ReBEQI’s aims
· To establish a framework for the selection and subsequent implementation of interventions aimed at improving the quality of healthcare.
· To provide clinicians and others with a suite of evidence-based tools, which incorporate the above and other research and which make it easier to transfer research findings into clinical practice.

Identifying barriers to change
Changing clinical behaviour (eg. prescribing behaviour or the use of a diagnostic test) is not easy. The choice of quality improvement (QI) strategy should be guided by recognition of barriers to the change being proposed. Work underway in ReBEQI is adding to current knowledge about how to identify these barriers to change. Members of the ReBEQI group are collaborating on a systematic review of empirical methods of barrier identification that is being prepared for publication in the Cochrane Library. The barriers identification methods covered by this review are used, in the main, in connection with interventions aimed at the individual practitioner. However, obstacles to change are generally not limited to the professional. Additional measures and actions at the level of teams or organisations are frequently needed for change in clinical practice. The ReBEQI group is, therefore, also developing a review that considers studies of combinations of educational interventions and organisational interventions. This is a little-studied area and the review will generate new knowledge, which will be combined with the first review to develop practical tools for barrier identification over the next two years.

Can theory help with intervention planning?
There are many theories related to behaviour change in use in healthcare research, which is confusing for researchers and clinicians alike. A draft of a review on theories of change has been written as part of our work. This draft, in addition to analysing the theories in more detail than earlier work, takes a new approach and considers the empirical research evidence supporting the use of each theory. This is completely new work. This work has found, for example, that there is little empirical evidence to support the claim that interventions developed using the ‘Stages of change’ theory are better than other interventions aimed at behaviour change in patients. This work, when complete, will make a major contribution to the science of theory-based intervention development in healthcare.

Work on a practical, theory-based tool is also well underway. The tool, currently in the form of a manual, is based on a psychological model of behaviour change, the theory of planned behaviour (TPB) and is designed to assist researchers or health workers involved in quality assurance to produce a valid questionnaire. Questionnaires based on the TPB can be used to investigate the attitudes and beliefs underlying health-related behaviour and can, therefore, be used to plan the development of interventions. An evaluation of the manual has now begun in the UK and may involve other partners at a later stage.

In addition to the TPB manual, a model for the development of quality improvement programs is being developed. This work is focused on theory-based factors, for which measurement instruments are available and evidence to suggest a mediating or moderating influence on implementation interventions. This model will be tested in early 2004.

These tools, if found to be effective, will help to make intervention development more systematic and effective, and less dependent on the individual creativity and preferences of researchers. This work will be a big step towards an understanding of the active ingredients of complex intervention packages.

Sharing knowledge
Duplication of effort is a problem within QI. Each ReBEQI partner has now identified or initiated at least one QI study that will be coordinated as part of the ReBEQI project. The protocols for several of these studies have either been published or have been submitted for publication. The first version of the project’s Sharenet has almost been completed and this will be used to share documents, early results, articles and ideas between partners. Over time the Sharenet will become an important source of information on the design and conduct of QI initiatives in healthcare.

Practical evidence-based QI: ReBEQI tools
There is a great deal of information available about how to develop QI programs, some of it developed by members of the ReBEQI group. It is, however, spread across hundreds of journals, websites, books, conference proceedings and software tools. Over the last year we have developed a prototype of a software tool called NorthStar, which aims to package this information in a single, easily accessible and practical tool. NorthStar uses a familiar Windows interface, is searchable, will be customisable and can contain the full spectrum of electronic document formats. We can, therefore, include not only textual information but graphics, sound, video, links to websites and even other programs. Moreover results from other ReBEQI work can be operationalised as practical tools within NorthStar. This could be, for example, a decision-support system to help individuals design interventions, or identify barriers to change. The intention is to provide a tool that will help people to design effective, evidence-based intervention packages without the need for them to do huge amounts of independent work. We anticipate that NorthStar will prove to be one of ReBEQI’s major products.

Funding
ReBEQI is funded by the European Commission’s 5th Framework Quality of Life Programme, Contract Number: QLG4-CT-2002-00657. The project is coordinated by the Norwegian Health Services Research Centre and is scheduled to end 30th November 2005.


For more information contact Shaun Treweek at shaun.treweek@nchs.no , Astrid Dahlgren at astrid.dahlgren@nchs.no or Andy Oxman at oxman@online.no.