Clinical effectiveness is about: “the right persons, doing the right thing, the right way, in the right place, at the right time with the right result” (Graham 1996, cited in Bury and Mead 1998, p.27).
In the context of your own practice discuss the mechanisms that, in your opinion, have to be in place to deliver the above philosophy on clinical effectiveness.
AN EXPOSITION ON THE MECHANISMS REQUIRED TO ACHIEVE CLINICAL EFFECTIVENESS AT SOLWEZI GENERAL HOSPITAL (RADIOLOGY DEPARTMENT)
Radiography in Zambia has experienced a wealth of changes involving learning methods, curriculum, professional status and public expectations. Consequently, there has been a gradual transition of radiography from a mainly knowledge-based profession to an evidence-based discipline and the concept of clinical effectiveness has become ever more important in health care delivery in recent years.
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Solwezi general hospital is a 2nd level public hospital serving a local population of over 200,000 people and receives referrals from all over the rural North Western Province of Zambia. The hospital faces several challenges such as; staff shortages, inadequate medical equipment and has one of the highest mortality rates in the country. One thing that stands out clearly in the quarterly clinical and performance review meetings, is the need for evidence-based practice and achievement of clinical effectiveness in all the departments of this hospital. Therefore, this exposition specifically focuses on the radiology department at this hospital and addresses the mechanisms required to achieve clinical effectiveness.
Graham (1996) describes clinical effectiveness as been about “the right persons, doing the right thing, the right way, in the right place, at the right time with the right result” (cited in Bury and Mead 1998, p.27). The National Health Service Executive (NHS E 1996a) further defines it, as the extent to which specific clinical interventions achieve what they are intended to perform when used for a particular patient or population. The above definitions show that the concept of clinical effectiveness involves making clinical decisions based on solid evidence of what is effective in securing maximum health benefits and improving service delivery.
In the context of my practice, the right person would primarily be a well-trained and licensed radiographer. However, radiography education in Zambia is up to diploma level and as a result, most departments are managed by radiography technologists who undertake a wide range of radiological examinations. Locally, the administration of the department is coordinated by five radiography technologists (including the author) and a darkroom assistant. The senior medical practitioner performs most of the roles of a radiologist such as image pattern recognition. Despite of the general shortage of radiographers and radiologists in the country, this skill mix has proven to be cost-effective with marked reduction of organizational costs. The Zambian ministry of health has in this regard, increased the deployment and training of the above personnel as an effective use of limited resources and in line with the millennium development goals.
Clinical effectiveness is about doing the right thing and is aimed at making clinical practice more specifically based on the use of the best available evidence and the implementation of up to date research findings (McKibbon 1998). This infers the use of evidence based clinical guidelines and protocols to guide practice, as well as reviewing service delivery by way of clinical auditing. Doing the right thing also involves the use of investigations that have proven to be effective relative to specific patient needs and represent the best value for money (Muir 2007a).
With the rapid development of diagnostic imaging modalities, medical practitioners are frequently making use of a wide selection of radiological investigations. In this regard, the application of evidence-based principles in diagnostic radiography will enhance the performance and interpretation of imaging studies through the use of the right radiographic techniques consistent with current research. However, this department has so far not participated to any significant degree in evidence-based practice, although, there are now concerted efforts by the author to promote this approach. The barriers to achieving this have been due to inadequate training in integration of research evidence, lack of appraisal skills, out-of-date textbooks and limited access to clinical databases. Furthermore, the concept of clinical auditing has not taken its rightful place owing to lack of proper definition and failure to set priorities for audit activities.
The delivery of quality and cost-effective health care has been a core theme of the new management agenda in this era of evidence-based practice (Muir 2007b). To achieve this in the right way, it is necessary to have a well-trained and competent workforce having clear responsibilities and working together to deliver best value health care (Worcestershire Mental Health Partnership 2008). Despite the shortage of radiographers, the workforce in this department maintains an adequate level of competence in the execution of duties. However, continual skills development through training and education are necessary in keeping up to date with the rapid expansion of medical knowledge.
As per requirement of the Zambian Ionizing Radiation Act, the right place to undertake plain x-ray examinations is a designated x-ray facility with lead fortifications and up to date imaging equipment. This is to ensure radiation safety for patients and staff. However, not all radiological examinations are restricted to these facilities. Imaging modalities such as ultrasound can be stationed in remote localities. At my practice for example, we undertake a wide range of mobile x-ray and ultrasound examinations in wards for the benefit of patients who are unable to go to the main x-ray facility. Mobile ultrasound services are also extended to rural outposts in the province to serve patients who have no capacity of travelling to Solwezi General Hospital.
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Radiography in both its diagnostic and therapeutic aspects, stands at the core of medical diagnostics and provides important data for clinical decisions. Consequently, many patients are usually referred for radiological examinations at some stage of management, and it is thus imperative that these services are accessible at the right time. This implies that diagnostic imaging services should be available to patients as need arises. The department strives to achieve this by providing extended working hours, weekend calls and night-time service to cater for patients who cannot manage to access the services during normal working hours and in cases of emergencies such as road traffic accidents.
The right result refers to the maximization of health effects, which can be expressed in terms of improvement in the health-related quality of life. The Royal College of Nursing (RCN 1996) further states that, this outcome is achieved through the use of the best evidence, derived from research, clinical experience and patient choices. To attain the right results in the department in focus, the following mechanisms and strategies relative to Grahams’ definition of clinical effectiveness is suggested.
A change in the perception of evidence-based practice is the first step in the process of achieving clinical effectiveness in this department. There should be an earnest desire to find, appraise and use research-based knowledge; the hospital management should fully support this approach. With an evidence-based environment in place, a committee to promote and coordinate clinical effectiveness activities within the hospital should be established. This committee will ensure that all clinical departments besides radiology have identified activities of clinical effectiveness.
A mechanism must then be in place to ensure that relevant evidence based information is made available and appropriately distributed to support the achievement of clinical effectiveness in the department (Muir 2007c). An institutional library for example, must be in place with access to the internet and clinical knowledge databases such as Medline and Cochrane library. This can also be used by other members of the interdisciplinary health care team.
Developing appraisal skills should be central to continuing professional development and part of a multi-disciplinary systematic approach to continual quality development. Within the training and development program of the hospital, strategies to develop skills necessary to use evidence should be incorporated. Critical appraisal skills workshops can be organized on a periodical basis to realize the above goal. This training should also include assistants and other auxiliary staff to better use the available skill mix and resources.
Clinical guidelines and protocols for investigations should be available for the delivery of radiological services and should be based on the knowledge of what is effective. Clinical guidelines are systematically established statements which guide clinicians and patients in making informed decisions on effective treatments for specified conditions (NHS E 1996b). Adherence to standard protocols and set clinical guidelines will ensure that the right thing is been done in this department and based on the best available evidence.
To ensure that the clinical effectiveness activities are informing clinical practice and leading to improvements in quality and cost effectiveness of care, it is cardinal that a mechanism to monitor and evaluate practice should be in place. By way of clinical auditing, a review of clinical performance against set clinical guidelines and modification of practice in areas where lapses have been noted will thus be achieved.
Clinical effectiveness is about improving the effectiveness of clinical practice and is concerned with demonstrating positive changes in the quality and delivery of health care by way of well- chosen strategies as reflected in Grahams’ six R’s. It is also a process that relies on accessing evidence, reviewing and changing practice. In light of the rapid development of evidence-based health care and increased awareness on the limitations of traditional practice, the application of the clinical effectiveness mechanisms discussed in this exposition offer a potential solution to the challenges been experienced in the radiology department at Solwezi General Hospital.
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