The British Columbia Ministry of Health’s Clinical Care Management initiative was used as a case study to better understand large-scale change (LSC) within BC’s health system. Using a complex system framework, the purpose of this paper is to examine mechanisms that enable and constrain the implementation of clinical guidelines across various clinical settings.
Researchers applied a general model of complex adaptive systems plus two specific conceptual frameworks (realist evaluation and system dynamics mapping) to define and study enablers and constraints. Focus group sessions and interviews with clinicians, executives, managers and board members were validated through an online survey.
The functional themes for managing large-scale clinical change included: creating a context to prepare clinicians for health system transformation initiatives; promoting shared clinical leadership; strengthening knowledge management, strategic communications and opportunities for networking; and clearing pathways through the complexity of a multilevel, dynamic system.
The action research methodology was designed to guide continuing improvement of implementation. A sample of initiatives was selected; it was not intended to compare and contrast facilitators and barriers across all initiatives and regions. Similarly, evaluating the results or process of guideline implementation was outside the scope; the methods were designed to enable conversations at multiple levels – policy, management and practice – about how to improve implementation. The study is best seen as a case study of LSC, offering a possible model for replication by others and a tool to shape further dialogue.
Recommended action-oriented strategies included engaging local champions; supporting local adaptation for implementation of clinical guidelines; strengthening local teams to guide implementation; reducing change fatigue; ensuring adequate resources; providing consistent communication especially for front-line care providers; and supporting local teams to demonstrate the clinical value of the guidelines to their colleagues.
Bringing a complex systems perspective to clinical guideline implementation resulted in a clear understanding of the challenges involved in LSC.
Funding for this study came from the Michael Smith Foundation for Health Research in partnership with the BC Patient Safety and Quality Council. The authors would like to acknowledge the contributions of the staff at the Michael Smith Foundation for their supervision and management of this study. The BC Patient Safety and Quality Council wishes to recognize support from the Large-Scale Change Steering Committee which provided guidance to this work, as well as the staff of the Ministry of Health, the Clinical Care Management Steering Committee, and the health care providers in the health authorities, who have been engaged in the implementation of clinical care management for the betterment of all (British Columbians). In particular, the authors thank those who provided their advice and counsel to this work.
Best, A., Berland, A., Herbert, C., Bitz, J., van Dijk, M., Krause, C., Cochrane, D., Noel, K., Marsden, J., McKeown, S. and Millar, J. (2016), "Using systems thinking to support clinical system transformation", Journal of Health Organization and Management, Vol. 30 No. 3, pp. 302-323. https://doi.org/10.1108/JHOM-12-2014-0206Download as .RIS
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