Evidence in the learning organization

<p>Abstract</p> <p>Background</p> <p>Organizational leaders in business and medicine have been experiencing a similar dilemma: how to ensure that their organizational members are adopting work innovations in a timely fashion. Organizational leaders in healthcare have attempted to resolve this dilemma by offering specific solutions, such as evidence-based medicine (EBM), but organizations are still not systematically adopting evidence-based practice innovations as rapidly as expected by policy-makers (the knowing-doing gap problem). Some business leaders have adopted a systems-based perspective, called the learning organization (LO), to address a similar dilemma. Three years ago, the Society of General Internal Medicine's Evidence-based Medicine Task Force began an inquiry to integrate the EBM and LO concepts into one model to address the knowing-doing gap problem.</p> <p>Methods</p> <p>During the model development process, the authors searched several databases for relevant LO frameworks and their related concepts by using a broad search strategy. To identify the key LO frameworks and consolidate them into one model, the authors used consensus-based decision-making and a narrative thematic synthesis guided by several qualitative criteria. The authors subjected the model to external, independent review and improved upon its design with this feedback.</p> <p>Results</p> <p>The authors found seven LO frameworks particularly relevant to evidence-based practice innovations in organizations. The authors describe their interpretations of these frameworks for healthcare organizations, the process they used to integrate the LO frameworks with EBM principles, and the resulting Evidence in the Learning Organization (ELO) model. They also provide a health organization scenario to illustrate ELO concepts in application.</p> <p>Conclusion</p> <p>The authors intend, by sharing the LO frameworks and the ELO model, to help organizations identify their capacities to learn and share knowledge about evidence-based practice innovations. The ELO model will need further validation and improvement through its use in organizational settings and applied health services research.</p

Discordant identification of pediatric severe sepsis by research and clinical definitions in the SPROUT international point prevalence study

Introduction: Consensus criteria for pediatric severe sepsis have standardized enrollment for research studies. However, the extent to which critically ill children identified by consensus criteria reflect physician diagnosis of severe sepsis, which underlies external validity for pediatric sepsis research, is not known. We sought to determine the agreement between physician diagnosis and consensus criteria to identify pediatric patients with severe sepsis across a network of international pediatric intensive care units (PICUs). Methods: We conducted a point prevalence study involving 128 PICUs in 26 countries across 6 continents. Over the course of 5 study days, 6925 PICU patients &lt;18 years of age were screened, and 706 with severe sepsis defined either by physician diagnosis or on the basis of 2005 International Pediatric Sepsis Consensus Conference consensus criteria were enrolled. The primary endpoint was agreement of pediatric severe sepsis between physician diagnosis and consensus criteria as measured using Cohen's ?. Secondary endpoints included characteristics and clinical outcomes for patients identified using physician diagnosis versus consensus criteria. Results: Of the 706 patients, 301 (42.6 %) met both definitions. The inter-rater agreement (? ± SE) between physician diagnosis and consensus criteria was 0.57 ± 0.02. Of the 438 patients with a physician's diagnosis of severe sepsis, only 69 % (301 of 438) would have been eligible to participate in a clinical trial of pediatric severe sepsis that enrolled patients based on consensus criteria. Patients with physician-diagnosed severe sepsis who did not meet consensus criteria were younger and had lower severity of illness and lower PICU mortality than those meeting consensus criteria or both definitions. After controlling for age, severity of illness, number of comorbid conditions, and treatment in developed versus resource-limited regions, patients identified with severe sepsis by physician diagnosis alone or by consensus criteria alone did not have PICU mortality significantly different from that of patients identified by both physician diagnosis and consensus criteria. Conclusions: Physician diagnosis of pediatric severe sepsis achieved only moderate agreement with consensus criteria, with physicians diagnosing severe sepsis more broadly. Consequently, the results of a research study based on consensus criteria may have limited generalizability to nearly one-third of PICU patients diagnosed with severe sepsis

Improvisation and entrepreneurial bricolage versus rationalisation: a case-based analysis of contrasting responses to economic instability in the UK brass musical instruments industry

In periods of economic crisis and instability, the response of many business organisations is to try and adapt to prevailing market conditions. This typically results in a pattern of retrenchment and rationalisation designed to cut costs. Responses of this kind may be justifiable and, to varying degrees, effective at a firm-level. However, their wider repercussions can include the worsening of a pre-existing economic downturn (e.g. large- scale redundancies affecting local communities and cancelled orders affecting other firms in the supply chain).When faced with an economic crisis, some firms adopt a more entrepreneurial approach, in which the key features are strategic reappraisal and various forms of product, process and organisational innovation (Filippetti and Archibugi, 2011). While large corporations are capable of this kind of transformation, there is an increasing recognition of the important part that smaller entrepreneurial firms can play in innovation (Christensen, 1997) including the reinvigoration of industry sectors through open innovation (Chesbrough, 2003) and contributing to the reconfiguration of geographic clusters (Best, 2001). Studies of long wave cycles have shown that periods of economic crisis and depression can be important for innovation: they can disrupt established industry structures and cause entrepreneurs to see markets and customers in a different light so that they re-think products and services (Barras, 2009). However, comparatively little attention has been directed to considering just how entrepreneurial individuals in smaller firms mobilise the resources necessary for innovation and cope with risk in the unfavourable and demanding conditions that prevail in times of economic crisis. This exploratory study seeks to address this research gap. It does so through an in-depth historical case study of the contrasting responses of two firms, in the same industry sector but operating on different scales with differing modes of production (i.e. artisanal v. mechanised), to the greatest economic crisis of the 20th century, namely, the Great Depression of the 1930s (Crafts and Fearon, 2011). The two firms, which served the same markets and were affected by the same external forces, followed very different paths: the larger one engaged in a series of acquisitions as a means of rationalising production and cutting costs, while the much smaller firm that operated on a very modest scale chose to innovate. This innovation involved developing a product that was new to Britain at the time, namely the sousaphone, an unorthodox musical instrument that hitherto had only been produced in the United States. As well as comparing the activities of the two firms operating on different scales, the study examines why the owners of this small firm decided to innovate in the very difficult trading conditions that prevailed at the time, and exactly how they were able to acquire and mobilise the resources needed to pursue this path. In particular, the study focuses on the use of improvisation (Kamoche, Cunha and Cunha, 2002), that is to say ‘impromptu action’ (Dickson, 1997: p. 37), and the closely related concept of entrepreneurial ‘bricolage’ (Baker and Nelson, 2005; Phillips and Tracey, 2007) or ‘making do’ (Eisenberg, 1990: p. 154), as a means of accessing the resources required. The findings suggest that while large-scale enterprises often concluded that a strategy of retrenchment and rationalisation was the appropriate response to economic crisis, firms operating on a smaller scale viewed the situation differently and responded to the altered trading conditions in more positive, creative and entrepreneurial ways. As a result they were able to identify opportunities associated with new and expanding markets with scope for innovation. The study provides insights into the ways in which these small firms were able to identify and access the necessary resources for their innovations. It also sheds new light on the improvisatory nature of their entrepreneurial response, and its capacity to overcome seemingly insurmountable obstacles to growth in a recessionary environment (e.g. adapting existing resources to new uses, forming unconventional subcontracting arrangements and turning existing skills to new uses). The paper concludes with a summary of the key findings and their implications for future research and practice

Multimodality Treatment of Advanced Non-small Cell Lung Cancer: Where are we with the Evidence?

Purpose of review The majority of patients with non-small cell lung cancer (NSCLC) present with advanced disease and overall survival rates are poor. This article outlines the current and outstanding evidence for the use of multimodality treatment in this group of patients, including in combination with an increasing number of treatment options, such as immunotherapy and genotype-targeted small molecule inhibitors. Recent findings Optimal therapy for surgically resectable stage III disease remains debatable and currently the choice of treatment reflects each individual patient’s disease characteristics and the expertise and opinion of the thoracic multi-disciplinary team. Evidence for a distinct oligometastatic state in which improved outcomes can be achieved remains minimal and there is as yet no consensus definition for oligometastatic lung cancer. Whilst there is supporting evidence for the aggressive management of isolated metastases, the use of consolidative therapy for multiple metastases remains unproven. Summary Evolution of new RT technologies, improved surgical technique and a plethora of interventional-radiology-guided ablative therapies are widening the choice of available treatment modalities to patients with NSCLC. In the setting of resectable locally advanced disease and the oligometastatic state, there is a growing need for randomised comparison of the available treatment modalities to guide both treatment and patient selection