By Rebecca Lawton, Gillian Janes and Abi Albutt
Why is this necessary?
Within an NHS that has an acute shortage of time and resources, the often heard demand is ‘to do more with less’. However, evidence suggests that as much as 25% of healthcare is unecessary (Grol & Grimshaw, 2003). The NHS is characterised by a tendency to add more initiatives, protocols, interventions in an attempt, at least in part, to make care safer. Such processes and practices are not always evidence based but they may become integrated in a complex healthcare system and embedded within the culture of the institution.
There is increasing recognition that some clinical procedures are unnecessary and can do more harm than good. The Choosing Wisely campaign is actively encouraging health professionals to help patients choose care that is: supported by evidence, not duplicative of other tests or procedures already received, free from harm and truly necessary (http://www.choosingwisely.org/our-mission/). This campaign and much of the work to date has focussed on the removal of health technologies (Haas et al, 2012) and clinical practices such as specific tests and treatments that offer little or no benefit (see for example Bekelis et al 2017). In other words, the focus has been on clinical practices. However, to build a safer healthcare system, reduce costs and improve the process of care we must also consider the necessity of non-clinical safety practices, rules and procedures that do not necessarily result in safety improvements or no longer add value (Norton et al 2017). Whilst there is a lack of published evidence on this topic, making progress on this issue could also help create the space and time needed for healthcare staff to deliver more effective, patient-centred care.
How might it be achieved?
Whilst a common language for the process of removing practices that are no longer useful is still lacking (Davidoff, 2015; Bekelis 2017), terms such as decommissioning and disinvestment are often used. These reflect the top-down strategies most often deployed for this purpose by which external policy makers and commissioners decide what practices are least cost ineffective or evidence based and discourage health professionals from their use, based on funding disincentives and guidelines (Roosenhas et al 2015). This approach to influencing the clinical practice of health professionals is challenging and difficult to implement (Haas et al, 2012) with limited success thus far. It is plausible, however, that the staff themselves might know best which safety practices are not fit-for-purpose, do not result in benefits for safety or are just not possible to implement. While the use of bottom-up processes may prove more promising, there is little evidence on how to do this work or whether staff are able to identify low value safety practices that might represent opportunities for ‘disinvestment’ in the context of safety.
Moreover, if we are able to identify low-value safety practices, we do not yet know how easy it will be for staff to ‘stop’ doing these things. Enrico Coiera (2017) uses the term ‘mindful forgetting’ to highlight the conscious decision-making process that is needed to let go of low-value practices. In other words, concerted effort may be required. For example, there may be awareness that a safety rule, process or practice is not very effective, but this doesn’t mean it will automatically be stopped (Roman and Asch, 2014). The best way to approach the cessation or ‘mindful forgetting’ of inefficient or unhelpful safety practices in healthcare however is little understood (Niven et al 2015; Bekelis et al, 2017) and may be even more difficult for staff than the adoption of new innovations (Ubel et al 2015). It may be that the use of evidence-based behaviour change techniques could be considered to support staff in the cessation of unhelpful safety practices.
How can you get involved?
Researchers in the Yorkshire and Humber Patient Safety Translational Research Centre are working to address this evidence gap. Initially, we are seeking to understand what safety rules, processes and practices frontline healthcare staff perceive as low-value. Where the evidence supports this we will then work with staff and patients to develop interventions to support and evaluate ‘mindful forgetting’ of these in practice.
If you work in frontline patient care and would like to contribute to this new patient safety initiative, tell us your example(s) of low-value safety rules, practices or processes for consideration.
Bekelis K; Skinner J, Gottlieb D, Goodney P (2017) et al De-adoption and exnovation in the use of carotid revascularization: retrospective cohort study BMJ 359:j4695 doi: 10.1136/bmj.j4695
Choosing Wisely campaign http://www.choosingwisely.org/our-mission/
Coeira E (2017) The Forgetting Health System Learn Health Sys. 1:e10023 https://doi/org/10/1002/lrh2.10023
Davidoff F (2015) On the Undiffusion of Established Practices JAMA Internal Medicine 175(5): 809-811
Grol R, Grimshaw J (2003) From best evidence to best practice: effective implementation of change in patients’ care Lancet 362(9391): 1225-1230
|Haas M, Hall J, Viney R, Gallego G (2012) Breaking up is hard to do: why disinvestment in medical technology is harder than investment Australian Health Review 36(2): 148-152|
Roman BR, Asch DA (2014) Faded promises: the challenges of de-adopting low-value care Ann Intern Med 161(2): 149-151
Roosenhas L, Owen-Smith A, Hollingworth W, Badrinath P, Beynon C, Donovan JL (2015) “I won’t call it rationing…”:’ An ethnographic study of healthcare disinvestment in theory and practice Social Science and Medicine 128: 273-281
Ubel PA, Asch DA, Chase C (2015) Commentary: Creating Value in Health by Understanding and Overcoming Resistance to De-Innovation Health Affairs 34(2): 239-244