Healthcare Quarterly

Healthcare Quarterly 12(1) January 2009 : 97-98.doi:10.12927/hcq.2009.20421
Longwoods Review

Sustaining Change: A Senior Leadership Perspective

Kevin P.D. Smith

[This paper is a commentary on Sustaining Change: Once Evidence-Based Practices Are Transferred, What Then? by Tazim Virani, Louise Lemieux-Charles, David A. Davis and Whitney Berta.]

The authors of "Sustaining Change: Once Evidence-Based Practices Are Transferred, What Then?" offer a rigorous, evidence-based approach to sustaining clinical practice change in healthcare organizations. In addition, they also remind those of us in hospitals - both academic and community - that we may need to revisit whether adequate infrastructure and capacity exist to champion best practices in the clinical and administrative domains.
Perhaps the corresponding literature most helpful to this thoughtful article might be found in that of behavioural psychology. If we were to apply the psychology literature to changing the behaviours of healthcare providers and consumers alike, might we have greater uptake? For example, we know that when provider organizations offer a prompt by mail to a patient to schedule a preventive screening examination, uptake is significantly lower than with a similar intervention in which a designated time is offered and the consumer must actively decline.

The other corollary infrastructure requirement to seek optimization of practice transfer and uptake is the creation of a comprehensive and modern information technology infrastructure. Through integrated information technology, we will have the opportunity to use real-time data to better understand both the practices of our staff and the preferences of our patients. With the convergence of information technology, social marketing and behavioural psychology, and a push toward pay-for-performance - incenting what you value - might we improve the transfer of evidence to practice?

As I reviewed this article, I was struck by the importance of considering pay-for-performance as it relates to best practice. Dr. Meredith Rosenthal of the Harvard School of Public Health offered a critique of pay-for-performance in healthcare in October of 2006. She reinforced that since 1980, fewer than 20 comprehensive rigorous studies have been completed. Of those that have been completed, overall findings are mixed; however, there is some suggestion that negative findings might be related to the short-term nature of pay-for-performance and the small incentives offered. Similarly, the National Health Service in the United Kingdom has experimented with pay-for-performance to improve the uptake of evidence by the use of performance indicators. In this case, the bonus amount of 25% appears to have been of a significant enough nature to catch the attention of providers.

The authors also provide strong evidence of the importance of senior leadership's engagement in both the application and dissemination of best practice information. Do the majority of senior leaders in our healthcare organization have an adequate grasp of evidence-based best practice? Senior leaders in the system have a responsibility to ensure that members of the senior management team as well as those in the key operational management portfolios do in fact have more than a passing awareness of the literature, both an understanding of the pros and cons of its application and the skills to determine high-quality research findings from those of a lesser nature. Thankfully, there are a number of organizations advancing this cause, including the Canadian Health Services Research Foundation through its Executive Training for Research (EXTRA) Fellowship Training program. The article leads one to consider whether or not senior management is adequately marketing best practice information. I would suggest a significant improvement is both possible and necessary. In Table 1 of this article, "Knowledge Reservoirs and Organizational Memory," the authors offer a helpful series of descriptions and examples, as well as advantages and disadvantages with respect to organizational memory, which I believe is a useful adjunct to those methods used in knowledge and organizational memory in most teaching hospitals.

Similarly, the article explores the concept of knowledge reservoirs and offers a helpful way to conceptualize how and where knowledge may exist, as well as a useful model to explore both the application and success of organizational memory.

The authors also offer thoughtful advice around the importance of formal structures and changing role expectations. As systems managers, have we ensured that the process for organizational memory is in fact transparent within our organizations and that both our compensation and job evaluation process reflect the values we wish to demonstrate as they relate to best practice? We know that the introduction of best practice information is key to its uptake. Have senior leaders in your organization ensured that in their information dissemination throughout their communities of influence they are both aware of, and talking about, the information that must be embedded into practice?

The article offers interesting observations with respect to organizational memory. While often accepted as a given, it is worthwhile to restate the tremendous importance of key inter-relationships that can and will affect the passing on of new knowledge and its acceptance across various sites. If we embed this knowledge in too few colleagues, we should be less than surprised that it is not further disseminated and making its way into standard practice.

Of particular note is the importance of recognizing the impact of staff turnover and transfer at a time when we are likely to see significant retirement from the health sector, coupled with economic challenge. It will be more important and difficult than ever to ensure that with both turnover and transfer, key staff have a knowledge base that can be appropriately updated and adequately linked with their experiential knowledge and that of their colleagues. This may be made further complex by the findings that hiring lower-skilled workers significantly affects the learning curve with respect to information uptake.

As we know, a shortage of skilled healthcare providers may necessitate us moving to the employment of a less highly trained labour force. Have we adequately considered how knowledge transfer and information uptake will occur and whether we might need to augment our traditional mechanisms for so doing?

The authors also offer wise advice with respect to our proliferation of policies and remind us that policies and procedures that are out of date are, in fact, bad policies. In an industry known for a high degree of policy management, are we at risk of favouring stability over flexibility at a time when the latter may be more necessary than the former? The article brings to mind one of the famous quotations of Marshall McLuhan (1964) - "the medium is the message." This is to say, how information is stored, the level of detail, the perceived importance, the issue of retrieval and those who deliver the message are key to its impact and application.

Most important and pragmatically, the article reminds leaders in the system that we must create the time and place for open dialogue in discussing patient care or systems management and in undertaking educational development. The absence of such opportunities results in the siloed practice of practitioners and significantly declines the likelihood of organizational learning.

This article also reminds healthcare leaders that in today's complex healthcare environments, ensuring adequate process and structure is a key component of leadership. In so doing, one offers an environment and mechanisms for observations and questioning, which is of course the role of each of us in healthcare if we are to advance both our knowledge and how we care for those we are privileged to serve.

Last but not least, it is a helpful reminder to all of us in the health sciences that there are powerful learnings outside of our discipline, including those of organizational scientists, social scientists and anthropologists. We should be considering the literature of others as evidence equal to our own.

About the Author(s)

Kevin P.D. Smith, DPhil, is president and chief executive officer of St. Joseph's Healthcare, Hamilton, Ontario.


McLuhan, M. 1964. Understanding Media: The Extensions of Man. Cambridge, MA: MIT Press.


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