The determinants of evidence use by Australian clinical networks as agents and stewards of safety and quality: a conceptual framework.

Abstract

Background: Healthcare systems are increasingly complex given devolution of powers, decentralization of decision-making, and escalating fragmentation of effort. This indicates a role for governments in how they can bring this together, oversee and improve across the system. Goals pertaining to the safety and quality of clinical care are advanced by governments using stewardship and agent-based strategies that increasingly place reliance on being evidence based. In Australia, clinical networks are a safety and quality stewardship model that convenes multidisciplinary and intersectoral actors to define evidence-based expectations for clinical practice, management and policy. Yet understandings of the role that evidence is intended to play within clinical networks remain under investigated. Despite vast literature examining the contribution of stewardship, networks and evidence use in healthcare, research on these topics have occurred in relative isolation. There lacks an integrative approach to these concepts to advance stewardship research and practice.

Methods: By employing a theory generating approach, this research outlines the determinants of evidence use by Australian clinical networks as safety and quality stewards. A conceptual framework is developed, informed by examination of the theoretical and empirical literature, findings from mixed methods research involving interviews, documentary analysis and Q-methodology, and validation of findings with research partners.

Results: The Clinical Network Safety and Quality Stewardship Conceptual Framework situates the determinants of evidence use by networks within understandings of safety and quality stewardship. It encompasses three layers: (i) the model of health system coordination and governance, (ii) network inputs and understandings of evidence, and (iii) points of influence. Within each layer, several attributes are identified that are explained with reference to agency and stewardship theory. We describe the interactions within and between the layers incorporated in the framework that are of importance in order to explain how evidence can shape the decisions that contribute to safety and quality.

Conclusions: Theoretical contributions offer greater conceptual clarity with regard to the role of evidence within the context of networked stewardship models and systems where foundations are in agent-based approaches of coordination and governance. The conceptual framework seeks to advance scholarly research and practice. Merits, limitations and considerations for further testing of the framework are outlined.