Research Australia Turning What We Know Into What We Do August 2017

Turning what we know into

what we do Date: 24 August, 2017 Macquarie University, AU

Jeffrey Braithwaite, PhD, FAIM, FCHSM, FFPHRCP, FAcSS, Hon FRACMA Professor and Director Australian Institute of Health Innovation Director Centre for Healthcare Resilience and Implementation Science Australian Institute of Health Innovation

Our mission is to enhance local, institutional and international health system decision- making through evidence; and use systems sciences and translational approaches to provide innovative, evidence-based solutions to specified health care delivery problems. www.aihi.mq.edu.au Australian Institute of Health Innovation Australian Institute of Health Innovation

•Professor Jeffrey Braithwaite • Foundation Director, AIHI; Director, Centre for Healthcare Resilience and Implementation Science •Professor Enrico Coiera Director, Centre for Health Informatics •Professor Johanna Westbrook Director, Centre for Health Systems and Safety Research Australian Institute of Health Innovation Implementation Science

The Journal “Implementation Science” has a core aim:

To get evidence into practice Implementation stages: A linear path?

• Early in EBM movement we construed knowledge translation in linear terms • Knowledge ‘pipeline’ The ‘Knowledge Pipeline’

Cooksey, D. (2006). A review of UK health research funding. The Stationery Office. The pipeline is an idealisation

Blockages and fractures

POLICY AND BASIC RESEARCH BEDSIDE PRACTICE Basic Research Clinical Practice across the T2 T1 Human Clinical Research system Preclinical Studies Case Studies Animal Research Phase 1 and 2 Controlled Observational Studies Delivery of recommended care to Basic Health Services Research Clinical Trials Phase 3 Clinical Trials and Health the right patient at the right time Epidemiology Services Studies Identification of new clinical questions and gaps in care

TRANSLATION TO HUMANS

T2 Practice Based Research T3 Guideline Dissemination Development Phase 3 and 4 Trials Research Meta-Analysis Observational Studies Implementation Systematic Reviews Survey Research Research

TRANSLATION TO TRANSLATION TO Failure PATIENTS, POLICY POLICY AND AND PRACTICE PRACTICE

Westfall JM, et al. (2007) JAMA, 297(4):403-6. Increasingly sophisticated models

Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Quarterly, 82(4): 581-629. Still: the challenge of implementation

Systems-level studies of care that are in line with evidence or consensus based guidelines

1. McGlynn et al.—US adults, 2003 54.9% 2. Margione-Smith et al.—US children, 2008 46.5% 3. Runciman et al.—Australian adults, 2012 57.0% 4. Braithwaite et al.—Australian children, 2017 XX%

11 Still: the challenge of implementation

Work-as- Work-as- done imagined

Wears, R. L., Hollnagel, E., & Braithwaite, J. (Eds.). (2017) Resilient Health Care: The Resilience of Everyday Clinical Work. Surrey, UK: Ashgate Publishing, Ltd. 12 Implementation: not like this …

So work-as-imagined folks often have some sort of linear, mechanistic view of the system.

13 More like this …

And don’t deliver care in the way blunt end prescriptivists want them to.

14 Enter complexity science

15 Complexity Science in Healthcare: A WHITE PAPER What can implementation science learn from complexity science?

1. Health care is complex; it’s a CAS 2. It’s adaptive without top-down initiatives 3. Behaviours are emergent 4. Bottom-up produces localised rules 5. Linear models only get you so far

17 Exposing the CAS features

18 Translational Cancer Research Network – Eastern Sydney, Australia

2012 2014 2015

Long, Hibbert, Braithwaite (2016), Structuring successful collaboration: a longitudinal social network analysis of a translational research network, Implementation Science: 11 (19). Interprofessional care

Admin 12

Admin 1 Sr nurse 22 Admin 11 Sr dr 3 Admin 8 Admin 9 Allied health 3 Jr RN 9 Sr nurse 13 Admin 5 Jr dr 2 Sr RN 13 Sr RN 14 • Problem solving Sr nurse 18 Sr RN 6 Admin 4 Sr nurse 1 Sr RN 1 Sr nurse 9 Jr dr 10 Jr dr 21 Sr nurse 11 Admin 3 Jr dr 7 Sr nurse 21 Sr dr 7 Jr dr 15 Sr nurse 6 Admin 2 Jr dr 20 Sr dr 5 Jr RN 4 Sr nurse 17 networks in an ED Jr dr 8 Ward asst 1 Admin 10 Sr nurse 2 Admin 7 Jr dr 5 Sr dr 4 Sr dr 1 EN 4 Sr nurse 4 Sr RN 5 Admin 6 Jr dr 17 Sr nurse 8 Jr dr 12 Sr RN 4 Sr nurse 10 Ward asst 2 Jr dr 9 Jr dr 23 Sr nurse 5 Jr dr 1 Sr dr 2 Sr RN 7 Sr nurse 14 Sr nurse 12 Allied health 4 Jr dr 4 Sr nurse 3 Jr RN 10 Sr RN 8 Sr dr 6 Jr RN 8 Sr nurse 7 Jr dr 13 Jr RN 11 Jr RN 3 Sr RN 2 Jr dr 16 Nurses Sr nurse 15 Sr RN 10 Jr dr 6 Jr dr 11 Jr dr 29 Jr RN 1 Sr nurse 16 Allied health 2 Jr RN 6 Sr RN 3 Jr dr 22 EN 2 Jr dr 24 EN 5 Jr dr 18 Jr RN 7 Jr RN 2 Jr dr 25 EN 1 Doctors Sr RN 9 EN 3 Allied health 1 Jr RN 5 EN 6 Sr RN 11 Sr nurse 20 Jr dr 14 Jr dr 19 Jr RN 12 Allied health Sr RN 12 Jr dr 3 Sr nurse 19

Jr dr 27 Jr dr 30 Admin and support Jr dr 26 Jr dr 28 20 Creswick, Westbrook and Braithwaite, (2009) Interprofessional care

Admin 1 Admin 12 • Ward asst 1 Medication Sr RN 14 Admin 8 Allied health 3 Sr RN 13 Admin 7 Sr nurse 22

Jr dr 26 Admin 3 Sr nurse 1 advice-seeking Jr dr 30 Admin 4 Jr dr 28 Allied health 4 Admin 9 Allied health 2 Sr dr 3 Sr nurse 13 Admin 11 Sr nurse 11 Admin 5 networks in an ED Jr dr 27 Sr nurse 9 Jr dr 2 Sr RN 8 Admin 10 EN 6 Sr nurse 21 Sr dr 4 Sr nurse 2 Sr dr 6 Jr dr 25 Sr nurse 12 Sr nurse 17 Jr dr 9 Jr dr 20 Jr dr 6 Admin 2 Ward asst 2 Sr dr 2 Sr nurse 3 Jr RN 4 Sr nurse 4 Admin 6 Jr dr 10 Sr dr 1 Sr nurse 10 Sr RN 4 Jr dr 29 Jr dr 8 Sr nurse 6 Sr dr 7 EN 1 Sr RN 1 Sr RN 7 Sr RN 6 Allied health 1 Jr dr 3 Sr RN 11 Jr RN 11 Sr RN 9 EN 2 Nurses Sr nurse 5 Jr dr 19 Jr dr 24 Jr RN 10 Sr nurse 8 Sr nurse 20 Sr dr 5 Sr nurse 14 Jr RN 2 Jr dr 11 Jr dr 12 Jr RN 3 Sr RN 2 Jr RN 6 Sr nurse 7 Jr dr 17 Jr dr 21 Jr RN 8 EN 5 Doctors Jr dr 22 Jr dr 1 Sr RN 10 Jr dr 23 Sr RN 5 Sr nurse 19 Jr dr 16 Jr dr 15 Jr RN 1 EN 4 Sr nurse 15 Sr nurse 18 Jr dr 18 Jr dr 7 EN 3 Jr RN 9 Allied health Sr nurse 16 Jr dr 4 Jr RN 5 Sr RN 3 Jr dr 13 Jr RN 12 Jr dr 5 Jr RN 7

Sr RN 12 Jr dr 14 Admin and support Creswick, Westbrook and Braithwaite, 2009 21 Interprofessional care

Jr dr 20 Allied health 3 Allied health 2 Admin 1 Jr dr 3 Admin 5 Sr nurse 22 Admin 2 Jr dr 27 Jr dr 6 Allied health 1 Admin 3 Admin 12 • Sr RN 13 Socialising Admin 8 Sr dr 4 Sr dr 1 Admin 4 Jr dr 5 Sr RN 14 Sr dr 7 Sr nurse 1 Admin 10 Sr dr 2 Jr dr 8 Sr nurse 5 Jr dr 25 Admin 7 Jr dr 2 Admin 9 networks in an ED Sr dr 6 Sr nurse 4 EN 5 Admin 11 Sr dr 5 Sr nurse 12 Jr dr 1 Jr RN 2 Sr RN 11 Sr dr 3 Sr nurse 3 Ward asst 1 Sr nurse 11 Ward asst 2 Sr RN 5 Sr nurse 10 Allied health 4 Sr RN 4 Jr dr 15 Sr nurse 6 Jr RN 1 Jr dr 22 Sr nurse 15 EN 6 Jr dr 9 Admin 6 Sr nurse 9 Sr nurse 20 Jr dr 11 Jr dr 16 Jr dr 7 EN 4 Jr RN 3 Sr nurse 2 Jr dr 24 Jr RN 10 Jr RN 9 Sr RN 7 Jr dr 26 Jr RN 8 Nurses Sr nurse 13 Sr nurse 8 Jr dr 10 Sr nurse 14 Sr nurse 17 EN 1 Jr dr 17 Sr RN 2 Jr dr 23 Jr RN 7 Jr RN 6 Jr RN 11 Sr nurse 18 Jr dr 14 Sr nurse 21 Sr RN 3 Sr nurse 16 Sr RN 8 Sr RN 12 Sr RN 6 Doctors Jr dr 18 EN 2 Jr dr 21 Sr nurse 7 Sr nurse 19 Jr dr 13 Jr RN 4 Sr RN 1 Sr RN 10 EN 3 Jr dr 12 Sr RN 9 Jr dr 19 Jr RN 12 Allied health Jr dr 28 Jr RN 5

Jr dr 4

Jr dr 29 Admin and support

Jr dr 30 Creswick, Westbrook and Braithwaite, 2009 22 Lessons

New rules for an old problem

1. Don’t ever think getting evidence into practice is easy 2. Progress will always be hard work 3. Linear will only get you so far—often, nowhere fast 4. Work with the natural characteristics of the CAS 5. Always look out for unintended consequences

Braithwaite, 2010; Braithwaite 2015 Gaps in systems 23 Lessons

New rules for an old problem

6. Don’t do it alone … it’s a system of systems 7. Harness others—mavens, cosmopolites, bridges, brokers, opinion leaders 8. You’ll need institutional support, too 9. Look at what goes right, and think why 10. Do more of things going right

Braithwaite, 2010; Braithwaite 2015 Gaps in systems 24 Some examples using complexity science

25 Example 1: Safety-I and Safety-II

The amazing thing about health care isn’t that it produces adverse events in 10% of all cases, but that it produces safe care in 90% of cases.

26 Example 2: Lynch Syndrome, WAI

Work-as- imagined:

Screen

High risk

Refer Example 2: Lynch Syndrome, WAD

Clinicians thought Screening test there there would Key: be around 15-20 119 Start/End of patients 16 + Process High risk Low risk Refer to No. of Time genetics No NO REFERRAL patients data service? Clinicians thought 14 there may be some 2 patients who Yes Clinicians thought would attend Work as only 1 or 2 would imagined private clinics be missed Patient agrees to referral 0 Referral to a private clinic or another public Yes Clinicians thought genetics service <14 referrals could be Referral made 2 days to HCC made up to 18 months after surgery Clinicians thought Yes there may be some patients who 0 would not attend Patient attends Not seen No appointment at HCC 2 <5 days

Yes Clinicians thought there was a wait Seen at HCC list to be seen Example 3: CareTrack Australia

Runciman WB, Hunt TD, Hannaford NA, Hibbert PD, Westbrook JI, Coiera EW, Day RO, Hindmarsh DM, McGlynn EA, and Braithwaite J. (2012) CareTrack: assessing the appropriateness of health care delivery in Australia. Medical Journal of Australia, 197:2. Example 4: Interprofessional practice

Braithwaite J, Westbrook M, Nugus P, Greenfield D, Travaglia J, Runciman W, Foxwell AR, Boyce RA, Devinney T. and Westbrook J. (2012) A four- year, systems-wide intervention promoting interprofessional collaboration, BMC Health Services Research, 12:99 Example 4: Interprofessional practice

aihi.mq.edu.au/project/wombat-work-observation-method-activity-timing Work Observation Method By Activity Timing -

34 Work and Communication Patterns Example 6: High performing hospitals

[Taylor N, Clay-Williams R, Hogden E, Braithwaite J, Groene O. BMC HSR 2015.] Example 7: Health Systems Improvement Across the Globe

We gathered case-study accomplishments from a diversity of countries spanning the Americas, Africa, Europe, Eastern Mediterranean, South-East Asia, and the Western Pacific.

Rather than starting with the premise that things need to be fixed, this book comprehensively surveyed and synthesised success stories of healthcare systems around the world. Contributors

• 161 contributing authors from over 60 countries • Five low-income, 22 middle-income, 35 high-income healthcare systems, covering two-thirds of the world’s 7.4 billion people • The authors’ tasks were to:

Chose an exemplar of Identify the main Advance success and lessons learnt recommendations analyse their case

38 The Americas

Canada Venezuela United States Improving stroke outcomes Mision Barrio Adentro (“Inside of America through accreditation the Ghetto Mission”) national Improving safety primary care program in surgical care

Mexico Monitoring and evaluation system for health reform Guyana Elderly patient care Ecuador Improving hospital management Brazil Quality improvement Chile Argentina Creating symbolic Government legislation capital and institutional and non-government motivation for success initiatives Africa

West Africa (Guinea, Nigeria Liberia, and Sierra Leone) The responsive Ebola affected countries health delivery system

Rwanda Community- based health insurance Ghana Arresting the medical brain drain Namibia South Africa Quality Regulation of healthcare management establishments via a model juristic body Europe

Scotland Northern Sweden Netherlands Norway Russia Partnership and Ireland Researching ‘Prevent harm, Standardization of Legislative collaboration Improving and learning work safely’ measuring and monitoring improvements to prompting maternal and from clinical program adverse events improve health collaboration pediatric care data care quality

Ireland Finland Innovative eHealth in treatment of clinical practice hemophilia Denmark Wales Pathways for Shared decision France Turkey Cancer patients making in Care-centered National practice and approach: healthcare Serbia strategic increasing accreditation Child abuse and improvements patients’ feelings system neglect of safety Portugal Italy Hospital Austria Spain Management of Acquired Stroke-units Organ donation pharmaceutical Infection Switzerland Malta and Collaborations Medical innovation Israel transplantation to improve training and Electronic health patient safety regulation records and the Germany Estonia health ‘Healthy Kinzigtal’ Reform in England information population-based primary health The role of the National Institute for exchange health care system care Health and Care Excellence (NICE) program Eastern Mediterranean

Iran Afghanistan Pakistan Lebanon The wide ranging reforms of the Improving hospital Role allocation, Social Health Transformation plan services: Implementing accreditation and innovation and minimum standards databases e.g., cardiac blood donations surgery database

United Arab Emirates Jordan Single payment Health care system accreditation council Oman Al-Shifa The Gulf States electronic health record system (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, the United Arab Emirates): Procuring Qatar pharmaceuticals and Qatar Early Yemen medical supplies from Warning System Improvement of basic health services GCC countries (QEWS) for in Yemen: A successful Donor-driven deteriorating Improvement Initiative patients South-East Asia and the Western Pacific

China Japan Self-service in Health insurance tertiary hospitals

Taiwan Improvements in information technology

Hong Kong Care for elderly patients after hospital discharge

Papua New Guinea Provincial health authorities Malaysia Maternal health

India Australia Fiji New Zealand Public-private Between the flags Strengthening Ko Awatea partnership to rapid response primary care Organization increase safety system in for innovation and affordability emergency and quality of care departments improvement Meta-lessons

• Success can be achieved regardless of economic status or political situation • Local initiatives can and often do lead to system- wide improvements: acorn-to-oak tree principle • Information exchange and communication via the right technology is fundamental: data-to-information- to-intelligence principle Meta-lessons

• Collaboration between stakeholders, making evidence-based decisions with clear reform principles, is key: many- hands principle • The patient is the centre of the reform enterprise: patient as pre-eminent player principle

45 Model 1: Implementation science factors

PHASE 2 PHASE 1 PHASE 3 PHASE 4 PHASE 5 Capacity for Preparing for Types of Resources; implementation Sustainability change implementation Leverage A) People B) Organisational

Desirable implementation enabling features (eg. communication, incentives, feedback)

Braithwaite J, Marks D, and Taylor N. (2014) Harnessing implementation science to improve care quality and patient safety: a systematic review of targeted literature. International Journal for Quality in Health Care, 26:3 Model 2: Implementation at scale

Clay-Williams R, Nosrati H, Cunningham FC, Hillman K, and Braithwaite J. (2014) Do large-scale hospital- and system- wide interventions improve patient outcomes: a systematic review. BMC Health Services Research, 14:369. Questions or comments?

48 Recent Published Books Published

2010 2013 2015 2015 2016 2017 2017 • Culture and Climate in Health Care Organizations

• Resilient Health Care

• The Resilience of Everyday Clinical Work

• Healthcare Reform, Quality and Safety: Perspectives, Participants, Partnerships and Prospects in 30 Countries

• The Sociology of Healthcare Safety and Quality

• Reconciling Work-as-imagined and Work-as-done

• Health Systems Improvement Across the Globe: Success Stories from 60 Countries 49 Forthcoming Books

In Production

• Health Care Systems: Future Predictions for Global Care

• Gaps: the Surprising Truth Hiding in the In-between

• Surviving the Anthropocene

• Field Guide to Resilient Health Care

• Counterintuitivity: How your brain defies logic 50 Contact details

Jeffrey Braithwaite, PhD Foundation Director Australian Institute of Health Innovation Director Centre for Healthcare Resilience and Implementation Science Professor, Faculty of Medicine and Health Sciences Macquarie University NORTH RYDE NSW 2109

Email: [email protected] Web: https://jeffrey-braithwaite.squarespace.com/ AIHI Website: http://aihi.mq.edu.au Wikipedia: http://en.wikipedia.org/wiki/Jeffrey_Braithwaite 51