Knowledge to Action? Evidence-Based Health Care in Context

by Dopson, Sue; Fitzgerald, Louise

• ISBN13: 9780199259014
• ISBN10: 0199259011
• Format: Hardcover
• Copyright: 2005-07-28
• Publisher: Oxford University Press

Summary

Health services can and should be improved by applying research findings about best practice. Yet, in Knolwedge to Action?, the authors explore why it nevertheless proves notoriously difficult to implement change based on research evidence in the face of strong professional views and complexorganizational structures. The book draws on a large body of evidence acquired in the course of nearly fifty in-depth case studies, following attempts to introduce evidence-based practice in the UK NHS over more than a decade. Using qualitative methods to study hospital and primary care settings, they are able to shed lighton why some of these attempts succeeded where others faltered. By opening up the intricacies and complexities of change in the NHS, they reveal the limitations of the simplistic approaches to implementing research or introducing evidence-based health care. A unique synthesis of evidence, the book brings together data from 1,400 interviews with doctors, nurses, and managers, as well as detailed observations and documentary analysis. The authors provide an analysis, rooted in a range of theoretical perspectives, that underlines the intimate linksbetween organizational structures and cultures and the utilization of knowledge, and draws conclusions which will be of significance for other areas of public management. Their findings have implications for the utlization of knowledge in situations where there is a professional tradition workingwithin a politically sensitive blend of public service, managerial accountability, and technical expertise. Knowledge to Action? will be of interest to Academics, Researchers, and Advanced Students of Organizational Behaviour, Public and Health Management, and Evidence-Based Medicine; and also of particular interest to Practitioners, Clinicians, and Public Health Managers concerned with implementingchange to clinical practice.

Author Biography

Sue Dopson is a Fellow in Organization Behaviour and Vice-President at Templeton College, the University of Oxford. A member of the Oxford Health Care Management Institute, she is involved in the development of courses for the NHS and a number of research projects, including the evaluation of projects aimed at improving clinical effectiveness, exploring issues of getting the results of medical research evidence into clinical practice, and more general research in the area of NHS management. She has published several books and articles on the changes in the management of the NHS, the changing nature of middle management, management careers, and developments in public sector management. Louise Fitzgerald is Professor of Organizational Development in the Department of Human Resource Management at De Montfort University. She completed her PbD whilst a lecturer at Salford University, was a Senior Lecturer at Warwick University, and a Professor and Director of Research at St. Bartholomew's School of Nursing and Midwifery, City University. Her research interests centre on the management of change in professional organizations, particularly health care, and she has published widely in journals such as Human Relations, Personnel Review, and the Journal of Health Services Research and Policy, as well as having co-authored several books including The New Public Management in Action (OUP, 1996). Ewan Ferlie is Professor of Public Services Management, and Head of Department, at the School of Management, Royal Holloway, University of London. He has published widely on questions of organisational change and restructuring in the public services, especially health care. He has published in such journals as Organisational Studies, Human Relations, the Milbank Quarterly and the British Journal of Management (of which he has been Associate Editor). He has been a Non Executive Member of Warwickshire Health Authority.
John Gabbay is Professor of Public Health and Director of the Wessex Institute for Health R&D, University of Southampton. He has previously taught at the Department of History and Philosophy of Science, University of Cambridge, trained in public health in the Oxford Region, gained an MSc in Community Medicine at the London School of Hygiene and Tropical Medicine, and conducted research at Templeton College, Oxford. His recent research has examined the use of medical knowledge in the delivery of health services, including a study of communities of practice in the design of care for the elderly, an ethnographic study of knowledge management in primary care, a qualitative study of GP and patient views on depression, and an evaluation of the development of Diagnosis and Treatment Centres.

Table of Contents

List of Tables	xiii
List of Figures	xiii
List of Appendices	xiii
Abbreviations	xv
1 Introduction	1	(7)
Sue Dopson and Louise Fitzgerald
1.1 The organization of the book	2	(6)
2 Studying Complex Organizations in Health Care	8	(20)
Ewan Ferlie and Sue Dopson
2.1 Introduction	8	(3)
2.2 Key research traditions within organizational studies	11	(1)
2.3 Qualitative organizational research	12	(1)
2.4 Three core models of organization	13	(3)
2.4.1 Modernist perspective	13	(1)
2.4.2 Symbolic interpretive perspective, enactment, and the social construction of reality	14	(1)
2.4.3 Postmodern organizational theory	15	(1)
2.5 Organizational studies and the analysis of health care organizations: differing development patterns	16	(1)
2.6 The current literature on EBHC implementation and an organizational 'gap'	17	(4)
2.7 High organizational complexity and variability: implications for EBHC implementation	21	(5)
2.7.1 The importance of context	21	(2)
2.7.2 Processes, not events	23	(1)
2.7.3 The contestability of evidence	23	(1)
2.7.4 Multiple actors	24	(1)
2.7.5 Autonomous professional groupings	24	(1)
2.7.6 Cognitive boundaries: different research paradigms	25	(1)
2.8 Methodological implications: a finely grained approach to analysing EBHC initiatives	26	(1)
2.9 Concluding remarks	26	(2)
3 Evidence-Based Health Care and the Implementation Gap	28	(20)
Sue Dopson, Louise Locock, John Gabbay, Ewan Ferlie, and Louise Fitzgerald
3.1 Introduction	28	(1)
3.2 What is EBHC?	29	(2)
3.3 The rationale for EBHC: the gap between research and practice	31	(1)
3.4 The emergence of the EBHC movement	32	(4)
3.4.1 Interest from policy-makers	34	(2)
3.5 Can EBHC bridge the implementation gap?	36	(10)
3.6 From EBHC to EBP?	46	(1)
3.7 Concluding remarks	46	(2)
4 Research Design: 'Upscaling' Qualitative Research	48	(31)
Louise Locock, Ewan Ferlie, Sue Dopson, and Louise Fitzgerald
4.1 Introduction	48	(1)
4.2 The positivistic paradigm and HSR	49	(2)
4.3 The interpretive paradigm and HSR	51	(2)
4.4 What are the signs of rigour within qualitative research?	53	(1)
4.5 Case study design	54	(3)
4.5.1 Improving the quality of case study research	54	(3)
4.6 Upscaling: a search for higher external validity	57	(7)
4.7 Our methods	64	(9)
4.7.1 Cross-study comparison: are our seven studies similar or different?	65	(8)
4.8 Methodological challenges in cross-study synthesis	73	(3)
4.8.1 The complexity of process data	73	(1)
4.8.2 Synthesizing data on multiple units and levels of analysis with ambiguous boundaries	74	(1)
4.8.3 The influence of the theoretical assumptions of researchers and issues of interpretation	74	(2)
4.9 Concluding remarks	76	(3)
5 The Active Role of Context	79	(25)
Sue Dopson and Louise Fitzgerald
5.1 Introduction	79	(1)
5.2 Context and organizational studies	80	(7)
5.3 Aspects of context that influence the career of EBHC initiatives	87	(11)
5.4 What are the building blocks of a more sophisticated notion of context?	98	(4)
5.5 Concluding remarks	102	(2)
6 Professional Boundaries and the Diffusion of Innovation	104	(28)
Louise Fitzgerald and Sue Dopson
6.1 Introduction	104	(2)
6.2 Power, professional jurisdiction, and the State	106	(2)
6.3 The role of knowledge in securing and maintaining professional status	108	(1)
6.4 Becoming a professional: professional socialization and training	109	(4)
6.5 Professionals as managers and managers as professionals	113	(3)
6.5.1 Professionals as managers	114	(2)
6.6 Review of our empirical material on professional boundaries and their impact on translation processes	116	(9)
6.6.1 The role of the State in the diffusion of innovations	117	(1)
6.6.2 Professional socialization and the diffusion of innovations across social boundaries	117	(4)
6.6.3 Cognitive professional boundaries and hierarchies of credible evidence	121	(2)
6.6.4 Mechanisms for moving across boundaries	123	(2)
6.6.5 The role of professionals as managers	125	(1)
6.7 Concluding remarks	125	(7)
6.7.1 On the power of the professions and power dynamics within the diffusion process	125	(3)
6.7.2 On the changing social relationships of professional work	128	(1)
6.7.3 On the complexity of professional boundaries and influence processes	128	(4)
7 Knowledge, Credible Evidence, and Utilization	132	(23)
Louise Fitzgerald and Sue Dopson
7.1 Introduction	132	(2)
7.2 From knowledge creation to diffusion and management	134	(4)
7.3 Review of empirical data on the credibility of evidence	138	(14)
7.3.1 A hierarchy of evidence? Perceptions of credible evidence	138	(7)
7.3.2 Processes of accepting research evidence: appraisal or trust	145	(4)
7.3.3 The role of tacit or experiential knowledge	149	(1)
7.3.4 Other sources of evidence	150	(2)
7.4 Concluding remarks	152	(3)
8 Knowledge in Action	155	(27)
Louise Fitzgerald, Sue Dopson, Ewan Ferlie, and Louise Locock
8.1 Introduction	155	(2)
8.2 Illustrative vignettes	157	(18)
8.2.1 Aspirin to prevent secondary cardiac incidents	157	(2)
8.2.2 Services for heart failure	159	(4)
8.2.3 Managing anticoagulation provision in primary care with a computer support system	163	(2)
8.2.4 Diabetes care	165	(4)
8.2.5 Maternity care	169	(2)
8.2.6 Glue ear	171	(4)
8.3 Concluding remarks	175	(7)
8.3.1 Multiple cues affecting the processes of innovation utilization	175	(1)
8.3.2 Multifaceted contexts with differential power to influence	176	(2)
8.3.3 Evidence is important, and is translated into use through social processes	178	(1)
8.3.4 Configuration of variables	179	(1)
8.3.5 Complementary collective and individual processes	179	(3)
9 Conclusion: From Evidence to Actionable Knowledge?	182	(16)
Ewan Ferlie
9.1 Developing a social perspective on the enactment of evidence	182	(9)
9.1.1 Key elements of the social perspective	184	(2)
9.1.2 The professionalized organization, health care professions, and their boundaries	186	(2)
9.1.3 A knowledge management perspective?	188	(3)
9.2 Some policy implications	191	(3)
9.2.1 Clinical opinion leaders and clinical leadership	191	(1)
9.2.2 Moving knowledge across boundaries	192	(1)
9.2.3 EBHC policy in the future	193	(1)
9.3 Future research needs	194	(4)
9.3.1 Knowledge types and their combination	194	(1)
9.3.2 Learning from the positive outliers	195	(1)
9.3.3 Some methodological issues	195	(1)
9.3.4 Final thoughts: a social perspective on the enactment of EBHC	196	(2)
References	198	(15)
Index	213