Those working in healthcare are aware of the considerable gap between what we know from research and what is done in clinical practice.1
For example, enforced bed rest is ineffective in several conditions where it is still used; exercise reduces mortality in heart failure but is rarely used; and brief counselling after trauma is fashionable but ineffective. The response to this well-documented problem includes both Evidence-Based Medicine (EBM)2 3
and Clinical Quality Improvement.4 5
The term EBM was coined by Gordon Guyatt in 1992 for the JAMA ‘User Guide’ series to describe the bedside use of research to improve patient care. At the time it was common at McMaster teaching hospitals for patients' notes to include a key research paper relevant to their care, and for this to be discussed at ward rounds (personal observation—PG). Improved information technology allowed Dave Sackett's team to use an ‘evidence cart’ on ward rounds at the John Radcliffe in Oxford; the team asked and answered two questions for every three patients, with the searches changing 1/3 of clinical decisions.6
Different specialties and different individuals have adopted the principles of EBM to different degrees and in vastly different ways (Interviews on www.cebm.net/index.aspx?o=4648
illustrate this diversity).
In parallel, the Quality Improvement (QI) movement emerged to address similar problems, but with a focus on recurrent problems within systems of care. The first methods used in the National Demonstration Projects in the 1980s were adopted from those introduced by Deming into industry.4
But the methods soon evolved to the different environment of healthcare, with the founding of the Institute for Healthcare Improvement, and the development of the breakthrough series collaborative, the model for improvement, and other modifications and extensions of QI methods.
EBM and QI have had overall similar goals but focus on different parts of the problem. EBM has focused more on ‘doing the right things’: actions informed by the best available evidence from our clinical knowledge base (), whereas QI has focused more on ‘doing things right’: making sure that intended actions are done thoroughly, efficiently and reliably; however, these are complementary () and in combination direct us how to ‘do the right things right’.7
Figure 1 Relationships between Quality Improvement (QI) and Evidence-Based Medicine (EBM). (a) sequence of EBM followed by QI; (b) EBM uses clinical knowledge to inform individual clinical decisions about patient care; (c) QI focuses on improving recurrent problems (more ...)
Before ‘fixing’ an evidence–practice gap, we would be wise to ask ‘is this the right thing to do?’ Is there really a problem? Is there something effective we can do about it? For example, many QI initiatives in diabetes had aimed to achieve low HbA1c levels8
for which the evidence was weak, and subsequent large scale randomised trials (ACCORD and ADVANCE) have suggested may be unhelpful or even harmful.9
The ‘right things right’ process might be illustrated by a familiar clinical example. In the clinic of one of the authors, the primary care team was considering whether to try to wean elderly patients from long-term benzodiazepines being given for insomnia. We and the patients seemed reluctant. However, the team reviewed the evidence10
and found the risk of falls on benzodiazepines was higher than we'd expected and other adverse effects, such as cognitive loss, added to the problems. So cessation was the ‘right thing’, but how best to achieve this? A review of the controlled trials showed weaning was possible, but that simple (but very slow) tapering was as effective as more intensive methods such as cognitive therapy counselling. Finally, sending a structured letter to the patient (on why and how
to withdraw) had also been shown to be effective.11
Without this evidence review by the clinical team, we might have wasted a lot of effort on ineffective means to achieve our goal. But without a clinical improvement process to change our practice, this knowledge might not have provoked action. Of course, QI would also suggest additional questions such as how many patients are on which benzodiazepines and for how long? How many falls or other adverse events have occurred on the benzodiazepines? What will occur with our patient's anxiety once we remove the medication?
This article aims to look at what each of these disciplinary areas might learn from the other. The difference in approach of the two disciplines may be better understood by looking at the problem each perceives it is addressing.
The EBM perspective
One cause of the evidence–practice gap is information overload, for example, approximately 8000 references—including around 350 randomised trials—are added to MEDLINE each week. But only a small fraction of this is research that is sufficiently valid and relevant to change practice. So keeping up to date with new developments and information is problematic. One arm of EBM has been to synthesise and summarise this flood of research, and be able to access evidence wherever and whenever it is needed. To achieve this requires both ready access (to resources such as MEDLINE and the Cochrane Library) and skills (in finding, appraising and applying evidence) that few healthcare workers currently have. The EBM movement has focused on developing both the skills and tools to better connect research and clinical practice, with some12
but not universal successes.
A particular focus of EBM has been to take a more sceptical approach to innovation, asking for clear evidence before changing practice. Given that few innovations represent a real advance, this cautious approach means less disruption arising from unnecessary changes in practice.13
The QI perspective
The problem addressed by the QI approach might be characterised as the ‘knowing–doing’ gap: we know (individually and collectively) what to do, but fail to do it or fail to do it correctly. The gap has many causes, from simple lack of (some individuals) knowledge about what should be done, to uncertainties about the ‘how to’. For example, we may know that certain groups of patients should receive influenza vaccine but fail to do this because the system does not encourage reliable administration of the vaccine.
For example, at one institution, the electronic medical record (EMR) was fully implemented for many years, so the physicians-in-training, the staff physicians and nurses trusted the EMR. On discharge from the hospital a prompt in the EMR enquired whether a patient needed to receive the influenza vaccine. No one realised that this prompt led to a blind alley—no vaccine was ordered and no vaccine was given. The individuals (and the EMR) knew
that influenza vaccine was the ‘right thing to do’, but the EMR and the culture of trusting the EMR inhibited ‘doing the right thing’. Fixing this problem proved to be a challenge—requiring several Plan–Do–Study–Act iterations. The simple change in the EMR system and the influenza vaccine ordering were low on the priority list for the IT support group. This necessitated that the care team create a work-around and learn how to reliably ‘do the right thing’ in the context and setting of care.14
Even an intervention as simple as administering influenza vaccine in a fully integrated EMR environment required a thorough knowledge of the system and then creativity in dealing with its limitations—much more than just the knowledge of the ‘right thing’.
The techniques of QI have focused on integrating what we know and moving it to how we should be doing it. Common techniques to achieve this are reminder systems (paper or computer), simplification of processes (reducing unnecessary steps), structuring the system to do the right thing at the right time and place (putting hand-washing equipment and/or instructions in the right place) and testing new interventions to determine what works in this particular setting. This task is often a creative and iterative process of identifying barriers, and working out solutions to overcome these.