“Provoking conversations”: case studies of organizations where Option Grid™ decision aids have become ‘normalized’

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Abstract

Background

Implementing patient decision aids in clinic workflow has proven to be a challenge for healthcare organizations and physicians. Our aim was to determine the organizational strategies, motivations, and facilitating factors to the routine implementation of Option Grid™ encounter decision aids at two independent settings.

Method

Case studies conducted by semi-structured interview, using the Normalization Process Theory (NPT) as a framework for thematic analysis. Twenty three interviews with physicians, nurses, hospital staff and stakeholders were conducted at: 1) CapitalCare Medical Group in Albany, New York; 2) HealthPartners Clinics in Minneapolis, Minnesota.

Results

‘Coherent’ motivations were guided by financial incentives at CapitalCare, and by a ‘champion’ physician at HealthPartners. Nurses worked ‘collectively’ at both settings and played an important role at sites where successful implementation occurred. Some physicians did not understand the perceived utility of Option Grid™, which led to varying degrees of implementation success across sites. The appraisal work (reflexive monitoring) identified benefits, particularly in terms of information provision. Physicians at both settings, however, were concerned with time pressures and the suitability of the tool for patients with low levels of health literacy.

Conclusion

Although both practice settings illustrated the mechanisms of normalization postulated by the theory, the extent to which Option Grid™ was routinely embedded in clinic workflow varied between sites, and between clinicians. Implementation of new interventions will require attention to an identified rationale (coherence), and to the collective action, cognitive participation, and assessment of value by organizational members of the organization.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-017-0517-2) contains supplementary material, which is available to authorized users.

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Implementation, context and complexity

Carl R. May, Mark R Johnson, Tracy Finch (2016)

Background Context is a problem in research on health behaviour change, knowledge translation, practice implementation and health improvement. This is because many intervention and evaluation designs seek to eliminate contextual confounders, when these represent the normal conditions into which interventions must be integrated if they are to be workable in practice. Discussion We present an ecological model of the ways that participants in implementation and health improvement processes interact with contexts. The paper addresses the problem of context as it affects processes of implementation, scaling up and diffusion of interventions. We extend our earlier work to develop Normalisation Process Theory and show how these processes involve interactions between mechanisms of resource mobilisation, collective action and negotiations with context. These mechanisms are adaptive. They contribute to self-organisation in complex adaptive systems. Conclusion Implementation includes the translational efforts that take healthcare interventions beyond the closed systems of evaluation studies into the open systems of ‘real world’ contexts. The outcome of these processes depends on interactions and negotiations between their participants and contexts. In these negotiations, the plasticity of intervention components, the degree of participants’ discretion over resource mobilisation and actors’ contributions, and the elasticity of contexts, all play important parts. Understanding these processes in terms of feedback loops, adaptive mechanisms and the practical compromises that stem from them enables us to see the mechanisms specified by NPT as core elements of self-organisation in complex systems.

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“Many miles to go …”: a systematic review of the implementation of patient decision support interventions into routine clinical practice

Glyn Elwyn, Isabelle Scholl, Caroline Tietbohl … (2013)

Background Two decades of research has established the positive effect of using patient-targeted decision support interventions: patients gain knowledge, greater understanding of probabilities and increased confidence in decisions. Yet, despite their efficacy, the effectiveness of these decision support interventions in routine practice has yet to be established; widespread adoption has not occurred. The aim of this review was to search for and analyze the findings of published peer-reviewed studies that investigated the success levels of strategies or methods where attempts were made to implement patient-targeted decision support interventions into routine clinical settings. Methods An electronic search strategy was devised and adapted for the following databases: ASSIA, CINAHL, Embase, HMIC, Medline, Medline-in-process, OpenSIGLE, PsycINFO, Scopus, Social Services Abstracts, and the Web of Science. In addition, we used snowballing techniques. Studies were included after dual independent assessment. Results After assessment, 5322 abstracts yielded 51 articles for consideration. After examining full-texts, 17 studies were included and subjected to data extraction. The approach used in all studies was one where clinicians and their staff used a referral model, asking eligible patients to use decision support. The results point to significant challenges to the implementation of patient decision support using this model, including indifference on the part of health care professionals. This indifference stemmed from a reported lack of confidence in the content of decision support interventions and concern about disruption to established workflows, ultimately contributing to organizational inertia regarding their adoption. Conclusions It seems too early to make firm recommendations about how best to implement patient decision support into routine practice because approaches that use a ‘referral model’ consistently report difficulties. We sense that the underlying issues that militate against the use of patient decision support and, more generally, limit the adoption of shared decision making, are under-investigated and under-specified. Future reports from implementation studies could be improved by following guidelines, for example the SQUIRE proposals, and by adopting methods that would be able to go beyond the ‘barriers’ and ‘facilitators’ approach to understand more about the nature of professional and organizational resistance to these tools. The lack of incentives that reward the use of these interventions needs to be considered as a significant impediment.

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Option Grids: shared decision making made easier.

Glyn Elwyn, Amy Lloyd, Natalie Joseph-Williams … (2013)

To describe the exploratory use of short decision support tools for patients, called Option Grids. Option Grids are summary tables, using one side of paper to enable rapid comparisons of options, using questions that patients frequently ask (FAQs) and designed for face-to-face clinical encounters. To date, most evidence about 'patient decision aids' has been based on tools with high content levels, designed for patients to use independently, either before or after visits. We studied the use of Option Grids in a quality improvement project, collecting field notes and conducting interviews with clinical teams. In the 'Making Good Decisions in Collaboration' (MAGIC) program, clinicians found that using Option Grids made it easier to explain the existence of options and reported a 'handover' effect, where patient involvement in decision making was enhanced. Option Grids made options more visible and clinicians found it easier to undertake shared decision making when these tools were available. Used in a collaborative way, they enhance patients' confidence and voice, increasing their involvement in collaborative dialogs. Further work to confirm these preliminary findings is required, to measure processes and to assess whether these tools have similar impact in other clinical settings. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

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Author and article information

Contributors

Peter Scalia:

ORCID: http://orcid.org/0000-0002-5050-435X

Peter.Scalia@dartmouth.edu

Glyn Elwyn: glynelwyn@gmail.com

Marie-Anne Durand: 603-653-0832 , Marie-Anne.Durand@dartmouth.edu

Journal

Journal ID (nlm-ta): BMC Med Inform Decis Mak

Journal ID (iso-abbrev): BMC Med Inform Decis Mak

Title: BMC Medical Informatics and Decision Making

Publisher: BioMed Central (London )

ISSN (Electronic): 1472-6947

Publication date (Electronic): 18 August 2017

Publication date PMC-release: 18 August 2017

Publication date Collection: 2017

Volume: 17

Electronic Location Identifier: 124

Affiliations

ISNI 0000 0001 2179 2404, GRID grid.254880.3, The Dartmouth Institute for Health Policy and Clinical Practice, , Dartmouth College, ; 1 Medical Center Drive 5th floor, Lebanon, NH 03756 USA

Author information

Peter Scalia http://orcid.org/0000-0002-5050-435X

Article

Publisher ID: 517

DOI: 10.1186/s12911-017-0517-2

PMC ID: 5562992

PubMed ID: 28821256

SO-VID: 64a5b99d-838d-4d4b-9aca-8e3f89dd7629

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 25 April 2017

Date accepted : 1 August 2017

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ScienceOpen disciplines: Bioinformatics & Computational biology

Keywords: shared decision making,option grid™ encounter decision aids,implementation,decision support techniques,normalization process theory,patient centered care

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ScienceOpen disciplines: Bioinformatics & Computational biology

Keywords: shared decision making, option grid™ encounter decision aids, implementation, decision support techniques, normalization process theory, patient centered care

“Provoking conversations”: case studies of organizations where Option Grid™ decision aids have become ‘normalized’

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Most cited references 24

Implementation, context and complexity

“Many miles to go …”: a systematic review of the implementation of patient decision support interventions into routine clinical practice

Option Grids: shared decision making made easier.

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