligible population (e.g. socio-demographics), of the provider (e.g. location, typology) and of the intervention. Differently from previous quantitative research, we will embed in the statistical model also predictors measuring variations in the local implementation of the programme, in order to highlight also if specific implementation model or organizational features are correlated with higher uptake or effectiveness.
Developing a whole-system Management Network for Medically Unexplained Symptoms in Birmingham and Solihull Mental Health Foundation Trust and Sandwell and West Dr Giovanni Radaelli,
Warwick Business School
Birmingham and Solihull Mental Health Trust This project investigates the development and implementation of a new system for detection and management of patients with Medically Unexplained Symptoms in the Birmingham and Solihull Mental Health NHS Foundation Trust.
A New Vision for Patient Safety Learning: Conceptualizing Unlearning in Routines and Practices Prof Graeme Currie, Warwick Business School Heart of England NHS Foundation Trust This PhD will examine organizational learning and service development following root cause analysis (RCA) of serious patient safety incidents through identifying the barriers and enablers to learning. Healthcare is a rich empirical setting for carrying out research grounded in organisational studies, in particular theories related to professional power, knowledge management, and organisational learning. Unfortunately, it has been found that hospitals rarely learn from failure: several researchers have hypothesized this is the result of challenges and barriers including a prevailing culture of blame, an organisational environment that promotes quick fixes and work-arounds, and a normalization of deviance among staff, who view patient safety incidents as normal and routine. There have been numerous studies analysing the efforts of healthcare organizations to learn from patient safety incidents to prevent recurrence. These studies have generally focused on identification of risks, analysis of patient safety incidents using tools such as RCA, and sharing of lessons learned via publishing formal reports of recommendations for improvement. There has been little research that investigates how healthcare organizations are ac-countable for implementing, embedding, sustaining and monitoring these recommendations, and to ensure service improvements are made, which prevent reoccurrences and improve patient safety. This PhD will focus on analysing these critical steps of the patient safety learning process through a qualitative study of three RCA case studies at the Heart of England NHS Foundation Trust that will include interviews with staff, committee observation, and documentation reviews. A historical review of RCA practice in high reliability industries such as aviation, manufacturing, and nuclear power will be analyzed to understand how RCA has been successfully utilized to improve safety in these industries, and what lessons can be learned for healthcare. RCA success from these industries will be looked at critically to determine what role professional power and knowledge has played in safety improvement and learning initiatives, and how we can apply this to healthcare. Theoretical development will be iterative in nature and involve a back-and-forth between the existing literature, data collection, and data analysis.
Handover and Innovation at a Children's Hospital Prof Graeme Currie, Warwick Business School Birmingham Children's Hospital In 2013, a team of medical, nursing and management professionals at Birmingham Children's Hospital (BCH) gained funding support from the Health Foundation to increase the safety of handovers between their day and night clinical services across the hospital. Since legal changes to the hours people can work were put in place in hospitals from 2009, a hospital-wide service has been co-ordinating and delivering services for the children and young people receiving treatment and care at night. The Hospital@Night (H@N) team attends and participates in a comprehensive handover every evening as they commence their work, and then hands over to clinical specialty-based staff every morning.Information had been collected which showed that these handovers were too long, complex, poorly organised and were implicated in avoidable errors in patient care.However, new understandings of and approaches to handover have been developed in many hospital settings. An exciting development in the US has offered a new format for handover. Early indications have suggested that this has made a positive contribution to patient safety and quality in a leading US Children's Hospital.Experts advising the team at BCH helped to devise a package which built upon the successes in the US. Three new elements were introduced: an electronic handover system; a new handover tool/framework which encourages increased awareness of relevant information; and, a new online training package to support staff. With support from the dedicated team at BCH attempts have been made to introduce this package across the hospital. However, to date, only the electronic handover system has been successfully implemented. It isn't entirely clear why this has occurred.This doctoral study aims to examine the introduction of new and safer ways of working by clinical staff such as doctors and nurses at Birmingham Children's Hospital (BCH). In particular, one focus will be upon attempts to support staff in becoming and remaining aware of their working environment. In the hospital setting, this is especially important where some information may not seem important at the time it emerges and might otherwise be overlooked or disregarded. There is published research evidence that organisations such as hospitals, which operate in the face of high levels of risk and uncertainty, should develop a range of approaches to becoming more mindful of a wider array of information in support of safety.The study will gather data from observations of and interviews with key staff members. Documentary evidence will also be collected. Analysis of this data will afford opportunities to gain deeper understanding of the introduction and implementation of patient safety innovations in UK hospital settings.
Understanding the experiences of patient and public involvement in research implementation in CLAHRC-WM: A longitudinal study of the role of public advisors Dr Alison Hipwell, Warwick Business School   A lot of work has looked at Patient and Public Involvement (PPI) in research, but there has been less looking at PPI in service delivery. In both areas, we know little about what PPI works, for whom, why, and where. There are also limited definitions of PPI and what it actually is. Few studies have looked at PPI reference groups and the experiences of the advisors who contribute to the groups. This study will look at some of those research gaps; it is part of the Collaborations for Leadership in Applied Health Research and Care West Midlands (CLAHRC WM) Implementation Science and Organisation Studies (ISOS) theme of work, based at Warwick Business School. The ISOS work theme looks at ‘implementation’ - identifying how, where and why research findings can be turned into services for patients, which use the evidence-base of what works. So the proposed study will look at what PPI is in CLAHRC WM, and how it contributes to the work of the CLAHRC, including implementation.
PPI in implementation: towards a research agenda Dr Lee Gunn, Warwick Business School   There is very little work published on the subject of patient and public involvement (PPI) in the implementation of evidence in healthcare. It appears that different understandings of PPI and of implementation make this a difficult subject to research effectively. We decided to review publications that might help us to understand how PPI and implementation are thought about in different research traditions, and to build on these foundations.
Our study draws on methods outlined by Greenhalgh and colleagues for their work on the diffusion of innovation. We consulted experts on patient and public involvement and on the implementation of evidence in healthcare, and also held discussions with patient and public involvement advisors for the West Midlands Collaboration for Leadership in Applied Health and Care. We identified key journals and papers from many different research traditions, to gather a wide range of ideas. From these, we have selected a set of concepts which we are using to suggest a framework for further research, based on PPI roles and on ideas about absorptive capacity in the complex context of healthcare. (21/102015)
Evaluation of impact of PPI Advisor role in implementation of research evidence in practice Dr Sophie Staniszewska, Warwick Business School    
Managing Patient Safety Evidence in Birmingham Children’s Hospital - SAFE project Dr Brian Litchfield-Cant, Warwick Business School    
The ‘Mental Health Service for Children and Young Adults aged 0-25’ in the Greater Birmingham Area: translation of evidence during the development and implementation of a new integrated service Dr Giovanni Radaelli, Warwick Business School Birmingham Children's Hopistal (Forward Thinking Birmingham), University of Warwick The project investigates the design and implementation of a community and inpatient mental health service for children and young adults aged 0-25. The new service has been commissioned by Birmingham South Central CCG and aims at improving the management of patients in the teenager-adult transition. Before its introduction, patients aged 16-25 experience three separate pathways (i.e. 0-16; 16-18 and adult pathway 18+ patients), each with a different approach and providers. Such segmentation has led to poor clinical outcomes and patient and carer experience. Research-based evidence has called for an integrated pathway, where 16-25 patients are managed with a single approach and set of providers, thus avoiding dramatic transitions in terms of service and settings of care.From the perspective of CLAHRC WM, the development and implementation of the 0-25 Service are extremely precious to investigate how a complex network of organizations acquires, negotiates and transforms knowledge (and, in particular, research-based evidence) to address macro-level demands from patients and commissioning groups as well as micro-level demands and requirements within organizations and professionals groups. In particular, it represents an important occasion to investigate how networks of healthcare providers are able to organize their professional frontline (typically careful to protect their autonomy and practices) for a radical change. Following this, we will investigate the ‘translation’ of knowledge as a complex and pluralist phenomenon, i.e. we will investigate how actors in the network use and transform a combination of research-based evidence about clinical and cost effectiveness, patient/carer experience, clinicians’ experiences and viewpoints – to address external and internal demands.Methodologically, our research follows the translation ‘journey’ through which preliminary ideas and templates of reinventing the service are translated into actual practice. Particularly, the process leading to the identification of Forward Thinking Birmingham as preferred provider will be investigated through a retrospective case study; while the implementation process will be investigated in real-time and prospectively. We will in particular investigate: (i) how different partners had developed their proposal (i.e. how they acquired, assimilated and transformed evidence to outline a 0-25 service that proved particularly successful in eliciting CCGs’ positive response); (ii) how CCGs have identified the preferred provider and managed the bidding process; (iii) how the knowledge/evidence embedded in service proposals are translated and possibly transformed during the actual implementation in real-life contexts (and thus: what is the fidelity between the original proposal and the implemented service, and what explain the differences); (iv) how evidence has been selected, used, interpreted, adopted and created throughout these processes; (v) what are the interactions between different personnel within a wide and heterogeneous network of healthcare, social care, and other organizations.
Triage project on infection control Dr Brian Litchfield-Cant, Warwick Business School University Hospital Coventry & Warwickshire  
Increasing Organizational Learning in an NHS Hospital Dr Kelly-Ann Schmidtke, Warwick Business School Heart of England NHS Foundation Trust  
Improving statistical data visualization to inform decisions about healthcare safety Dr Kelly-Ann Schmidtke, Warwick Business School Heart of England NHS Foundation Trust This PhD will examine organizational learning and service development following root cause analysis (RCA) of serious patient safety incidents through identifying the barriers and enablers to learning. Healthcare is a rich empirical setting for carrying out research grounded in organisational studies, in particular theories related to professional power, knowledge management, and organisational learning.
The midwifery support worker role Prof Eivor Oborn, Warwick Business School Birmingham Women's Hospital and other partners  
Organisational Mindfulness and Healthcare Prof Graeme Currie, Warwick Business School University Hospital Coventry & Warwickshire  
Modelling The Healthcare Pathway for Individuals with Frailty Prof Leroy White, Warwick Business School Shrewsbury & Telford Hospitals