Key Driver 6: Nurture Leadership and Create A Culture of Continuous Learning and Evidence-Based Practice

A maxim of organizational change theory is that leaders’ support for change is crucial. When it comes to making fundamental changes in a practice, however, more than support alone is necessary for success. Leaders need to convey a vision and manage the process of change actively through deliberate and consistent communication, role modeling, education, review of implementation and outcome measures, and use of resources to reinforce their message. Part of that continual effort is enlisting others in the practice to be champions for seeking and implementing new evidence. Another important role for leaders is empowering everyone, especially those who do not traditionally exert influence, to speak freely about opportunities for improvement. While leadership looks different in small practices, even solo practitioners need to nurture themselves and their employees to create a culture of flexibility in which new evidence is eagerly and routinely integrated into practice.

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Change Strategies

Create a culture in which all practice members feel comfortable identifying opportunities for quality improvement
The pursuit of evidence-based practice will inevitably engender some missteps. Leaders should find ways to overcome the reluctance of practice members to admit mistakes, doubts, or ignorance or to voice potentially controversial ideas. As with patient safety, leaders want to establish a blame-free atmosphere where mistakes are considered learning opportunities. To create a cohesive culture, leaders will need to engage in active listening and gain an understanding of the perspectives and motivations of practice members. Leaders can model the behavior they want to see by publicly expressing appreciation when their views are challenged. It is important to recognize that not everyone in the practice has the same amount of power, and to make a point of seeking out and respecting the voices of people who have less power or are otherwise cautious. By creating an ethos that everyone is equally responsible for making sure the practice lives up to high, jointly held expectations, leaders free people to go into problem-solving mode rather than being on the defensive.

Encourage learning about new evidence and best practices
Leaders who are committed to ensuring that people receive the most up-to-date care embrace learning as an organizational value. Leaders create a learning atmosphere by freeing up bandwidth for staff to take advantage of learning opportunities in the daily flow of work as well as the occasional out-of-the-office experience. This means more than just paying for conference registrations. Leaders steer practice members toward opportunities that provide either a deep dive into new evidence on specific topics, or more general skill building, such as teaching practice members to be savvy consumers of clinical and organizational evidence or learning about the quality improvement process. In this way, practice members join practice leaders in becoming locators and customizers of new evidence. (Go to Key Driver 1: Seek, select, and customize the best evidence for use by the practice.)

Forge a vision of a practice that adapts to a changing evidence environment
Leaders must first develop, and then communicate, a vision of the practice as one that responds flexibly to changes in evidence. This vision provides a foundation for customizing and implementing new evidence. Making changes in a practice is always difficult. Without a consistent and sustained message from practice leaders, staff tend to stay entrenched in their customary routines, and believe them to be the best way of delivering care. Communicating the vision can begin with the practice mission statement or charter, but it can’t end there. Leaders should develop their own style for re-enforcing the vision, such as sharing their excitement about new evidence as it emerges, modeling how they use it with their own patients, nominating new evidence for quality improvement projects, and publicly praising those who identify and use new evidence.

Identify and support champions for learning, evidence-based practice, and quality improvement within the practice
Successful organizational change efforts require both strong senior leadership and collective and distributed leadership throughout the practice. Leaders should identify individuals, such as clinicians, practice managers, nurse leads, and others who are passionate about evidence-based practice and quality improvement and are able to motivate others. If natural champions are scarce, leaders can cultivate champions through training, mentoring, appropriate rewards for improvement, and helping practice staff engage in self-reflection about the unique contributions they can make and leadership skills they would like to develop. Recruiting opinion leaders from every corner of the practice increases the likelihood of getting the entire practice on board and sustaining changes over time.

Review measures of implementation and impact of evidence-based practices regularly
To create a culture of evidence-based care, it is essential that leaders review measures of whether the practice has in fact made the changes needed to align care with new evidence and whether those changes are having the expected effects on patient outcomes. This is in addition to the reviews done by the practice’s quality improvement and clinical teams. (Go to Key Driver 2: Implement a data-driven quality improvement process to integrate evidence into practice procedures.) Leaders should visibly use those measures to signal the importance of adapting to new evidence. When results are disappointing, leaders should collaborate with practice members to figure out what the barriers are and how the practice can adjust resources and supports to spur improvement. Similarly, when results are good, leaders should commend practice members and celebrate.

Provide organizational and leadership support for evidence-based practice and quality improvement
Like any quality improvement effort, the drive to be responsive to new evidence will require staff time and other practice resources. Everyone in the practice, not just clinicians, may need time to create and adjust to shifts in what and how they deliver care. Leaders can provide support by acknowledging those activities in job descriptions and releasing staff from other duties to participate in quality improvement and team meetings. Leaders also should ensure that adequate resources are available to implement new evidence, for example by revising information systems to monitor the delivery of evidence-based care, re-structuring the built environment, or purchasing new supplies. Leaders will also need to stand at the ready to defend staff for following the evidence. For example, if new evidence dictates de-prescribing a certain medicine, leaders should support staff in the face of patient complaints. Leaders should champion the adoption of evidence that improves health outcomes, while also working to align the practice's business model with what is best for patients (e.g., through value-based payments). (Go to Key Driver 2: Implement a data-driven quality improvement process to integrate evidence into practice procedures.)

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