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Researchers-in-Residence;
moving improvement research closer to practice
Laura Eyre, Research Associate, UCL
Martin Marshall, Professor of Healthcare Improvement, UCL
Nuffield Trust; Evaluation of complex care 2015
What problem is the researcher-in-residence model trying to solve?
1. There’s a lot of useful Health Services Research out there but it doesn’t have sufficient impact on practice
2. Evaluation findings are rarely of much use to those being evaluated
3. Researchers aren’t scratching where decision makers are itching
Defining features of the in-residence model
1. Core member of an operational team2. Bring specific expertise in:
• the evidence base and its interpretation• theories of change• evaluation, both formal and informal• use of data
3. A focus on negotiation and compromise rather than imposition – ‘a meeting of experts’
“The scientific man has been too scientific and the practical man too practical and the result has been unfortunate for both”
WM Barton, quoted in JAMA, 1912
“Evidence-based practice needs practice-based evidence”
Larry Green, 1974
Origins (1): separation of academia and practice
Origins (2): use in other sectors
Barnsley FCPoet-in-residence
British LibraryInnovator-in-residence
Department for EducationResearcher-in-residence
Adapted from Canadian Health Services Research Foundation, 2003
Problem
Knowledge transfer
Solution
Improved dissemination of evidence to users (‘Push’) or
demand for evidence from users (‘Pull’)
Knowledge production
Work together to define, refine, generate and implement evidence (‘Co-creation’)
Nature of evidence
A product
A process
Nature of decision process
One-off event
Iterative social
process
Origins (3): knowledge mobilisation
Origins (4): participatory research• Collaboration across a range of relevant stakeholders• Desire to solve practical problems• Focus on initiating change through greater understanding
and shared learning• Emphasis on reflection and collective inquiry• Willingness to find common ground through negotiation
and compromise• Grounded in experience and sensitive to context• Orientation to agency and democracy• Reject polarised epistemologies
Examples of UCLP’s R-in-R modelsUniversity College
HospitalGreat Ormond Street Hospital
Waltham Forest, East London
And City (WELC)Newham
General PracticeWhittington
Health
Setting Acute provider Acute provider
Collaborative made up of CCGs, acute providers, mental
health provider and AHSN
General Practice/Primary
Care
Acute Provider/Integrated Care Organisation
Type of expertise
Social Science - Anthropology
Operational Research
Social Science – Critical discourse
Social Science - management
Health Services Research
Seniority Senior Mid-level Early Post-doc Mid-level Research Fellow with MSc
Workforce model Full time 3 years Part time 3 years Full time 2 years Full time 2 years Part time 1 year
Positioning in the
organisationExecutive Team With front line
clinicians Across levels Across levels Service Improvement team
Funding Organisational host funding
Organisational host funding
Organisational host funding
Organisational host funding
External funding (through a
fellowship scheme)
Types of projects
OD, strategy on clinical leadership
Improving patient flow
Evaluation, implementation
Evaluation, implementation
Evaluation, data analysis, strategy
development,
Early learning• The model seems attractive to commissioners and
providers• Some academics like the idea – particularly those at
the beginning and end of their careers - but many have concerns
• The required skill-set is becoming clear: credibility; ability to listen and reflect; excellent communication skills; negotiation and influencing skills; resilience
• The current service environment is a challenging one in which to build relationships
• It takes time to develop trusting relationships – initial suspicion that the researcher is ‘just another management consultant’
• Some conversations are very sensitive – knowing when to intervene can be challenging
• The role of patients in the model is not yet clear• The ethical dimensions are uncertain
Applying the Researcher-in-Residence model in East London
Evaluating the Waltham Forest, East London and City (WELC) integrated care
pioneer programme
Waltham Forest, East London and City (WELC) integrated care pioneer programme
WELC integrated care pioneer programme
The role of the Researcher in Residence in WELC: stakeholder expectations
“…the executive group want a more embedded and process oriented evaluation…focuses less on whether the programme ‘works’ and more on how to use research evidence to optimise effectiveness of the programme…”
“…hold up a mirror to the implementation of the integrated work on the ground…. the role is wide ranging…expected to negotiate their contribution once in post …likely to include :• being a visible and accessible resource for evaluation…• working with stakeholders to interpret international evidence for the WELC context… • examining engagement and understanding of stakeholders…• examining implementation of interventions on the ground… • comparing approaches to implementation across WELC…• exploring facilitators and barrier…
“…expected to utilise established social science methods … including analysis of documents, participant observation of meetings and implementation, interviews with stakeholders...”
The role of the Researcher in Residence in WELC: my contribution
• Critical and interpretive approach to policy analysis• Critical discourse analysis
– Language as social practice– Importance of context– A focus on the processes of recontextualisation the vision and objectives of
integrated care are translated through phases of development, implementation, and delivery from a centralised perspective to a local perspective and from a strategic to an operational perspective
• Optimising delivery of the programme objectives • Responsive, relevant, useful an exciting opportunity!
Challenges: getting embedded and engaging with key stakeholders
Friday 3rd October 2014 This week has been almost overwhelmingly full of new and increasingly complex seeming information. The complexity of the WELC programme combined with what feels like my own ignorance (?) or naivety (?) around aspects of the programme can feel very frustrating. No amount of reading has, to date, prepared me for the often impenetrable language and complex practices of the people, workgroups and teams engaged in the IC programme.
The process is slow and often bewildering. Nonetheless I am, slowly but surely, making connections with a wider network of people involved in IC not just at a WELC programme level, but also, increasingly, at a local borough level and at a provider level…there is hope…!
Strategies: Getting embedded
• Be prepared to get uncomfortable (!)• Networks and contacts:
– In the programme (‘gatekeepers’ and ‘key informants’ ‘sponsors’)– Outside the programme (UCL, embedded researchers, mentors)
• Be visible (physically and electronically)• Use key forums to negotiate your role and your position within the programme
(Evaluation Steering Group)• Develop key contact points, i.e. meetings, and attend regularly:
– IC board meetings in Newham/Tower Hamlets/Waltham Forest– WELC wide workstream meetings– IC steering group/board/delivery group/operational meetings in provider
organisations• Research diary – this is valuable learning!
Not physically embedded in one organisation/place but embedded in the space between strategy and delivery
Defining the scope of the research
• Challenges:– One researcher in a complex, large scale programme that is conceptualised centrally, delivered
locally– Demands and expectations– Negotiating a critical and qualitative approach in a traditionally positivist field
• Strategies:– Be clear about my skills (and limitations) from the beginning– Evaluation Steering Group and executive stakeholders defined expectations of the evaluation
prior to starting the role– Be clear about my position within the programme between strategy and delivery– Discussion and negotiation of research design and methodological approach leading to
collaborative development of protocol – agreed through Evaluation Steering Group– Continuous communication, negotiation and reflection based on emerging findings,
programme developments, etc. reflective discussion and action planning sessions – Clarity re. milestones, timelines, processes, etc.
Defining the scope of the research = an ongoing process
Getting evidence into practice
• Challenges:– Demonstrating value– Influencing development across WELC with limited time and resources and multiple
responsibilities
• Strategies:– Communication and regular updates to all stakeholder partners– Negotiate expectations and timelines – be honest– Phased approach to data analysis and negotiation start with high level analysis for quick
feedback and early discussions; buy time for more detailed analysis following negotiations– Be reflexive and embrace interpretivism knowledge and learning are co-created so
don’t be afraid to share early and emerging findings – but do caveat– Find tangible areas to demonstrate value and impact – i.e. MDT development across
WELC– Be flexible about the approach – negotiate approach for specific context/practice/person
Getting evidence into practice: emerging findings
A highly complex programme in which complexity is often underrepresented (and therefore underestimated?)
Contradictory discourses around IC:• ‘scale and pace’ vs. it takes time – there is no
quick fix• Innovation and transformation vs. existing
structures and risk averseness• Empowering patients vs. this is not the right
time/place to engage them
A continuum of engagement – full buy in to vision/ethos of IC regardless of role, background, length of service, etc. – “this is the right thing to do” BUT fragmentation at level of interventions and enablers, i.e. service delivery