”There is nothing so practical as a good theory” Management research in the improvement of health services Mats Brommels Medical Management Centre Karolinska Institutet 15 June 2012

”There is nothing so practical as a good theory” Medical management … … research … … in the spectrum of health research … … requires a change of paradigm … … shows its value by its usefulness … … by virtue of application

Medical Management Centre Mission Improve health care as a contribution to KI’s mission to improve people’s health More specifically, by developing useful knowledge on organising and managing health care, to promote safe, high-quality and cost-effective medical services

Medical Management Centre Goal Establish management knowledge as an academic discipline in its own right at the medical university Make a management career legitimate, visible and attractive among health professionals

Medical Management Value Through collaborative research and knowledge transfer create space and give legitimacy to managers of professional organisations acting in a political environment ”We have solid evidence ….” ”We have a useful theory (palusible hypothesis) that we intend to test and evaluate …”

Medical Management Research “Medically informed research on the organisation and management of health services” Health services research (AcademyHealth): “the multi- disciplinary field of scientific investigation that studies how social factors, financing systems, organisational structures and processes, health technologies, and personal behaviours affect access to health care, the quality and cost of health care, and ultimately, our health and well-being” More focus on “organisations, institutions and communities” than on “individuals, families and populations”, Brommels M. Management and medicine: odd couple no more. Bonding through medical management research. Scand J Public Health 2010;38(7):673-7.

Why Medical Management? MMC’s medically qualified staff has unrestricted access to clinical settings and the substance knowledge needed to develop successful practice change strategies and methods Implementation research is done in close cooperation with clinical practitioners All biomedical research, education and practice will need the know-how thus acquired to handle change successfully

Medical Management Special contribution: What Generally applicable methods for the implementation of medical research into real- world practice – ”translational research, part II”, ”from bedside to transformed practice” –The challenge: “Translating basic discoveries into clinical trials and studies, followed by implementation of the results into the real- world practice of medicine” (NIH 2005, 2007)

The 3T’s road map Dougherty D, Conway PH. The ”3T’s” road map to transform US health care: the ”how” of high-quality care. JAMA 2008; 299:

Brommels M. Time for the third step? Implementation is the greatest challenge for clinical research. Swedish Med J;2006:103: Brommels M. Management and medicine: odd couple no more. Bonding through medical management research. Scand J Public Health 2010;38(7):673-7.

Basic researchClinical (applied) research Implementation of inventions and new knowledge Organisational (process) development Governance, stewardship, management, follow-up Data sourcesBiobanksPatient databasesEmpirical observations on practice Administrative databases Practical experience FocusBiological mechanisms Indications for treatment and treatment effects Changes in struc- tures, organisa- tions, processes Improved safety and quality Efficiency Needs, resources and performance Approaches and methods Cell and molecular biology Clinical trialsObservational and action oriented studies Locally organised improvement Objectives, resource allocation, follow-up Contribution to practice Diagnostic and therapeutic methods Patterns, Methods support mechanisms, Knowledge and decision support models, theories, strategies ActorsPre-clinical researchers Clinical researchers Health services/ care sciences researchers PractitionersDecision-makers Medical Management Centre, Karolinska Institutet 2012

Studies of organisational change Programme evaluation (assessment of effects) combined with descriptive case study Frame of reference - Strategic change management model (Pettigrew & Whipp 1991): Analyse programme content, extarenal and internal context, change process and outcomes (intended and unintended)

Studies of organisational change Look for patterns and explanatory models Establish ”programme theory” (about what works and under which circumstances), formulate hypotheses and collect data to assess those (realist evaluation, Pawson & Tilley 1997) Feed back observations and interpretations to the organisation (leadership) to enable modifications of the programme and further monitoring (action research) ”Generalise to theory”

Realist evaluation (Pawson & Tilley 1997)

Plan Do Study Act