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