Evaluating an integrated quality improvement and research approach: the Just Cos Initiative

Health service staff have been criticized for implementing practices (e.g. a new procedure, new checklist) into care because they seem like 'good ideas' yet may not have the evidence to support them. The Just Cos Initiative (Just Cos) was developed based on a Learning Health System approach to address this problem. It encourages staff to think critically about their work practices and provides a pathway for staff to submit queries about potentially low-value or non-evidence based/informed (low-value) practice. Just Cos then integrates internal audit data and external research evidence with stakeholder consensus and puts that knowledge into practice using quality improvement methods. The aim of this study is to evaluate whether this integrated quality improvement and research approach can identify low-value practices and where identified, whether these practices can be minimized. It is important to adopt and evaluate systematic approaches to identifying low-value practices in health so that the patient care is delivered optimally and risks are minimized.

This study was a multi-method evaluation utilizing the RE-AIM framework. Submissions received over 14 months were collated from a Just Cos submission log. Implementation of Just Cos was explored through nine semi-structured interviews with staff who either submitted a Just Cos request or otherwise participated in at least one element of the Just Cos process.

Twelve unique Just Cos submissions were received from nursing (7), allied health (3), executive (1), and management (1). Two submissions identified a low-value practice that required practice change. Policy changes (e.g. clarification of a process or approach) occurred in four submissions. No change to practice or policy was required in three, and three submissions did not complete the Just Cos process. Participants described Just Cos as giving staff a 'voice' and that they valued being able to update practices. The use of centralized resources to review submissions saved time for busy staff, and protected individuals from any criticism for raising the concern.

An integrated model using research evidence combined with quality improvement identified two low-value practices that required practice change. It provided a psychologically safe mechanism through which staff could be curious about their practice. There is the opportunity to scale this approach to further improve the uptake of evidence based or informed practices within the healthcare setting.