Never has there been a topic so subject to lexicological ambiguity as that of Service Delivery Research. Many of the terms it uses are subject to multiple meanings, making communication devilishly difficult; a ‘Tower of Babel’ according to McKibbon, et al. The result is that two people may disagree when they agree, or agree when they are fundamentally at odds. The subject is beset with ‘polysemy’(one word means different things) and, to an even greater extent, ‘cognitive synonyms’ (different words mean the same thing).
Take the very words “Service Delivery Research”. The study by McKibbon, et al. found 46 synonyms (or near synonyms) for the underlying construct, including applied health research, management research, T2 research, implementation research, quality improvement research, and patient safety research. Some people will make strong statements as to why one of these terms is not the same as another – they will tell you why implementation research is not the same as quality improvement, for example. But seldom will two protagonists agree and give the same explanation as to why they differ, and textual exegesis of the various definitions does not support separate meanings – they all tap into the same concept, some focussing on outcomes (quality, safety) and others on the means to achieve those outcomes (implementation, management).
Let us examine some widely used terms in more detail. Take first the term “implementation”. The term can mean two quite separate things:
- Implementation of the findings of clinical research (e.g. if a patient has a recent onset thrombotic stroke then administer a ‘clot busting’ medicine).
- Implementation of the findings from HS&DR (e.g. do not use incentives when the service providers targeted by the incentive do not believe they have any control over the target.
Then there is my bête noire, “complex interventions”. This term concatenates separate ideas, such as the complexity of the intervention vs. the complexity of the system (e.g. health system) with which the intervention interacts. Alternatively, it may concatenate the complexity of the intervention components vs. the number of components it includes.
It is common to distinguish between process and outcome, á la Donabedian. But this conflates two very different things – clinical process (such as prescribing the correct medicine, eliciting the relevant symptoms, or displaying appropriate affect), and service level (upstream) process endpoints (such as favourable staff/patient ratios, or high staff morale). We have described elsewhere the methodological importance of this distinction.
Intervention description is famously conflated with intervention uptake/ fidelity/ adaptation. The intervention description should be the implementation as described (like the recipe), while the way the interventions is assimilated in the organisation is a finding (like the process the chef actually follows).
These are just a few examples of words with multiple meanings that cause health service researchers to fall over their feet. Some have tried to forge an agreement over these various terms, but widespread agreement is yet to be achieved. In the meantime, it is important to explain precisely what is meant when we talk about implementation, processes, complexity, and so on.
— Richard Lilford, CLAHRC WM Director
- McKibbon KA, Lokker C, Wilczynski NL, et al. A cross-sectional study of the number and frequency of terms used to refer to knowledge translation in a body of health literature in 2006: a Tower of Babel? Implementation Science. 2010; 5: 16.
- Lilford RJ. Financial Incentives for Providers of Health Care: The Baggage Handler and the Intensive Care Physician. NIHR CLAHRC West Midlands News Blog. 2014 July 25.
- Lilford RJ. Two Things to Remember About Human Nature When Designing Incentives. NIHR CLAHRC West Midlands News Blog. 2017 January 27.
- Donabedian A. Explorations in quality assessment and monitoring. Health Administration Press, 1980.
- Lilford RJ, Chilton PJ, Hemming K, Girling AJ, Taylor CA, Barach P. Evaluating policy and service interventions: framework to guide selection and interpretation of study end points. BMJ. 2010; 341: c4413.
- Brown C, Hofer T, Johal A, Thomson R, Nicholl J, Franklin BD, Lilford RJ. An epistemology of patient safety research: a framework for study design and interpretation. Part 3. End points and measurement. Qual Saf Health Care. 2008. 17;170-7.